Housecalls for Frail Elderly: The Ultimate Patient- Centered Medical Home

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1 Housecalls for Frail Elderly: The Ultimate Patient- Centered Medical Home What is a housecall? Commonly defined as a doctor or NP/PA seeing a patient in their private residence, apartment or assisted living. Bennett Parnes MD Tom Lally MD History Pre-WWII 1º care delivered mainly through house calls US more rural Doctors not patients with access to transportation Most of diagnosis and treatment fit in black bag % of all physician visits were house calls 1

2 Decline after WW-II 1950 to 1980 from 10% to < 1% of all physician visits % of physicians ever make house calls Reasons: Changes in health care financing/specialization Growth of non-clinician Home Health care in Medicare Pts own cars or easy access to transportation in urban areas Office practice efficiencies, emphasis on productivity. Technology (labs, imaging) that require large fixed settings. High-tech= good medicine ; House calls= old fashioned medicine. Education: Home care not taught in medical schools. Resurgence The case for house calls Improved POC technology, mobile EHRs, faster wireless Aging demographics create demand Capitated models reward better care, reduced admissions 1998: new Medicare billing codes for home visits with 50% increased reimbursement (later for ALs) Home visits still <1% of physician Medicare visits but from 1.5 million in 2000 to 2.2 million in 2007 (~ 1.8 million AL visits) Most done by FPs Greatest growth in geriatricians 2

3 Current Rationale for House Calls Top 5% costliest Medicare beneficiaries are ~50% of Medicare expenses Can be identified based on hospitalizations, home health needs, ADL impairments, diagnoses Don t fit easily into traditional office flow 3 million Medicare beneficiaries cannot easily access physician offices and therefore lack optimal 1º care Advantages of a Housecall Compared to an Office Visit Provides access to care for pts that do not fit into conventional 1º care office Identify problems often missed in office: EtOH-ism incontinence early caregiver burnout triggers for falls social support issues ADL impairments Better medication reconciliation Generally more team oriented than 1º care Provider Perspectives better picture of what is going on with the pt and family than you can get in the office a more intimate relationship with pt and family and they trust you more better able to use family to improve life-health of pt quickly saw the need was enormous I realized this was the best way to care for frail elderly and it became a cause for me SH Landers, 2009 Current Models All: Low volume, high intensity Opposite of Primary Care VA Home Based Primary Care (HBPC) Academic Nonprofit Independence at Home Concierge Medicine Private Practice for frail elderly 3

4 VA: Home Based Primary Care The pioneers: began 1972, now widespread nationally Aim to reduce use of ER as primary care VA IT system facilitator of the program 96% men; 47% dependent for at least 2 ADLs; mean 8 chronic conditions inc 1/3 rd with dementia, 3/4 th with heart disease Interdisciplinary team approach inc physician, nurse, social worker, PT, pharmacist, dietitian, psychologist Outcomes 2002, pre/post enrollment: 62% fewer inpt bed days 88% fewer NH bed days Cost savings, 24% ($38K to $29K per person per year) % reduction in 30 day readmissions 29% fewer admissions, 79% fewer inpt days = much shorter stays Academic programs: Teaching and Research opportunities Minimal national requirements currently IM residents do average <1 housecall during training Growing/mature programs in selected medical schools (e.g., Mt Sinai, Virginia Commonwealth) for MS1s, 1º care residencies, geri fellowships Opportunity to learn teamwork rather than hierarchy Compared to private housecall practices: fewer pts/day, generally don t cover expenses Non Profit Model Generally funded by grants. Generally cannot cover their expenses. Some associated with non profit hospitals, often as a loss leader. Independence at Home (IAH) House Call based program in Sec 3024, Health Care & Education Affordability Reconciliation Act, yr demo project begins Jan 2012 for 10,000 highest cost Medicare pts > 2 high cost conditions inc CHF, DM, dementia, COPD, CAD, stroke Needs assistance with > 2 ADLs Providers accountable for: Cost savings first 5% goes to CMS, remainder split between CMS and providers Medical outcomes Pt/caregiver satisfaction If fully implemented nationally and cost savings similar to VA HBPC, then potential $15 billion savings annually 4

