Part of the Age-Friendly Health Care Special Report
(Editor’s note: This story is part of a series for The John A. Hartford Foundation.)
Margaret Birt, then 62, had routine surgery in 2006. But in the recovery room, she had complete cardiac arrest. Initially in a vegetative state, Birt regained much of her cognition. Her life, however, was never the same. She was left with no physical capabilities, needing constant care.
Rather than ending up in a nursing home, though, Birt lives at home in Wheaton, Ill. with her husband, Maurice. She receives primary medical care there, covered by Medicare, from Dr. Thomas Cornwell and his team at Northwestern HomeCare Physicians. They perform exams, chest x-rays and blood draws — all in the comfort of Birt’s home. “We’re very fortunate,” says her husband. Cornwell is also CEO of the Home Centered Care Institute, dedicated to mentoring and training home-based providers.
“When you are in someone’s home, you [as the doctor] are not the center, it is the person. It is on their territory. You have to be comfortable with a change in the dynamic.”
In addition to her Medicare-covered primary care, Margaret Birt requires 24-hour help from caregivers that the couple must pay for out-of-pocket. Without the generous long-term care policy purchased years ago, Maurice Birt says, he would be bankrupt.
House Calls: A Cost-Saving Measure
Margaret Birt is among the 100,000 older adults in the United States with complex medical conditions who receive their primary care at home. In 2015 (the most current data available) some 2.5 million house calls were made in the U.S., according to Health Affairs.
“Home-based primary care focuses first on a vulnerable and disenfranchised population, often older adults with multiple chronic conditions who also experience problems with basic activities of daily living [such as walking or dressing],” says Dr. Bruce Leff, director of The Center for Transformative Geriatric Research at Johns Hopkins University School of Medicine. “They are what payers refer to as ‘high need, high cost.’”
Prior to January 1, 2019, health providers had to document the medical necessity for why a house call was needed instead of an office visit. Medicare has since eliminated this requirement. Now it is at the provider’s discretion where a patient is seen, explains Cornwell.
“The main difference is house calls could not be done prior to this year for the convenience of patients who could easily get to the office. Now they can. Having said this, most house call programs have as their mission to serve patients who otherwise cannot get to a provider’s office,” notes Cornwell.
It may seem counter-intuitive, but giving these vulnerable patients individualized primary care at home saves money for the nation’s health care system, according to studies by Department of Veterans Affairs and the Centers for Medicare and Medicaid Services (CMS), among others.
“Now there is strong evidence that home-based care results in better care outcomes and better experience of care by patients and by caregivers, who often have a lot put upon them,” says Leff, who is working with colleagues to develop quality standards for home-based primary care. “It also has a pretty robust effect on reducing health care costs.”
The John A. Hartford Foundation (a Next Avenue funder) awarded Leff and colleague Dr. Christine Ritchie, in partnership with the Home Centered Care Institute and the American Academy of Home Care Medicine, a $1.5 million grant to foster and expand home-based primary care.
“What we’re focusing on is a population who is really in need,” says Brent Feorene, executive director of the American Academy of Home Care Medicine. “Even if the adult son could get mom to the doctor’s office, the average primary care practice is not equipped to handle the patients. The doctors don’t have time, and often [the patients] have psychosocial issues.”
Patients with dementia may experience fear and anxiety at a doctor’s office, for example, and be disruptive to others in the waiting room.
At least 2 million older adults would benefit from home-based primary care, according to Health Affairs. Because these patients have difficulty getting to an office visit, they frequently end up in emergency rooms or hospitals. Per-patient savings range from $1,000 to $4,000 annually through reduced hospital and nursing home stays, emergency room trips and specialist visits, according to research cited by the American Academy of Home Care Medicine.
According to the American Academy of Home Care Medicine, the CMS Independence at Home Demonstration, part of the Affordable Care Act, estimated that Medicare would save $10 to $15 billion total over a 10-year period if home-based primary care were extended nationally to those on Medicare who are homebound.
Benefits to Patients and Families
For patients with chronic conditions, in addition to the convenience of home-based primary care, “The biggest benefit is that the care is very well coordinated,” says Dr. Zia Agha, chief medical officer of West Health, a research and policy center focused on improving care delivery to older adults.
