On the Home Front
On the HOME FRONT
Leading Edge Physicians Endorse House Calls
By Francie Scott
Petite, vivacious Gabrielle Fish, DO, doesn’t fit the Norman Rockwell stereotype as she strolls down a street in North Philadelphia with medical supplies stuffed into a blue canvas bag slung over her shoulder. But there is a reason why her staff members have pasted her photo over the gray-haired Rockwellian doctor’s face in the picture that hangs in her office.
Dr. Fish incorporates many old-fashioned ideals into her medical practice. She makes house calls. She considers her patients as friends and knows their names. The doctor spends hours on the job, often knocking on the door of her first patient at 8 a.m. She may still be completing paperwork at the office at 8 p.m.
Although her practice dominates her life, Dr. Fish enjoys the satisfaction of knowing the status of her patients and coordinating their care.
“You get a complete picture of the patient,” she says. “Patient care is my No. 1 focus.”
Dr. Fish, who established VNA HouseCalls for the Visiting Nurse Association of Greater Philadelphia in July 1998, represents a new breed
of physicians who are cultivating a medical model from the past in the climate and soil of the present. Although their numbers are small, they are growing, and the Health Care Financing Administration (HCFA) recently increased their reimbursement rates.
This movement recognizes that most homebound patients find visits to a doctor’s office difficult. They do not ambulate easily, they do not drive, and they are distressed by changes in their routines. Because they are frail, they are vulnerable to exposure to infection. Most of these patients are medically complex and need more attention than the allotted 10 minutes many physicians provide. Some suffer from psychiatric conditions such as dementia, and their behavior upsets other patients in the doctor’s office.
“The patient ends up getting better care when the doctor goes into the home,” says Mike Struhs, vice president for marketing at the Call Doctor Company in San Diego.
Gresham Bayne, MD, the emergency room physician who founded the company in 1985, illustrates this claim with the story of a 98-year-old blind man. When Dr. Bayne responded to a 911 call he found the man was dehydrated, in shock and had a 70 systolic blood pressure. He questioned the man, who was mentally alert, and realized the condition was caused by a mistake with his medications. Because the patient could not read labels on his pill bottles, he had quadrupled his dose of a furosemide and dehydrated himself.
Patients like Veronica Messer, 83, of Philadelphia appreciate the house call program. She has heart disease and has suffered two strokes. No longer able to drive, Messer depends on public transport or family members if she leaves her neat-as-a-pin 11th-floor apartment with city views from every window. She suffers from equilibrium problems and has difficulty maintaining balance in the jolting movement of a bus. Cabs are out of the question for Messer, who ekes by on Social Security and spends her birthday money on medication.
“You feel lifted,” she says of Dr. Fish’s visits.
Some see the re-emergence of house calls as a movement to improve the quality of medical care in a society where patients often get lost in a high-tech jungle and their care is driven by profit margins.
“It is certainly very countercultural,” observes Constance Row, executive director of the Edgewood, Md.-based American Academy of Home Care Physicians.
“Many physicians feel they have to stay in their offices and see 20 patients a day,” Row says. “It is only a small group of leading edge physicians who are advancing (house calls).”
Dr. Bayne talks about more than quality of care when he explains why he prefers to make house calls.
“I’m absolutely convinced we are saving lives by getting to (patients) earlier,” he says.
His company makes around 1,700 house calls per month in the San Diego area, employs more than 20 clinicians and operates a fleet of six vans, fully equipped as mobile emergency rooms.
By keeping his patients out of the hospital, Dr. Bayne prevents exposure to nosocomial infections, a complication suffered by 30 percent of patients in most hospitals. When treated at home, patients are also spared the trauma of a hospital admission, and this can accelerate the recovery process.
Take the young child wheezing in the midst of a severe asthma attack, for example.
In the privacy of the home, familiar objects surround the child. Parents and favorite stuffed animals are there. The child cannot hear the screams of a gunshot victim in the hallway.
“It’s so much nicer,” Dr. Bayne says. “An emotional reaction makes the respiratory problem worse.”
George Taler, MD, director of long-term care at the Washington Hospital Center in Washington, D.C., agrees that house calls enable doctors to provide better care.
“You have a much better overall picture of the patient’s environment,” he says, explaining that he can assess the functional level of a patient’s home, identifying obstacles like steep stairs. He can evaluate a patient’s support network and sees how well they perform daily living skills, such as food preparation.
