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To illustrate how critical a house call can be for a homebound elderly patient, Rebecca Conant, MD, director of the University of California at San Francisco Medical Center's Housecalls Program, offers a telling anecdote about one of her patients, who had been hospitalized.
After the patient stabilized, Dr. Conant recounts, hospital staff sent her back home - not only with new medications but also with duplicates of drugs she'd already been taking. Unfortunately, the duplicate drugs were labeled with their generic names, and Dr. Conant's patient didn't realize that they were identical to the name-brand formulations she had at home. She was planning to take both.
"I was so glad I went to see her the next day, because these weren't benign drugs - if she'd taken two of them she could have died," says Dr. Conant, who has headed the Housecalls Program since she completed a geriatrics fellowship at UCSF in 2001 and is an associate clinical professor of geriatrics at the medical center. "Making a home visit -- going into the patient's home -- really allows you to see things you wouldn't if you only saw your patient in the office."
When it was launched in 1999, UCSF's Housecalls Program provided at-home care for five to 10 homebound patients at a time, most of them elderly. The program, established and supported by foundations and individual donors, has since expanded and that number has risen to roughly 75 active patients. Given the frailty of the patients, about half the roster turns over every year.
"Without us, most of these patients would be completely cut off from primary medical care and would get no medical care until they got so ill that they were taken by ambulance to the ER and were admitted to the hospital," Dr. Conant says.
Research suggests that providing house calls to homebound patients can prevent ER visits and hospitalizations and save money. It also suggests that, among patients with health problems amenable to at-home care, those who receive care at home have better outcomes, fewer complications, faster recoveries, less functional loss, and lower healthcare bills than those treated in hospitals.
After declining dramatically over the last several decades, interest in house calls -- and in home-based care in general -- is growing. But there are still too few healthcare providers who make house calls to go around, Dr. Conant notes. Though the Housecalls Program has expanded considerably since 1999, it still has an average of 50 people on its waiting list at any given time.
The American Geriatrics Society (AGS) recently caught up with Dr. Conant to talk house calls:
AGS: What can you do during a house call?
RC: A lot. And that's one of the things we show our students. There's all manner of equipment we can use in the home -- handheld finger stick blood machines and in -- home ultrasound. But we want our students to understand that what's fundamental is the history and the physical. We show the students that they can do a really good physical exam and get a great history and use their brains and that this is most important. And I think the students really get this. They realize that the depth of the history you can get in the context of the home is tremendous. In addition to asking your patients what's going on -- you can actually see first hand what patients are dealing with at home. It's amazing for these students to see how patients live. Some are living in horrible situations and others, in very good situations.
AGS: How great is the need for healthcare providers who make house calls?
RC: There's incredible need out there. You have no idea how grateful patients and families are when they find someone who will make a house call. Until people are in a situation in which they're trying to care for someone who's homebound, they don't realize how difficult it is to find this kind of care. And the need is just going to grow with the demographic. We already know there's a large unmet need and that will only get bigger.
AGS: Why is there still such a shortage of professionals who make home visits?
RC: Reimbursement is still an issue. Medicare pays about the same for two home visits as it does for three office visits, but home visits are far more time consuming. Among other things, travel time is a real issue. In addition, there's a lot of care coordination that still isn't reimbursed by Medicare. I spend a great deal of time talking to family members, others providing care to patients, and to patients themselves. I spent 20 minutes yesterday helping a patient fill out his urology paperwork. That's not billable, but it needs to be done. Now, I'm able to do that because about half of my job is education and half is clinical, and we're run as a nonprofit that gets support from philanthropy. But my situation is unusual.
AGS: What's the focus of the Housecalls Program's training efforts?
RC: One of our messages to our students is that, regardless of what field you go into, given the demographics, you're going to be taking care of old people -- so you need to know how to do that well. We want to demystify the house call and make trainees understand that anyone can make a house call. It doesn't require special certification.
Our hope is that if people have a more open mind about house calls, more of them will make at least some house calls. That would be extremely beneficial. Our hope is that the surgeon will say, "I've got this post-op patient and I'm concerned about his wound, so I'm going to swing by and check on him," and that the oncologist whose patient is too weak to get to the office will visit that patient at home.
AGS: What kind of feedback do you get from your trainees?
RC: It's very positive. They enjoy being with us and going on the house calls. They're very well supported because we're there with them. Some UCSF students do a home visit during their first year that's more of a social thing - they do that visit with another student but no faculty member. A study of third-year medical students that we were able to do with the support of a grant from the Donald W. Reynolds Foundation found that the mentored home visits we provide are much more positive than those done without a faculty member.
AGS: What's the outlook for home visits?
RC: I'm very optimistic. I think people in public policy are realizing that we need new approaches and solutions to meet the needs of the increasing number of older people. With groups like AGS and the American Academy of Homecare Physicians (AAHCP) actively involved, I have great hope that house calls will be recognized as an important service that is cost-effective and important to provide for older patients.
There's already growing realization that care coordination is critical to good outcomes for patients, and we spend a lot of time and effort providing care coordination without reimbursement under the current payment system. There are now proposals before Congress to address this issue. One is the Geriatric Assessment and Chronic Care Coordination Act, for which AGS has been advocating. Others are the American College of Physicians' Medical Home proposal, and the AAHCP's Independence At Home proposal.
AGS: Anything else trainees should know about making house calls?
RC: Yes. I also want to emphasize how much fun it is to do house calls, and the incredible job satisfaction that comes with it. House calls make an enormous difference in the lives of patients and their family members. Those of us who make house calls love what we do. It's really very, very rewarding.
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