Until the mid-20th century, doctors routinely made house calls, treating patients in their homes for everything from childbirth to end-of-life maladies. But that began to change after World War II and by the late 1960s, it was mostly a thing of the past.
As healthcare costs balloon nationwide, doctors and hospitals are beginning to realize treating some patients at home is a cost-effective means for reducing emergency room visits and readmissions.
Enter the nonprofit Home Centered Care Institute, which has developed a curriculum for doctors, nurse practitioners, physician assistants and their office staffs. The curriculum, which currently is offered by eight medical institutions across the country—including The Perelman School of Medicine at the University of Pennsylvania—trains providers and support staff to run a home centered care practice efficiently and profitably by giving guidance on everything from scheduling to medical coding and billing.
The Perelman School is implementing the program beginning this fall. The curriculum includes a two-day classroom course coupled with field training under the supervision of practitioners who have made house calls an integral part of their practices.
Dr. Bruce Kinosian, an internist and gerontologist who is heading up the HCCI program at Perelman, said a five-year demonstration project by the Centers for Medicare & Medicaid Services—which included the University of Pennsylvania, among other institutions around the country—showed that providing primary care at home results in significant cost savings by reducing the use of emergency rooms and readmissions to hospitals. In fact, he said, the Independence at Home project was the “most broadly successful primary-care demonstration.”
Congress is expected to extend the project for two years nationally. But Kinosian said more practioners are needed to provide the service, which is designed for elderly and homebound patients with chronic and complex conditions who are unable to regularly travel to doctors appointments or who are unable to abide by medication schedules on their own.
“We’re really excited about the curriculum. The mission is to produce a workforce to make Independence at Home a real program for Medicare,” Kinosian said.
Kinosian said the HCCI curriculum will include an ongoing mentorship program and multiple training modules in addition to the initial course, along with assistance to provider’s. Kinosian envisions two types of practioners: one who incorporates house calls into a broader practice, whether private or hospital or nursing facility related, and a second who does nothing but house calls.
“The real growth is going to be where practioners carve out a half-day or several half-days a week” to make house calls,” he said.
The care goes far beyond what is broadly available now to Medicare and Medicaid recipients as well as those covered by private insurance and is not limited to follow-up care after a patient has been released from a hospital or rehabilitation facility.
“With the advances in mobile tech, a house-call provider can now deliver pretty close to the level of services one gets in an emergency room,” Kinosian said. “There are mobile X-ray companies, pocket-size blood analyzers, ultrasounds. One can get a rhythm strip off an iPhone and an EKG [electrocardiogram] off an iPad. Much of what one gets in an ER you can get at a patient’s home in real time.
“The real focus isn’t acute emergency. It’s longitudinal primary care.”
In addition to Perelman and MedStar, Cleveland Clinic, Icahn School of Medicine at Mount Sinai Hospital in New York, Northwestern University Feinberg School of Medicine in Chicago, University of Arizona Center on Aging in Tucson, the University of Arkansas for Medical Sciences in Little Rock and the University of California, San Francisco, are offering HCCI Centers of Excellence for Home‐Based Primary Care training.
HCCI spokeswoman Tracy Hulett said the goal of the institute is to make sure “people in this country—the chronically ill, the high-risk—have access to the best kind of healthcare possible” and eliminate emergency room visits for basic care.
“We know those patients are incredibly costly and they’re not getting optimum care. When you’re really sick and frail, the hospital is the worst place for you,” Hulett said.
Hulett said research indicates that in order to reach half the people who need home-based primary care, “we need to add an additional 1,000 clinicians every year for the next five years. Obviously that also means more practice management staff who can do the scheduling and the coding.”
The demonstration project that began in 2013 identified a small number of practices to provide home care. A baseline of expected expenditures was set and the practices were told they could receive incentive payments after meeting a minimum savings requirement “as long as you meet clinical care and patient satisfaction standards,” Hulett said, noting that savings for some patients was as high as $30,000 but even saving a few thousand dollars per patients makes a huge difference.
In 2014, 10,000 doctors billed Medicare for house calls with the vast majority of those calls made by 1,000 clinicians.
The push now is being made by hospitals because of the federal government’s decision to penalize hospitals for frequent readmissions.
“So if Mrs. Smith is released from the hospital June 1 and goes back June 23, the hospital gets penalized. It’s in the best interest of the hospital to keep Mrs. Smith from coming back. One of the ways to do this is home-based primary care,” Hulett said.
Kinosian said managed care organizations also have realized the value of home-based primary care but the number of individuals available to provide that care is limited.
“There aren’t a lot of providers to do this,” Kinosian said. “This kind of training will offer nurse practioners as well as doctors and physician assistants a path to move into a career as well as practice managers. It’s really a team activity to manage these patients.”
The HCCI training was not offered to medical students and residents in general but Perelman did invite several residents to participate, according to a spokesperson.