Dr. Taler also assesses a patient’s level of compliance and believes he has more credibility when he suggests lifestyle changes. He believes the relationship between physician and patient changes when the physician is on the patient’s turf.
“In the office or the hospital, patients are very much in the physician’s realm,” he says.
In a traditional practice, physicians “bounce” between rooms while patients change in and out of gowns and nurse aids take their vital signs. Physicians have only one patient to see in the home, and Dr. Taler says he spends that time educating patients and their caregivers in managing the disease. They learn about diet, medications and early warning signs of exacerbations.
“I can think of no better way to educate patients than in their homes,” Dr. Taler says, adding, “You bring the professional cache but also the sense of love, that you really care for this patient.”
Modern technology enables doctors to provide a high level of care in the home. Patients no longer need to go to a physician’s or a hospital outpatient department for many procedures, including minor surgery. Dr. Taler notes that doctors who make house calls in the 21st century do not represent “the quaint and romantic” model that people recall from their childhood. Contemporary physicians are more likely to carry a computer case than a traditional black bag.
Most doctors take high-tech equipment that permits them to do procedures in the patients’ homes. They include a pulse oximeter, a dopler, an electrocardiogram, point-of-care blood testing equipment, needles and bags to start IVs.
Dr. Taler’s bag weighs about 15 pounds. He also packs a digital camera that he uses to record insurance cards and photograph symptoms like skin lesions for specialists.
“My bag is the envy of the clinic physician,” Dr. Taler explains.
Dr. Bayne may bring a mobile X-ray unit to the patient’s home. Dr. Fish often stows her manipulation table and instruments to perform minor surgery in the back of her Ford Explorer. She says she carries her basic equipment in a canvas bag and stores back-up equipment in a large container in her truck.
Dr. Fish sees five patients on an average day and spends the remainder of her time coordinating care and catching up on paperwork. Length of the visit depends on the status of the patient and which procedures must be performed. Her patient load includes 300 patients whose average age is 79 years old. Dr. Taler takes care of 125 patients whose average age is 80. Both practices are growing and admitting younger patients. Dr. Bayne responds to emergency calls and may only visit some of the patients once.
Although the three physicians have shaped their practices in different ways, they all stressed the importance of a multidisciplinary approach to health care. Dr. Fish and Dr. Taler, for example, work on a visitation roster with nurse practitioners. In Philadelphia, Dr. Fish visits her patients every third time and nurse practitioners pick up the other two visits, which can translate into a weekly visit from a health care professional for many patients in the program. Clinicians at VNA HouseCalls meet in the late afternoon twice a week to share notes and evaluate the status of patients.
Members of the team also coordinate other needs, such as social service and medical specialist care. Dr. Fish works with a couple of dentists and an ophthalmologist who will take their equipment home, for example. Dr. Taler has teamed up with community caregivers, including a parish nurse and an LPN hired by the apartment complex many of his patients live in. They also attend team meetings.
While Dr. Bayne specializes in emergency medicine, Dr. Taler lists disease management as the focus of his practice.
Because she started a new program, Dr. Fish defined her practice the way she wanted it when she launched VNA HouseCalls. She enrolled 120 elderly patients from her previous job at the Allegheny Homebound Program, which was discontinued during re-structuring at the sponsoring facility, Elkins Park Hospital in Philadelphia.
Dr. Bayne’s emergency medicine background in a military, county and university hospital convinced him that “90 percent of the patients we saw did not need to be there” in the emergency room. He compared the access to primary care in the populations at all three hospitals and concluded that patients who had good primary care “saved huge” amounts of money, especially in respiratory diseases. Dr. Bayne believed he could provide timelier, more efficient and more economical care by visiting patients in their homes. He cited a recent case of a 6-year-old girl who fell off her bike on a Sunday evening as an example. A Call Doctor took care of the little girl for $200, compared with the average charge of $800 in an emergency room.
Row, from the American Academy of Home Care Physicians, notes that the current care delivery model “spends far too much money for far too little outcome.” She believes the return of house calls marks “a new middle ground” to take care of patients with chronic diseases. Doctors who make house calls believe they are better for the patient, the health care system and the doctor.
“It is wonderful,” Dr. Taler says of his house-call practice. “I get more satisfaction. I am taking care of friends and loving families…I get a real sense of caring for people, not managing an office.”
Francie Scott is senior editor of ADVANCE.