For infirm older patients, Medicare finds that personal visits can keep people out of the hospital
For many chronically ill older patients, house calls are replacing some hospital stays.
Across the U.S., home-based primary-care practices are sending doctors, nurses and other clinicians on regular house calls to older, infirm patients. The goal is to prevent costly hospital stays and admissions to long-term-care facilities, while improving the quality of care, especially for the sickest 5% of Medicare beneficiaries, who account for 50% of the federal program’s costs.
Unlike traditional visiting-nurse services, which step in for a few weeks after a patient is discharged from the hospital, the home-based primary-care model calls for continuing appointments. The patients, often frail and homebound, typically are struggling to manage multiple serious illnesses, such as dementia, congestive heart failure, stroke and cancer.
Evidence has mounted that primary care at home, though not inexpensive to provide, can be more economical than a constant cycle of emergency-room visits and hospital stays. According to a study published last year in the Journal of the American Geriatrics Society, Medicare costs for patients in a home-based primary-care program in Washington, D.C., were 17% lower than those for a control group, averaging $8,477 less per beneficiary over two years. Another study in the same journal, of Veterans Affairs home-based care, showed that it not only reduced costs but also led to higher patient satisfaction.
A promising program
The Centers for Medicare and Medicaid Services in June announced promising results from a Medicare demonstration project called Independence at Home, which includes 17 medical practices serving more than 8,400 beneficiaries. Providing home-based care with teams directed by physicians and nurse practitioners, the practices saved over $25 million in the first year. Under a so-called shared-savings incentive payment model—where care providers that meet a cost-cutting goal earn a bonus payment—nine practices whose expenditures were at least 5% less than their spending targets received incentive payments totaling $11.7 million.
The project is part of the Obama administration’s goal, announced earlier this year, of tying 50% of Medicare payments to alternatives to the traditional fee-for-service model by 2018. “Payers are rapidly moving to a system of value-based care, one in which providers will be paid only for services that meet certain quality standards,” says Bruce Leff, associate professor of medicine at Johns Hopkins University School of Medicine.
Independence at Home, which was recently extended for two more years, “is targeting the sickest beneficiaries, who are very costly and have large gaps in care coordination and many hospital admissions per year,” says Patrick Conway, the acting principal deputy administrator and chief medical officer of the Centers for Medicare and Medicaid Services. The teams are “getting into the home, adjusting medications, understanding the patient’s environment and detecting early if the patient’s disease is suddenly getting worse, so they can prevent hospitalizations and readmissions.”
The largest share of incentive payments, or nearly $8 million, was awarded to five medical practices of the Visiting Physicians Association, which reduced costs by an estimated 16.4% due to lower admissions, readmissions and emergency-room visits. VPA, a leading provider of house-call medicine and geriatric home health care, uses mobile lab, radiology and medical equipment, and provides hospice and palliative-care services at home.
Providing home-care services “is a very expensive proposition in the fee-for-service world,” says Robert Sowislo, executive vice president for governmental affairs at U.S. Medical Management, Troy, Mich., which provides management services for VPA. “But having the shared-savings model makes it more economically feasible to expand across the U.S.”
Mr. Sowislo says patients are more engaged in their care when doctors and other clinicians come to the home, “so they are following doctors’ orders more carefully.” They often reach out to program staff, which is on call 24/7, instead of calling 911 when they have concerns, he adds.
Cleveland Clinic, one of the participants in the project, was able to reduce costs in the first year, in part by lowering hospitalizations, 30-day readmissions and emergency-room visits. But partly because it had a relatively small number of patients the first year, it wasn’t able to meet certain thresholds to qualify for an incentive payment.
Cleveland Clinic house-call physician William Zafirau says the clinic has since expanded the number of patients it is treating at home and hopes to meet the criteria for incentive payments when data for the second year of the program is released in a few months.
Cleveland Clinic physicians in the program usually see six or seven patients a day, driving within a 20-mile radius. Dr. Zafirau says stable patients are seen by a doctor every two to three months, but sicker patients may get visits once or twice a week. The doctors do everything from cleaning wounds to monitoring infections and removing ear wax.
A success story
One of Dr. Zafirau’s patients, Al Teisler, 90, was hospitalized last November due to a plunge in blood pressure, and was diagnosed with an enlarged prostate. He was discharged to a rehabilitation facility for a couple of months, and “couldn’t wait to get out of there,” says his wife, Marge, 85.
But when he got home, he still needed a walker and a catheter for his bladder, “and navigating around was becoming a real challenge,” she says. Mr. Teisler was offered home visits, which included a monthly appointment with Dr. Zafirau, weekly visits from a nurse to check on his blood-thinner medications, and regular sessions with physical and occupational therapists to strengthen his arms and legs.
Mr. Teisler no longer has the catheter and is strong enough to do the physical-therapy exercises on his own. The doctor now comes about once every six weeks, and Mr. Teisler feels well enough for his wife to drive him to a facility where he gets his blood thinners checked. “He’s able to get around much better,” she says.
If there is a concern, Ms. Teisler calls the home-care program, and she says she always gets a response almost immediately. “They really seem to care,” she says.
Eiran Gorodeski, director of the Center for Connected Care at the Cleveland Clinic, says home visits often are more productive than office visits for elderly patients. “It’s hard to understand in a brief visit what barriers patients have, either because they don’t recognize the problems or they are too embarrassed to tell you,” Dr. Gorodeski says.
While doctors can see only a limited number of patients each day in their homes, compared with an office setting, the shared-savings concept means “you can make a living doing house calls,” he says.
Christiana Care Health System, in Wilmington, Del., also didn’t qualify for an incentive payment in the first year of the Independence at Home project. But Omar A. Khan, associate vice chairman of the department of family and community medicine, says Christiana learned valuable lessons, such as the importance of focusing on making sure patients’ medication lists are in sync after a hospital discharge to avoid problems that could lead to a readmission.
Dr. Khan says Christiana hopes to qualify for shared-savings payments in the future. But the most important thing, he says, is that patients “appreciate a system of care built around their preference to be at home as long as they can.”
Ms. Landro is a Wall Street Journal assistant managing editor in New York and writes the Informed Patient column. She can be reached at firstname.lastname@example.org.