Bringing Back the House Call

Years ago, as a family physician in Louisiana, I made house calls. Certain patients were too sick or too hurt to get to my office. Sometimes a condition or injury had worsened, requiring my evaluation bedside. I would visit patients at home for the simplest of reasons: home was where they needed care.

By the mid-1980s, the pressures of time and money prevented most physicians from making house calls anymore. But I kept seeing patients at home until I retired from my practice after 29 years. Home visits enabled me to better detect, diagnose and treat most health conditions. Many of the patients I saw might otherwise have wound up in an emergency room and eventually been admitted to a hospital.

If we hope to rein in health care costs and improve quality, we need, in effect, to bring back the house call. Americans are living longer than ever before and a higher percentage of the population is elderly, with both trends sure to accelerate drastically in the decades ahead. Baby Boomers are now turning age 65 at the rate of roughly 10,000 per day.

As the older demographic expands, so, too, does the number of people who live with chronic diseases, chiefly diabetes, high blood pressure and heart failure. About three in four of Americans age 65-plus suffer from more than one such chronic condition. The single biggest and fastest-growing contributor to healthcare costs is chronic disease. That’s why an estimated, 49% of our health care costs go toward 5% of Medicare beneficiaries.

Yet the U.S. health care system is still based on a massive misconception: that health care for the sickest of the sick, typically the elderly and the chronically ill, should be carried out almost exclusively in institutions, primarily hospitals, but also nursing homes and assisted living facilities. And that health care delivery should consist largely of, say, a trip to the emergency room or a four-day hospital visit for pneumonia. That kind of episodic engagement represents short-term thinking. When it comes to health care, hospitals are essential, but are only a part of the answer.

Rather, health care should be practiced year-round, and even minute-by-minute. Managing chronic disease should involve post-acute care, complete with daily monitoring of vital criteria, including blood pressure, diet and physical activity. Only under such regular oversight can chronically ill patients expect to function well, much less fully. No single approach can do this better than home care. It can shorten hospital length of stay and lower readmissions. And there is mounting evidence that health care delivered at home enables patients to live longer lives and, equally important, better ones.

In the process, home care is doing exactly what’s most needed — increasing quality and driving down costs. An Avalere Health study found in 2011 that health care at home improved outcomes and saved $2.8 billion among patients with diabetes, congestive heart failure and COPD. A 2009 study revealed that home health care reduced hospitalizations and short-term nursing stays, saving Medicare dollars. Indeed, expanding access to home health care for chronic-disease patients could save a projected $30 billion, that same study concluded.

Yet the value of home care remains under recognized. As a result, vast needs are still going unmet. Here’s what has to be done:

Define the discipline better. The medical community, including physicians, medical schools, and hospital administrators must better describe what home care does and why it matters in order to bring it to life for policymakers and family caregivers.

Get in sync. Primary care physicians particularly, but also nurses, therapists, social workers and others, must align better with home-care clinicians to coordinate care, especially during and immediately after the transition from hospital to home.

Physician, educate thyself. Physicians should learn about home-care options and discuss them with patients who could benefit.

Adopt new technologies. More companies in the home-care business should use innovative technology to coordinate care in real time, including point-of-care laptops, telemonitoring devices, and Internet portals for physicians that allow all providers to share a patients’ information.

Remove policy obstacles. Reimbursements from Medicare and private insurers should reflect the true value of home care. But the payment system now in place sees home care, quite mistakenly, as merely an add-on with little clinical benefit. Policymakers should create a payment model that aligns providers’ clinical and economic interests, assigning proper value to good outcomes and recognizing that home care is pivotal to success.

Health care at home is patient-centered, outcomes-driven and truly collaborative, making it a microcosm of how the health care system should function across the board. Only by embracing home care can we truly reform the health care system.

Michael Fleming, MD is chief medical officer of Amedisys, a home health and hospice care company focused on bringing home the continuum of care, and past president of the American Academy of Family Physicians. This post appeared previously in the HBR Blog Network.

10 replies »

  1. Back in the 90’s I used to make house calls and still did rarely after the year 2000. Including transportation, house calls take 3 hours. That’s 3 a day at most. I loved the experience and it was valuable , saved money,hospitalizations
    and built up a trusting relationship. However it is unaffordable except for the very rich.

