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Going home: House calls to return with reform?

/ Source: The Associated Press

The doctor doesn't look like much of a crusader, bent over the frail frame of 90-year-old Alberta Scott.

He has a lavender stethoscope strung round his neck and some serious bedside manner at work on this stubborn nonagenarian who wants to be anywhere but where she is: in a nursing home bed, hoping to heal and get back home.

"Squeeze my hand," Dr. Peter Boling prods. "Squeeze my hand. Come on. Hard!"

This is Boling's day job, providing medical care to some of Richmond's oldest and sickest patients. A geriatrician and head of general medicine at Virginia Commonwealth University Medical Center, he visits nursing home patients with a smile, and he leads a team of specialists who take to the road, medical bags in hand, to see patients where and when they need it most — in their own homes, before a crisis lands them in the ER or a nursing facility.

Boling and his team make house calls.

And now he is on a mission: To convince Congress that the old-fashioned house call could be a fresh answer to the modern-day health care reform dilemma.

There are house-calls programs here and there. San Diego. Boston. The Veterans Health Administration cares for thousands in their own homes, saving money by reducing unnecessary hospitalizations and emergency room visits.

But Boling wants to bring house calls to the masses — up to 3 million of the most high-risk, high-cost Medicare patients in the country. The idea is not just cost-savings, but to provide a financial incentive to persuade more doctors to return to this kind of work. Mostly, it's about people like Alberta Scott and the questions that first came to Boling's mind when he heard she'd been admitted to an institution for treatment of a blood infection.

In a few weeks, if all goes well, can she go home? If so, who will take care of her?

House calls from bygone age

At 55, Boling has a vague memory of his own pediatrician standing in the kitchen of his childhood home. It's not an image many of us can conjure in an era of overcrowded ERs and specialty clinics.

The visiting doc went out not long after the horse and buggy, as technology advanced and institutionalized health care became the norm. In 1930, house calls accounted for 40 percent of doctor-patient encounters. Today, about 4,000 of the nation's 800,000-plus doctors make house calls a substantial part of their practices, the American Academy of Home Care Physicians estimates.

Boling was just a young doc himself in 1984 when a mentor persuaded him to spend half his time doing clinic work, and the other half developing a house-calls program. He hung a giant map of Richmond on his office wall and began identifying patients who lived within a 15-mile radius of the downtown VCU medical center.

Each home was marked on the map with colored pins, and visits were scheduled by geography to maximize Boling's time. It took only a few stops, and some memorable patients, for Boling to recognize that home care made sense.

Take the stroke victim restricted to a second-floor bedroom in his home. Time and again his wife had to call an ambulance, whose crew carried him by stretcher down rickety stairs to an emergency room — for a bloated gastrointestinal tract, high fevers and vomiting. Turns out, the patient had low blood potassium levels.

"It was so stark," says Boling, "the contrast between what he needed and what (the health care system was) giving him."

Support from Republicans and Democrats

It's that type of patient that Boling envisions being cared for under the proposal pending in Congress. The so-called "Independence at Home" provision is but one small piece of the larger health care reform measures.

Where other proposals have divided lawmakers, the house-calls idea is winning support from Republicans and Democrats alike as a "more cost-effective way for these patients to get the coordinated care they need," says Sen. Richard Burr, R-N.C.

The provision calls for the Medicare program to partner with home-based primary care teams to test whether house calls would reduce preventable hospitalizations, ER visits and duplicative diagnostic tests for high-cost, chronically ill patients.

That means patients with at least two chronic conditions — congestive heart failure, diabetes, dementia, stroke and so on — who have been hospitalized in the past year and require assistance for at least two daily living activities, such as bathing, dressing, walking or eating.

Patients with multiple chronic conditions account for some two-thirds of Medicare, the almost $500 billion federal health insurance program for seniors.

Cost savings from VA's house calls program

The Department of Veterans Affairs launched its own house-calls program back in the '70s targeting an expanding population of older veterans suffering from multiple chronic conditions. There are now some 20,000 vets enrolled, and a 2002 internal study showed a 24 percent total reduction in their cost of care. Another analysis of one program in Missouri showed costs going from $45,000 per patient per year to $17,000, said Dr. Thomas Edes, who runs the VA program.

