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Clinical Practice Statement

American Geriatrics Society (AGS)

THE ROLE OF HOUSE CALLS IN GERIATRIC PRACTICE

AGS Clinical Practice Committee

BACKGROUND

We recognize the importance of both the house call and the need for medical oversight of the home health care plan. The home is an important setting for health care delivery for the growing numbers of frail and disabled individuals, offering the advantages of maintaining patients in the community as part of an intact family, delaying or preventing reliance on public financial support, promoting the use of voluntary caregiver services and obviating the non-medical costs of institutional care (1,2). Improved technology has allowed more complex care to be provided in the home, extending the capabilities of physicians, physician assistants and nurse practitioners in the management of home-care patients. Medical providers are responsible for implementing and monitoring the appropriate use of home services in an integrated continuum of care, and fostering the most efficient use of limited resources. In order to promote these goals, the American Geriatrics Society has adopted the following position statement.

POSITIONS

1. Medical providers engaged in geriatric practice should make provision for house calls appropriate to the diagnostic, therapeutic, and psychosocial needs of the patient.

Rationale: The rapid growth of the home care industry reflects strong societal preferences to receive care in one's place of residence (3). The best interests of the patient and society are served when the provider has first-hand knowledge of the physical, psychosocial, environmental and economic factors that affect the patient's health care needs. Therefore, providers should become fully knowledgeable in providing care in the home.

Experience suggests that both quality of medical care and quality of life for patients can be improved when providers make house calls (4). For geriatric patients with severe disabilities, severe mobility impairment, disruptive behavioral problems or end-stage terminal illness, the expense, stress and discomfort of transporting the patient too often pose insurmountable obstacles resulting in a denial of access to care. The inability to fully access psychosocial and environmental factors undermines the capacity of the practitioner to provide appropriate medical management and oversight.

If medical services are not available in the home, patients and their families are faced with suffering from insufficient care or seeking institutionalization which disrupts the family structure, and may cast the financial burden largely on the government. National health care policy should support house call practices and care plan oversight appropriate to the needs of our citizens through assuring adequate payment for these services (5).

Considerations of time and economy require that house calls should be planned to produce maximum efficiency and effectiveness (4). Patients most likely to benefit include (3) those who are homebound due to severe functional and mental disabilities for whom the patient's environment and social milieu substantially affect medical care plan decisions; where concerns involve issues of potential abuse, safety or caregiver burnout; and when difficult ethical decisions will affect the family.

2. Education of physicians, physician assistants, and nurse practitioners should include the appropriate use of in-home services and house calls.

Rationale: Primary care faculty are in short supply, especially for teaching the care of the multiply impaired and disabled patient common to geriatrics practice. Many academic institutions are bereft of adequate clinical role models and potential educators for house calls due to inattention to the rapid advances in the technological capabilities available in the home care setting and because of inadequate remuneration for the primary service, let alone the added expense of instructing trainees. The education of physicians and other health care personnel is enhanced by the inclusion of information on and experiences with the home health care system (5). A broad appreciation of the capabilities of various settings of care enable practitioners to apportion their time most wisely, counsel patients most effectively, and provide care with the greatest overall clinical effectiveness and cost-efficiencies.

3. To promote these activities, appropriate reimbursement for the services provided must be part of any health care plan.

Rationale: The three specific reimbursement issues deserving increased attention are travel time between home care patients, the increasing number of homebound persons residing in congregate living facilities (at a 'domiciliary' level), and the need for comprehensive assessment as part of the home care process (6). Travel time is not included in the reimbursement formula for house calls. Practitioners providing house calls cannot possibly see the same number of patients they cover in the office due to travel time between patients. Some consideration for travel time or mileage seems equitable in providing coverage for the true cost of these services.

Increasing numbers of frail elderly persons with multiple comorbidities, developmental disabilities, and chronic mental illness reside in congregate living facilities including assisted-living facilities and boarding homes. Medicare reimbursement for these visits, below that of similar office encounters, is a disincentive to providers of house calls to entitled beneficiaries.

The pattern of illness and disability characteristic of appropriate home care patients makes them appropriate to a careful and comprehensive approach to evaluation. Geriatric Assessment may uncover medical, functional, and psychosocial problems in frail and chronically ill elderly persons in order to develop a comprehensive plan for therapy and long-term follow-up. Medicare does not currently reimburse for comprehensive geriatric assessment.

4. Continuing clinical and health care services research in this area is strongly recommended and urgently needed.

Rationale: Research should focus on maximizing organizational efficiencies and provider effectiveness in supplying services in the home, and on identifying patient and caregiver criteria that optimize health care expenditures in the least restrictive environment. Research efforts should address cost-effective use of personnel and technologies in acute, subacute and chronic care situations; patient and caregiver education methods; and best-practices evaluative studies linked to outcome analyses and satisfaction surveys. The role of technology including telehealth, medical informatics, and diagnostic testing at the point of care, deserve special attention (5). Clinical practice guidelines should be developed to inform care in the home. Alternatively, process algorithms may be developed through secondary extractions of other guidelines adapted to the unique aspects of this setting.

1. Alecxih LMB, Lutzky S, Corea J. Estimated Savings from the Use of Home and Community-Based Alternatives To Nursing Facility Care in Three States. Washington, D.C.: American Association of Retired Persons, 1996.
2. U.S. General Accounting Office. Medicaid and Long-Term Care: Successful State Efforts to Expand Home Services While Limiting Costs. Washington, D.C.: U.S. GAO, 1994.
3. Taler G. House calls for the 21st century. J Am Geriatr Soc 46:246-247, 1998.
4. Fried TR, Wachtel TJ, Tinetti ME. When the patient cannot come to the doctor: A medical house calls program. J Am Geriatr Soc 46:226-231, 1998.
5. Leff B, Burton JR. The future history of home care and physician house calls in the United States. J Gerontol: Med Sci 56(A):M603-M608, 2001.
6. Stuck AE, Aranow HU, Steiner A, et al. A trial of annual in-home comprehensive geriatric assessment for elderly people living in the community. N Engl J Med 333:1184-1189, 1995.

Developed by the AGS Clinical Practice Committee and approved November 1989 by the AGS Board of Directors. Reviewed and updated November 1993; May 1998; November 2002. The American Geriatrics Society, The Empire State Building, 350 Fifth Avenue, Suite 801, New York, NY 10118, 212-308-1414, Fax: 212-832-8646, info.amger@americangeriatrics.org. Note: The AGS Public Policy Committee has developed a separate position paper on Home Care and Home Care Reimbursement.