8.3: “Back to the Future- Making House Calls for Better Care, Reduced Costs” by K. Eric De Jonge

In the age of high tech medicine, busy ERs, and long waits for doctor appointments, house calls seemed to have gone the way of Marcus Welby MD, the 1970s TV drama. But that’s exactly what our Medical House Call teams do every day—and we’re providing high-quality care for very frail elders at a savings to Medicare.

Working in teams out of MedStar Washington Hospital Center, we provide skilled, coordinated care to frail elders, like 86-year-old Frances Humes who needs intensive monitoring and care but finds it difficult to get to a doctor’s office.

Her daughter, Veronica Butler, said: “She often went to the hospital or ER because it was so difficult to get her to office visits … 9 a.m. appointments required her to start getting ready hours earlier. She would just dread it.”

And like many other family caregivers and patients, Veronica noted “before, I didn’t have a sense of whether there was an emergency or not so I would call 911. Now, they’ll talk me through it. I think she’s healed better because she’s at home.”

With this program, part of the Independence at Home initiative under the Affordable Care Act’s Innovation Center, Veronica’s mother, who suffers from severe rheumatoid arthritis and recurrent pneumonia, can get the attention and high-quality care that she needs in the comfort of her own home rather than in an expensive and uncomfortable hospital setting. And Veronica can reach the team on a 24/7 basis if she has any concerns about her mother’s health.

Our current work with Independence at Home builds on our existing Medical House Call Program. Since it was founded in 1999, we have enrolled more than 3,100 elderly patients and now have 620 active patients. We have two House Call teams that include physicians, nurse practitioners and social workers. We share interdisciplinary home care and business staff.

On a typical day, a physician handles email and calls in the morning and then does house calls for a half-day session. We can arrange home-based blood tests, X-rays, EKG, and ultrasound tests. Our providers can perform minor procedures, adjust medications and prevent medical crises.

Our team makes sure patients have their correct medications and are connected to the community support resources they need. If patients do need ER or hospital care, we directly coordinate and provide that service. Our nurse practitioners perform routine and urgent visits and see patients within two days of any discharge from the hospital.

The teams have mobile, wireless access to the patients’ electronic health records to ensure clinicians can view accurate information. If I am not available when a patient or caregiver calls, they know that the team is well-briefed on their situation. We also offer same-day urgent care during weekday hours.

We share best practices in the Mid-Atlantic Consortium, a regional partnership with house call programs at Virginia Commonwealth University and the University of Pennsylvania.

Our efforts are now showing results: In Year 1 of the Independence at Home demonstration, the consortium met all six quality measures, including reducing 30-day hospital readmissions, admission rates for patients with serious chronic illnesses, and ER visits.

With these results, the Mid-Atlantic consortium reduced per capita Medicare costs by 20 percent and received a shared savings payment of $1.8 million from the Centers for Medicare & Medicaid Services.

The shared savings payment allows us to hire new staff and build new teams to serve more elders. The shared savings supports clinical quality and financial sustainability of home-based primary care. Before the initiative, the house call program operated at an annual loss and needed grants and donations to cover 25 percent of program costs.

Overall, the CMS Independence at Home demonstration nationally saved more than $25 million, an average of $3,070 per participating beneficiary, in the first year.

The most profound impact from the House Call service is a human one. Frail elders receive quality and dignified care in the comfort of their home, and family caregivers get the support they need.

Mrs. Humes’ daughter says it best: “My mother has a team that stays focused on her health. It’s added such a great quality to her life. She’s happy in her home.”