ORLANDO, FLA. — House calls are no longer a thing of the past.
Technology, which was largely responsible for the demise of physician house calls, is now the catalyst for their revival, Thomas A. Cornwell, M.D., said at the annual meeting of the American Academy of Family Physicians.
It is possible to provide quality care and make a good living doing house calls, he said. As a family physician with a full-time house calls practice in Chicago, he has made more than 16,000 house calls to more than 2,500 homebound patients. The job is rewarding, he said, but that is only one of the reasons he promotes house calls as a practice opportunity.
Another reason to consider offering house calls is the increasing need. The baby boomers are aging, and it is expected that the number of adults older than 85 years will quadruple by 2050.
About half of those in this age group typically require assistance with activities of daily living. Many homebound patients don't receive regular doctor visits, while similar patients in nursing homes average 11–12 visits per year.
Patients who receive medical care in the home also tend to receive better care. Diagnostic accuracy is enhanced when the patient is seen in his or her own environment, Dr. Cornwell explained.
For example, the physician can get a better sense of the patient's personality through pictures and religious symbols, which can be useful for improving communication. And a better sense of medical issues can be achieved by taking note of medications/medication bottles, the food available in the home, the presence of foul odors like urine, and potential fall risks.
He described one patient who had been receiving no benefit from an inhaler. A trip to the doctor's office would most likely have resulted in prescription changes or increased dosages, but a home visit and an examination of the inhaler and equipment used by the patient revealed that the patient was failing to remove the cap from the inhaler before use.
In one study, a home visit that was made following an office-based geriatric assessment yielded an average of two new diagnoses and four additional treatment recommendations, he noted.
Another benefit of providing house calls is the reduced need for hospitalization. Regular physician visits can prevent the need for inpatient care, which can improve outcomes. Numerous studies have shown that the elderly do not fare well in the hospital; several studies, for example, show that up to half of those who are admitted have functional decline not related to the admitting diagnosis.
Additional benefits of providing house calls include increased practice reputation and growth; tremendous potential for societal health care savings, mainly as a result of fewer hospitalizations and more patients remaining at home until their death; attractive financial incentives, including low overhead and recent increases in reimbursement for home care; and low liability, with a survey of more than 200 house calls doctors showing that none were aware of any lawsuits stemming from house calls, and a Web-based search in 2003 revealing only two such lawsuits, one of which was dismissed.
Patients tend to be very satisfied with physician visits at their home, Dr. Cornwell said.
Technological advances—such as the availability of home infusion therapy and portable equipment for x-rays and ultrasound—make home care viable for physicians. But you don't have to be technologically equipped to this level, because more than 95% of the care provided by a physician in the home is primary care, he said.
“What you have to be is a good primary care doctor,” he added.
House-Calls Practice: Getting Started
A successful house-calls practice requires research and thorough planning, Dr. Cornwell said.
First, set goals and objectives. A review of the reasons for providing house calls—such as increased demand, professional and financial rewards, increased practice growth, potential societal benefits, and improved care—can be helpful for initiating discussion regarding your goals and objectives, he said.
Next, he advised, consider four important issues:
▸ Geography. Determine the area to be serviced using town limits or zip codes, and adhere strictly to this, he advised. Straying outside the preset boundaries can be tempting early on, but will cause logistical problems as the practice expands.
▸ Time to be spent on house calls. Some physicians start slowly, adding half days or full days for house calls during the workweek, or fitting house calls in on the way home from work. Others have full-time house-calls practices. Determine in advance how much time you are going to spend doing house calls, he said.