  2. One of the most efficient ways to provide medical products and services is to use Doctors-on-call services which will provide much better coverage for patients. These solutions assist doctors in taking care of concerns for far more patients in a shorter amount of time, at a reduced cost 24/7.

  3. Great post! House calls are low tech but if that’s what the patients need, they should be given such care. Some are too old or badly hurt that they cannot go to the hospitals anymore. Nice job picking this topic!

  4. I agree that this is a wonderful post, especially the call to keep persons within their community (home) and to get all clinicians in sync in providing care. In your list of clinicians – physicians, nurses, social workers, therapists, and others – add the professional board certified chaplain. This is a discipline that has been overlooked in home health care and has much to offer. (Disclaimer: I’ve been a professional chaplain for over 30 years, working in community and academic hospitals and hospice – now a consultant for chaplaincy care and practice with HealthCare Chaplaincy in New York.) Many physicians, particularly associated with primary practice and home health agencies, are unfamiliar with what professional chaplains contribute to the care of patients. I’d love to see that area developed because our contributions can not only identify spiritual, religious, and/or cultural beliefs and values important to the patient and family (we listen, not preach), we are trained to work collaboratively with other members of the team so that the best care can be provided. We talk with patients about care preferences in language that they understand so that they feel comfortable about having the larger conversation with their doctor – and ensure that they know about the importance of advance directives. As the professionals who describe ourselves as “being comfortable with what is uncomfortable” we can facilitate family conversations and conflicts. The list goes on…but the bottom line is that we CAN do better care, and we must do it as a professional community.

  5. Thanks for your comments, Shirie and Diane. I think each of you is highlighting different sides our current paradigm that thinks of and incentivizes health care as a system of institutions and devices, not of patient outcomes and quality of life.

    I’ve always thought that when a patient is admitted to the hospital, they’re really being discharged from their community. There are many times when bringing a patient into that artificial environment is absolutely the right course of action. But the health care system has to realize that acute care is not the only course of action, and in many case – especially in regards to care for chronic conditions – there are safer, cheaper, better options in providing health care at home.

    I have many personal anecdotes of issues in the home that confounded care, and yet there isn’t an imaging device or lab test that can accomplish what a visit to the patient’s home can.

  6. Thanks for this post. I’m a geriatrician and I do housecalls as part of my direct-pay consultation practice.

    I do think there is a lot of potential to combine housecalls with remote care, so we can be both high touch and high tech. For instance, I manage a lot of the follow-up by phone, and could do even more if caregivers in the home could collect data electronically. (Most still prefer to write in notebooks however!)

    Also, although I’m not sure I want to be using smartphone devices in the actual exam room, they have a lot of potential to facilitate care when providers go into people’s homes.

  7. As my elderly mom has become more debilitated by age and chronic disease, she was just unable to go out to an office, sit in the waiting room and then wait in an exam room for a harried physician to see her. I was lucky enough to find an internal medicine doc who makes house calls. Now, she waits at her home. The doctor sets a two hour window for his visit. On his first visit, I waited with her and found the visit and exam to be unhurried and complete with black bag and stethescope. Now, the doc just emails me a report when he comes for his periodic visits. It’s been a blessing. Back to the future.

  8. This IS a wonderful post. And yes, house calls are low-tech but there was nothing like seeing a doctor walk into your home with the doctor’s bag with its stethoscope and various sundry instruments and bottles and that persona of wanting to be there and help you get better. Whether that was a fact and reality is something else, but you felt like help was there for you.

    High-tech procedures and therapies, ICUs, specialties, sub-specialties, hospitalists, medicalization — these things are good. They are very good at saving lives but there’s a drawback, the depersonalization and dehumanization of a person who happens to be a patient.

    And yes, everything is done to get folks home as soon as possible but the support system often isn’t there. Home care is more than going home; it’s offering some sort of help for those depleted and with chronic illnesses and for the caregivers who are caring.

  9. Wonderful post. I especially like your point about different kinds of providers coordinating out-patient care. Critically, the first days after discharge from a hospitalization. That is one of the most vulnerable times.

    Unfortunately, house calls are low-tech. The medical world gets much more excited about taking an elderly mans prostate out with a robot than providing the support he needs after the robot is done with him.