Doctors prescribe old-fashioned house calls when treating the old and frail
The Washington Post December 2015
Haydee Hernandez, 83, suffers from seizure disorder, degenerative joint disease and hypertension, and cannot walk well enough to visit the doctor. In many places in the country, the retired cafeteria worker would be in an assisted living facility. She is able to stay in her Columbia Heights apartment, surrounded by her plants and ceramic figurines, because her doctor comes to her.
Sitting in a wheelchair, Hernandez pointed to the spot where her oldest child took his last breath in her arms, two decades ago. “My son died in here,” she said, vowing, “I’m going to die in here.”
A study published last year in the Journal of the American Geriatrics Society, supported by other research, found that home-based primary care lowered costs as well as emergency room visits and hospitalization rates while increasing patients’ satisfaction with care. Now, a group of doctors — including Hernandez’s — is pushing to bring house calls to the nation’s
2 million oldest, frailest and costliest patients, saying it has the potential to save the government billions of dollars.
Independence at Home was developed by a group of doctors around the country who were already making house calls to such patients. Although the patients needed regular monitoring, they did not need to live in a nursing home or hospital as long as a provider could come regularly to take their blood pressure, talk about their medications and check other vital signs.
While such visits cost doctors more because of travel and care-coordination time, they can save Medicare large amounts of money otherwise spent on inpatient and residential care. Working with the American Academy of Home Care Medicine (AAHCM), the doctors developed a program through which Medicare would share the money saved via home care with the doctors who provided it.
A three-year pilot program in 17 practices around the country was included in the Affordable Care Act and implemented in 2012. The initial results were promising, and this summer Congress voted to extend it another two years for 14 of the practices.
Last Wednesday, K. Eric
De Jonge, co-founder of the medical house-call program at MedStar Washington Hospital Center and president-elect of the AAHCM, spoke on the Hill pushing for Independence at Home (IAH) to be included in the Senate Finance Committee chronic care working group, with the goal of making it available nationwide.
“This provides a path for us to care for all of America’s most vulnerable and frail elders in the environment in which they prefer to live and lower total costs for Medicare,” he said in an interview.
His partner and program co-founder, George Taler, put it more dramatically: Implementing the program nationally, he said, “would totally reverse the numbers for the sustainability of Medicare for the future.”
Such a scenario would save Medicare an estimated $21 billion to
$34 billion over 10 years, according to an analysis by Jen Associates, commissioned by the AAHCM — money that would otherwise go to hospitals, short-term nursing homes and other costs.
In the first year of the pilot, participants saved more than
$25 million — an average of $3,070 per beneficiary, according to the Centers for Medicare & Medicaid Services (CMS). The savings ranged between 6 percent and
31 percent across practices. Beneficiaries had fewer hospital readmissions and fewer hospital visits for conditions such as diabetes, high blood pressure, asthma and pneumonia. CMS passed $11.7 million of the savings to the providers.
Funding for house-call programs comes from a combination of the Medicare fee-for-service program, grants and private insurance. Results for the second year are expected soon.
In May, Finance Committee leaders said that they hoped to release a proposal to the public by the end of the year. Sen. Ron Wyden from Oregon, the top Democrat on the Finance Committee and a member of the working group, called IAH “an important opportunity for Medicare to lead a revolution in caring for people at home.”
Caring for chronically ill patients in their home is ideal, experts say. “If they’re at home, they’re in an environment that can expedite healing, for example, more natural light,” said Judah Ronch, dean of the Erickson School at the University of Maryland Baltimore County, which focuses on the elderly in society. Being at home also helps patients see themselves as “not a sick person,” he said.
Joyce Weatherly, 94, who suffers from hypertension, heart disease and osteoarthritis, sat in her Mount Pleasant living room last week, chatting with Taler, one of the doctors who came up with the idea for IAH.
Taler took her blood pressure and watched her walk unsteadily across the room, where her orange cat, Chester, crouched on an Oriental carpet. “When they tried to enroll me at that geriatric program at the hospital it was horrible. They took me from one computer to the other,” she said, adding, “It’s not just getting there, it’s waiting after you get there.”
Instead, the former government clerical worker waits on her couch for the home visits, which remind her of the 1920s, when her family doctor came in a buggy.
For her daily needs, Weatherly has a full-time assitant — a factor that could limit who is able to benefit from the program. Patients receiving home primary medical care must rely on a combination of family caregivers and paid assistants for other help, or Medicaid home help if a patient is eligible.
[DC Medicaid home help program for elderly reflects national trend]
Patients older than 85 are the nation’s fastest-growing cohort, and as the massive baby-boomer generation ages, that growth will accelerate: In the next 15 years, the number of people ages 80 to 84 will leap from 5.7 million to 10.5 million. Experts have warned of a looming crisis.
At the same time, the medical industry has resorted to outdated solutions, Taler said, adding that too often after an acute crisis, patients are sent to live in a facility even when round-the-clock care is not necessary.
“It is so much easier to discharge a patient to a nursing home than to set up a home-care program,” he said. “Two-thirds of people in nursing homes probably no longer need to be there because they don’t need 24-and-7 nursing care. . . . IAH provides the opportunity to move these people back into the community or to prevent new ones from coming in.”
A national implementation could substantially reduce hospital beds, he said, with nursing homes taking over some of the medium-tech care, such as delivering intravenous medications and fluid, that hospitals now provide.
Not all primary-care practices would qualify — house calls require specialized skills, and doctors would need to employ or partner with nurse practitioners and social workers and be able to coordinate care with family members. Someone would need to be on call 24 hours a day, seven days a week.
Those requirements, along with the growing number of older Americans, mean IAH is not likely to put nursing homes out of business, said Mike Cheek, senior vice president for finance policy and legal affairs at the American Health Care Association, which represents 13,000 nursing homes and assisted living facilities.
“Our businesses are most concerned about meeting the demands in the coming years,” he said, adding that if IAH were implemented nationally, some facilities might be interested in developing partnerships with participating providers, teaming up with them to help deliver some of the in-home skilled care.
But in some cases, facilities would no longer be required.
“Many old people in hospitals don’t need to be there,” Ronch said. “It’s not about serving the needs of the institution, but serving the needs of the people. It’s the idea that we can deconstruct the health-care system and reconstruct it to serve the patient in a way that’s fiscally and medically better.”