The program has lowered total costs of care and has reduced average inpatient length of stay from 8 to 6 days; in addition, 60 percent of deaths among program participants occur at home, compared with a benchmark of 10 percent of area elders who are not program participants.
Washington Hospital Center is a 900-bed nonprofit teaching hospital in Washington, DC, and is part of MedStar Health, a large nonprofit health system serving the Baltimore and Washington metropolitan areas. The hospital is located in an urban setting where the vast majority of frail elders are covered by Medicare; approximately 40 percent are also covered by Medicaid. The Medical House Call program was founded in 1999 by two Washington Hospital Center geriatricians, Dr. Eric De Jonge and Dr. George Taler, who decided to create a patient-centered elder care model that coordinated all needed medical and social services to the population that was most poorly served by the current health care system.
“The Medical House Call program includes teams of geriatricians, nurse practitioners, and social workers who make house calls to frail elders.”
A house call program staffed by an interdisciplinary team of geriatricians, nurse practitioners, and social workers provides primary health care and social services to homebound frail elders. By identifying and treating medical problems before they become acute, the program has lowered total costs of care and has reduced average inpatient length of stay from 8 to 6 days; in addition, 60 percent of deaths among program participants occur at home, compared with a benchmark of 10 percent of area elders who are not program participants. A study of Medicare patients showed that those who received home-based primary care had 17 percent lower costs than those who did not receive such care.
Frail elders living in the community face numerous barriers, such as mobility limitations, to obtaining primary care and needed social services. As a result, these elders are at risk of developing acute problems requiring hospitalization and/or institutionalization.
Barriers to primary care: Severe mobility limitations, social isolation, low income levels, and transportation difficulties make it difficult for frail elders to travel to physician offices. Consequently, frail elders are less likely to receive close monitoring and more likely to seek treatment only when problems become acute. These elders are at high risk of life-threatening acute episodes that require hospitalization and institutionalization.
Complex problems of frail elders challenging to primary care physicians: Even if frail elders do seek office care, primary care physicians often lack the time and/or skills needed to deal with multiple complex problems such as dementia, congestive heart failure, diabetes, functional impairment, and end-of-life care.
The Medical House Call program includes teams of geriatricians, nurse practitioners, and social workers who make house calls to frail elders. The goal is to identify and treat potential medical and social problems early, thereby avoiding the need for costly hospital or emergency care.
Key elements of the program are described below:
Eligibility: Eligible patients are individuals aged 60 and older who live in one of eight underserved zip codes near the Washington Hospital Center and who have difficulty traveling to a doctor’s office due to physical, social, or mental limitations.
Referral: Participants are referred by home health care providers, community social service agencies, Washington Hospital Center staff, and word-of-mouth. If a geriatrician in the program attends to an eligible inpatient at Washington Hospital Center, that patient is often enrolled after hospital discharge.
Primary care role: Each Medical House Call team consists of two geriatricians, two nurse practitioners, one social worker, and two office support staff. All patients must agree to obtain primary care from the Medical House Call program. If the patient has another primary care physician, the patient notifies the physician and medical records are transferred to the Medical House Call program.
Ongoing medical care: Program participants are assigned a primary Medical House Call geriatrician and nurse practitioner.
- Visit frequency: The geriatrician performs a comprehensive initial visit and subsequently visits the patient at least every 4 months. Nurse practitioners make interim scheduled follow-up visits at least monthly. The severity of patient illness determines visit frequency, and nurse practitioners also provide urgent care visits on weekdays. An office staff member calls to remind the patient of the appointment the day before the house call visit.
- Care provided: During each house call, the clinician evaluates the patient for changes in cognitive and functional status and monitors all chronic illnesses. House calls serve as a replacement for most office and urgent care visits. Common conditions treated during urgent care visits include simple pneumonia, fever, cellulitis, chronic osteomyelitis, or dehydration.
- Supplies: Clinicians carry a modern version of the “doctor’s black bag,” including a portable scale, blood pressure cuffs, a pulse oximeter, a phlebotomy kit, a wound care kit, an ear syringe, replacement gastric feeding tubes, and various medications. Clinicians use portable technologies, such as a Doppler ultrasound to assess blood flow and a portable electrocardiogram machine, to diagnose and treat patients at home. They also carry a laptop computer and access a wireless electronic health record in real time, which allows access to hospital data as well.