“You have a team of providers who are working together to provide services to you. There is a tremendous emphasis on delivering palliative care. We see a lot of these patients where mom used to be in the ER or hospital ten times a year, and now she has not had a single hospital admission,” says Agha. “That is the biggest advantage, to be helped at home and have the right care to allow them to have quality of life, and not be on aggressive medical services.”
Geriatrician Dr. Carla Perissinotto, medical director of UCSF Care at Home at the University of California, San Francisco, stresses that home-based primary care is person-centered by definition. “When you are in someone’s home, you [as the doctor] are not the center, it is the person,” she says. “It is on their territory. You have to be comfortable with a change in the dynamic.”
For example, she says, “In the clinician’s office, you very clearly know as a patient where you’re supposed to sit. When I go into someone’s home, I wait for them to tell me where to sit.”
She recently had a medical resident ask her what to do about a patient who was stuck in the hospital and becoming increasingly delirious, begging to go home. The hospital did not want to keep him and no nursing home would take him.
“I said, ‘Has anyone thought of taking him home?’” says Perissonotto. “’I can see him at home, we can get home physical therapy. Has anyone applied for in-home support services?’” Two days later, he was back at home where he and his wife have lived happily for 18 months.
“We’re spending billions and no one has asked, what are the barriers to being at home? That’s not rocket science,” Perissinotto says.
“I see this is mostly a high-touch field. But in order to provide quality care, you have to have high-tech capability,” Cornwell adds. “With my smartphone, I can do an EKG within a minute. We have x-ray services, lab services, ultrasound in the home to check things like blood clots in the legs or abdominal pain. I can have more done in the home with smart technology than most can do in the office. It’s having the technology that enables truly quality care.”
Obstacles to Expanding At-Home Care
Despite the growing evidence that home-based primary care is superior in terms of cost and quality for those with complex needs, only a fraction of eligible older adults are being served.
Huge swaths of the country have no home-based primary care, especially in rural areas in Idaho, Montana, the Dakotas and other states.
Most people who are homebound live at least 30 miles from a home-based practitioner. Experts point to two major obstacles: reimbursement and lack of physicians.
Providers of primary care at home, including physicians, nurse practitioners and physician assistants, see roughly six to 10 patients a day, compared to office-based physicians who see up to 25. Providers receive a modest amount more per house call (Medicare pays $10 to $30 extra), which usually does not cover the time spent driving or coordinating the care of these complex patients. In the traditional payment model, this has meant much lower salaries for home-based practitioners (unless they are subsidized by a health system), making it hard to attract doctors to the field.
But that is changing. The fee-for-service model is giving way to value-based payments, a flat-fee per patient for primary care, including home-based. Here, high-quality care is incentivized and more complex cases receive higher reimbursement. In January 2020, providers in 26 regions may voluntarily opt for this method of payment. Medicare also recently eased some of the record-keeping burdens on physicians making house calls by not requiring them to justify every home visit.
Beyond the reimbursement challenges, many doctors barely know of the field’s existence. Residency programs often do not require rotations in home-based medicine or even in geriatrics.
“When I say I’m a geriatrician, I don’t get ‘Wow, you must be brilliant’ like I would if I said ‘I’m a neurosurgeon,’” says Perissinotto. “A lot of it is how we as a society value older adults. And it’s exposure. We have to explain it’s very challenging work and it’s amazing.”
“If you’re going into medicine not with a procedural focus [such as surgery], but to have a relationship with the patient for many years, you find a home in home-care medicine,” says Feorene. “You’re seeing the patient’s surroundings, you get to know the elder’s story. We’re often there in the last three years of life, and we’re making a difference in that final chapter. For those providers looking for a Marcus Welby relationship with the patients, this delivers in spades.”
The field is growing. Feorene’s organization, the American Academy of Home Care Medicine, has 900 members, half of them physicians, one-quarter nurse practitioners and physician assistants and the rest being social workers and nurses.
Nurse practitioners are “flocking to the field,” he says.
To spread the word and develop best practices, the Home Centered Care Institute in 2017 created a national network of Centers of Excellence that includes the Cleveland Clinic, University of California, San Francisco and four others.
Cornwell urges consumers to ask their physicians and health systems to support home-based primary care and the new value-based payment programs.
“It would be wonderful to have a groundswell,” he says.
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