Medicare officials declined to discuss the house-calls proposal, but Mark McClellan, who ran Medicare under President George W. Bush, called the idea one that "could lead to cost-savings and better outcomes" for patients.

"It's definitely worth trying," said McClellan, adding that the strength of the proposal is that practitioners must demonstrate savings in their patients' medical costs in order to get a portion of the savings back from Medicare.

That might be easier said than done. Participating practitioners would have to coordinate care in a way that actually reduces all those visits to various doctors and hospitals and, McClellan said, "that's hard to implement in real-world health care."

Another challenge is persuading doctors to return to a practice that is unfamiliar to many and looks different in today's world.

Technology has certainly made the job easier. Electronic medical records are available via laptop computers. One bulky bag can carry diagnostic tools to test blood, urine and oxygen levels, a blood pressure cuff, an eye chart. Portable, digital X-ray machines and portable EKG machines are also available.

Cathi Smigelski, a VCU nurse practitioner on the house-calls team, says team members sometimes venture into areas known for drug trafficking. But that hasn't turned her off what she sees as a worthwhile endeavor.

"I believe in what we do. ... Peter always says, if all of you docs just did a few, we wouldn't have a phenomenal need. You're going to build a relationship with somebody special. And that person is going to get to a point where they're not going to be able to come see you.

Do you say, `Sorry, I don't want to see you anymore'? Or do you say, `Well, let me catch you on my way home'?"

Boling's one-man show has grown into a nine-person effort, with three doctors, five nurse practitioners and a social worker caring for about 275 patients with 50 waiting to get into the program.

Abbey puts 25,000 miles a year on her Honda Civic visiting one to six folks a day, patients like 83-year-old Edith Taylor, who's lived in the same gray clapboard house for 60 years — save the two-and-a-half years that she spent in a nursing home following a stroke.

"I was determined to come back to my home," Taylor said after a recent checkup. For the past six years, Abbey's been examining Taylor in the middle of a living room decorated with silk flowers and ceramic figurines. "She calls me. She gives me plenty of time to prepare for her. It's a great thing."

During the latest visit, Abbey took her blood pressure, listened to her lungs. But there are always important tidbits Abbey picks up just from being in a patient's home. When Abbey ventured into Taylor's kitchen to check her medicine box, she noticed some pills had gone untouched.

"You can learn so much about people, not just socially but also medically. You look at what they have. You see the interaction with caregivers. You look at the pills," Abbey says. "It's much easier to develop a medical plan of care if you know all these things."

Such was the case with Smigelski and Alberta Scott.

Smigelski first saw Scott in her home in late August, after she'd been released from the hospital for treatment of a low heart rate. The spunky 90-year-old told Smigelski that she had plenty of help from her friends at church. It took only a couple of visits for Smigelski to see that while Scott talked a good game, she was worse off than she let on.

"She's not eating the way she should. She's not participating in her personal care needs," Smigelski says.

Scott quickly deteriorated. She returned to the hospital for a small bowel obstruction and was discharged again only to come down with a urinary tract infection. Back in the hospital, doctors also detected the blood infection that requires two weeks of intravenous antibiotics, resulting in her transfer to the nursing home where Boling saw her.

That afternoon, as Boling examined her, Scott seemed small but still had fight. Her niece, Mary Cotton, was visiting from Washington, D.C., and told Boling that Scott desperately wants to remain independent at home.

"It's hard to make that decision," she said, noting that her aunt couldn't afford to pay someone to stay with her round the clock.

So Boling's team is working to get Medicaid to cover a personal care aide. That could take up to 60 days. Should Scott recover from the infection before that, Smigelski has arranged for temporary housing in an assisted living facility.

Ultimately, Smigelski and Boling hope that Scott can return home. If she does, she'll become a regular on the house-calls rotation. Boling knows exactly why.

"When I started making visits ... and I saw how poorly we were doing taking care of them and how much happier they were when we changed their care from the clinic to their home, I realized that for that group of people, it was just better," Boling says.

"It was just better to do."