- Social services: Social workers offer in-home counseling and caregiver support; coordination of resources for meals, home health care, and respite care; coordination of financial assistance; and case management for patients enrolled in the Medicaid waiver program. (Note: Because Medicare reimburses only for physician and nurse practitioner home visits, social work visits are provided mainly to patients in the Medicaid waiver program; a limited number of social service house calls are made to nonwaiver patients.)
Weekly team meetings: Weekly meetings include the Medical House Call medical and social work staff, team coordinators, the office nurse (a licensed practical nurse), a Visiting Nurses Association liaison, and the hospital’s home durable medical equipment and pharmacy partner. At these meetings, the team reviews care plans for new, unstable, and hospitalized patients. Each case typically involves managing complex medical and social issues.
Inpatient care and specialty visits: If acute hospital care is needed, patients are admitted to an inpatient geriatrics unit at the Washington Hospital Center, where the same geriatrician who conducts the house calls provides inpatient care. The Medical House Call coordinators also arrange specialty care and procedures at Washington Hospital Center as well as transportation when necessary. Patients can continue to visit specialists at other institutions if they wish.
Excluded services: Medicare does not reimburse for most intravenous (IV) antibiotics and other IV medications administered in the home; this means that use of IV medications are limited to episodic push of IV diuretics for patients in congestive heart failure.
The program has resulted in reduced costs for program participants, shorter lengths of stay for patients who require hospitalization, and a greater percentage of patients who die at home rather than in the hospital.
Lower costs: This type of home-based primary care (HBPC) lowers Medicare costs for ill elders, according to data provided in August 2014. Elders who received HBPC had 17 percent lower Medicare costs, averaging $8,477 less per beneficiary over 2 years of follow-up than the control group. Medicaid costs for House Call patients are 40 percent less than for similar patients in Washington, DC, nursing homes. Data provided in April 2009 indicated that Medicaid costs of nursing home-eligible patients in the Medical House Call program averaged $42,000 per year, compared with the $70,000 annual cost to Medicaid for a year in a Washington, DC, nursing home.
Shorter, less intense hospital stays: Hospital stays for program participants are an average of 2 days shorter since program implementation; according to data provided in April 2009, length of stay decreased from 8 days to 6 days in a pre/post-implementation analysis. Furthermore, fewer than 5 percent of program participants who are hospitalized require care in the intensive care unit.
Death at home rather than in the hospital: The program helps participants who are terminally ill die in comfort and dignity at home. Sixty percent of all program participant deaths occur at home, 10 percent occur in inpatient hospice, and 30 percent occur in the hospital. By contrast, only 10 percent of deaths occur at home for non-House Call elders in Washington, DC.
Resources Used and Skills Needed
The resources required to develop the innovation include the following:
- Staffing: Two interdisciplinary teams care for about 600 patients. Each team consists of two geriatricians, two geriatric nurse practitioners, one geriatric social worker, and two office staff. Each nurse practitioner makes 30 to 35 house calls a week, while each physician makes 15 to 20 house calls per week. The geriatricians share on-call duty and are available 24 hours a day/7 days a week by phone for urgent events.
- Costs: Data provided in April 2009 indicated that each House Call team costs approximately $600,000 to $700,000 per year. The Black Bag supply costs are $8,000 to $10,000 per clinician. The laptops and information technology support for the portable electronic health record is approximately $2,000 per machine plus annual information technology support expenses.
- Financial implications: The hospital suffers financially if the program is successful in preventing admissions. However, the hospital benefits from a reduction in inpatient length of stay. In addition, the program has been a source of new patient business for the hospital, because House Call participants, who have designated House Call geriatricians as their primary care physicians, are now admitted to the Washington Hospital Center when they require inpatient care. Estimates indicate that the program is responsible for admitting approximately 100 new inpatients each year.
There is virtually no capitation contracting in the Washington, DC, area, meaning that the Medical House Call program operates under fee-for-service reimbursement arrangements. The program accepts Medicare, Medicaid, and commercial coverage (except health maintenance organizations); Medicare covers more than 88 percent of patients enrolled in the program, with 40 percent also eligible for Medicaid. Most payers reimburse home visits, with nurse practitioners reimbursed at 85 percent of the physician fee; however, payers reimburse the program only for the visit itself, but not for travel time, team meetings, or care coordination/case management services. Contributions from private philanthropic organizations have helped sustain the program over time. The program also receives $1,800 per patient per year for Medicaid Waiver patients as part of a Home and Community-Based Services Waiver contract under Medicaid section 1915(c).