After arriving at Dennis “Gus” Nelson’s home in north-central Omaha one sweltering afternoon, Dr. Rebecca Wester began checking her patient’s vital signs.
“I think my appetite’s come back,” said Nelson, 75. He calculated he was up 8 pounds since returning home in June after five months in the hospital and a skilled nursing facility.
Wester said his gains meant he was rebuilding muscle, and with it, strength.
Meanwhile, Ashley Stein-Mayne, a medical assistant, had opened her laptop on the kitchen counter and was going over Nelson’s medications with his wife, Shyrl.
Although the scene — minus the computer — might seem like a vignette from days gone by, it was just another day outside the office for Wester and the Methodist Physicians Clinic House Call Program team.
Methodist Physicians Clinic launched the program in mid-April after identifying a gap in care for frail patients with complex chronic illnesses — particularly those who need support transitioning home after leaving the hospital or a skilled nursing facility.
A key goal is to help such patients avoid return trips to the emergency room or the hospital, which can be costly both in terms of dollars and patients’ independence. Frail seniors who return to the hospital can suffer cognitive and functional declines, leaving them less likely to go back home.
“People don’t want to have that,” Wester said. “They just want to get well and be at home.”
Home, in fact, once was where most doctor visits took place. Dramatic changes in health care and in society, however, sent house calls the way of the black bag, dropping from 40 percent of physician encounters in 1930 to less than 1 percent by 1980, according to a 2009 study in the journal Clinics in Geriatric Medicine.
Although still not commonplace, house calls today are seeing a steady uptick, said Dr. Eric De Jonge, director of geriatrics at MedStar Washington Hospital Center in Washington, D.C., and co-founder of the hospital’s medical house call program.
House calls billed to Medicare increased from about 1.5 million in 2000 to 2.6 million in 2015, according to data compiled by the American Academy of Home Care Medicine. That compares with the approximately 1 billion office visits billed each year.
The driving force, De Jonge said, is need, particularly among Medicare patients over age 80 who have multiple illnesses and difficulty getting to a doctor’s office.
Changes in Medicare billing that made payments for house calls comparable to those for office visits also provided momentum. In 2012 the federal government launched a Medicare demonstration project that allowed house call programs that reduced costs while meeting six quality metrics to share in savings, similar to Medicare shared-savings programs now in place in doctors’ offices.
“That’s a real game changer because you get rewarded for keeping people out of the hospital,” De Jonge said.
Several studies, including one De Jonge co-wrote, indicate house calls can save on health care costs. His study found a 17 percent savings equaling $4,200 per patient per year. Another reported a 13.4 percent cost savings in a Department of Veterans Affairs home-based primary care program, which reduced hospital readmission by 21 percent. Other studies have reported mixed results.
The results of the first two years of the Medicare project indicated that the program, which involved 10,000 patients, reduced spending by $32 million, De Jonge said. Reducing hospital readmissions was one mark the practices had to meet.
Home visits generally are covered by commercial insurance. Blue Cross Blue Shield of Nebraska officials said a service such as Methodist’s is invaluable to patients leaving the hospital or skilled care. Patients can avoid trips to the emergency room, and doctors can provide better, more cost-effective care because they already know the patient’s medical history and medications.
Methodist’s appears to be the only physician-led program making house calls on a regular basis in the Omaha area. Most home care is provided instead by home health agencies and services.
Some health systems also have programs to help patients make the transition home. CHI Health, for one example, has a team of nurse practitioners with a physician as medical director who care for patients discharged to skilled nursing facilities.
Some doctors may make occasional house calls. Family medicine residents are required to complete house calls as part of their training. Residents at Nebraska Medicine-Clarkson Family Medicine, for example, complete several each year, accompanied by a faculty physician. A doctor who has a local concierge practice also has been known to visit patients’ homes.
The bulk of doctor house calls, however, still are being made by a relatively small number of physicians. Family physicians, on average, make less than one house call a week, according to a survey by the American Academy of Family Physicians.
Dr. Arif Sattar, who started Nebraska House Call Physicians in Lincoln in 2005, makes house calls — to patients’ homes or skilled nursing facilities — full time. For most, he serves as their primary care physician. He estimated that some 60 percent of his patients are homebound, either temporarily or on an ongoing basis.
He or one of his staff is on call 24/7, although they typically don’t visit patients outside office hours. He said his team has prevented emergency room visits and hospitalizations by catching illnesses before they become serious. They also follow patients discharged from a hospital or skilled nursing facility closely once they do come home.
Wester, a geriatrician who had been making house calls on her own for a number of years, said house calls put the team in the home where they can see what’s going on. They can assess safety and watch for signs that caregivers need a break, among other things.
Rather than taking over a patient’s care, however, the Methodist team works with the patient’s primary care physician, specialists and home health services, updating medical records from a laptop so they’re available immediately for the patient’s other health care providers.
“We’re just trying to get them back to thriving with their primary care physician,” she said.
Available by physician referral only, the Methodist program also includes a 24/7 hotline that patients can call to connect with Wester. If a call comes in at night she can either guide the patient and caregiver through the problem or go to the home.
And because she’s a doctor, she can order medications or procedures — say, a new antibiotic for a patient who is developing a fever, or an IV for one who needs hydration. A home health nurse, on the other hand, would have to contact the patient’s physician and wait to get an order. And sometimes, a patient can’t wait.
“Before this program, and without this program, every one of these phone calls would be an emergency room (visit) and most likely a hospitalization,” she said.
Shyrl Nelson said having the hotline available was a big relief.
“When my first child came home, I was scared to death, and my baby was healthy,” she recalled. Her husband, on the other hand, came home too frail to get out of a chair unaided. He had walked an hour or more a day before he was sidelined by pneumonia and a string of complications, including blood clots in his lungs and legs.
He’d retired in 1999 after teaching high school business in Madison, Nebraska, for 35 years and farming for 41 years. She worried that she wouldn’t know what to do if a problem arose when they were home alone.
“To know that we could call — oh, my goodness,” she said.
Said Gus Nelson, “You have no fear when you go home, because you have the program behind you.”
The three-member team, which will expand this fall, typically follows patients for 30 to 60 days, with an intensive phase with daily to weekly visits for the first 30 days followed by a 30-day oversight phase where Wester is available as needed. The team can support 40 patients at a time — 20 in the supportive phase and 20 in the oversight mode. So far, 25 patients have completed the program.
In addition to addressing physical health, the team also includes Nichole Ridder, a transitional care coordinator who helps the patient and family navigate the health care system, from adjusting insurance coverage to arranging transportation. In Nelson’s case, she’s working to reduce the $1,500 monthly tab for his blood thinner injections.
Said Wester: “Whatever the roadblock to their success (in order) to thrive at home, we put a plan in place.”