5 Outcomes Relatively few studies in literature, designs generally not rigorous or RCTs; typically pre/post Health impact Meta-analysis: Reduced mortality (Elkan R, BMJ 2001) New problems identified 95% of pts in home visits had new problem not identified in office setting ((Ramsdell JW, 2004) Higher function maintained (Stuck AE 1995 NEJM; Yudin J AAHCP presentation 2005) Some evidence for QOL, caregiver burden, satisfaction Outcomes: Hospital Utilization The Call Doctor Medical Group, San Diego (25 yrs): 59% ER visits The GRACE House Calls program, Indianapolis (5 years): 50% ER visits; 43% hospitalizations The Home Physicians program, Chicago (15 yrs): 35-60% hospitalizations The Montefiore House Call program, Bronx, NY (5 yrs): 42% hospitalizations Mount Sinai Visiting Doctors, New York City (14 yrs): 66% hospitalizations Geriatric Care of Nevada house call program (8 years): 27% hospitalizations The House Call program, Washington Hospital Center, Washington, DC (10 yrs): 25% inpatient LOS and 75% hospitalizations at end of life. NP interventions: 4 weeks post discharge NP led intervention, average 4.5 home visits: readmissions reduced by half (Naylor et al, JAGS 2004) Mt Sinai NP transition program within Home Visit Program: improved communication and satisfaction, but did NOT decrease LOS/readmission rate (JAGS 2011, Ornstein) Outcomes: Costs savings The Virginia Commonwealth Medical Center house calls program (23 yrs): 60% hospital costs. The Call Doctor Medical Group, San Diego (25 yrs): $1075 per capita savings Geriatric Care of Nevada (8 yrs): $750 per capita savings The Montefiore Health System House Call program, Bronx NY (5 yrs): 33% total costs. NP led intervention, average 4.5 home visits in 4 weeks post hospitalization: total costs reduced by half (Naylor et al, JAGS 2004) Modern Housecall Medicine 5

6 a little about me. Purpose College of Medicine Accepted a GI fellowship Offered Chief Residency Turned down fellowship are you ok? Moved to Denver in 2003 Chairman of the Practice Management Sessions at the AAHCP annual meeting 2010 To introduce to the medical community to a modern housecall practice. Sustainability of Housecall Practices Academic model. VAMC HBPC Concierge model Medicare Private Practice model Concierge Model only, no insurance accepted Don t care for sick patients. Difficult to recruit and maintain patients Disrupts the doctor patient relationship since the patient has so much leverage 6

7 What is a Modern Housecall Practice? A Self Sufficient practice that is dedicated to caring for chronically ill Medicare and Medicaid homebound patients. Solo Practice Housecalls All a provider needs Black bag Laptop with an EMR Cell phone Mapping program Fax machine Billing Service Great, now how do I add a second bag? PROS: Low barrier to entry, low overhead, flexible hours CONS: No time off, not scalable, limited response times 7

8 Modern Housecall Group First we need to understand some limitations of describing the modern housecall practice. There is significant convergence in traditional practices, the housecall field however, is still in its infancy and there is still significant variability in practice models. There are many ways to skin a cat Physician Housecalls, LLC Brief Description: Established 2003 Serves the Denver Metro Area (Longmont to Parker) 90% Medicare 60% Assisted Living/40% Private Residence 80% elderly, 20% young disabled 700 Active Patents, 50 new referrals/month Staff 2 Full time MD s 4 Nurse Practitioners 1 RN 1 Office Manager 1 Certified Professional Coder 1 Scheduler/Office Assistant What we provide Primary Care Urgent Care Transitional Care Palliative Care Wound Care Care Coordination Dementia Care Hospice and Home health Oversight In Home Testing (Labs, X-rays, Ultrasounds, ABI, EKG, ECHO) How is it set up? 8

9 The Office Housecall Medicine forces us to rethink even the most basic traditional office practices. Forget your definition of an office. Instead of thinking of the office as a place think of it as a set of functions. The necessary office function for a housecall provider does not include a reception area. What is a virtual medical office? Elements of a virtual office Secure access Redundant and backed up Computerized database capable of storing patient data, (EMR) Capable of exchanging information with multiple remote users Processing faxes Scheduling patients Communication Billing What is a virtual office? A network allowing multiple users in different locations to remotely perform the following tasks at least as efficiently as if they were in the same physical location. Concurrent use of the EMR Ability to receive, sign and resend faxes Integrated phone system (VOIP) Patient scheduling Billing and practice management software What is a typical day? 7:00-7:30 Office tasks, i.e., sign orders, review labs, review daily schedule 8:00 arrive at first pts home 8:50 Mrs. Second 9:40 Mr. Third 10:30 Mrs. Fourth 11:20 Mr. Fifth Lunch/Return Calls 1:00 Assisted Living Mrs. Sixth Mr. Seventh Mrs. Eighth Mrs. Ninth 4:00 Mr. Add on Urgent Home visit Average 25 phone calls per day, squeezed between patients 9

10 Top 10 Lessons Learned 1. Traditional advertising is a waste of $$, just do a good job 2. Housecall patients are as complex and challenging as any patient in medicine 3. Don t trust your billing company 4. It is more challenging to remove medications than to add them 5. Establish goals early and often 6. Patient satisfaction leads to provider satisfaction 7. Elderly patients can be really insightful 8. Work as a team member, not just the captain 9. 90% of your office patients aren t taking the meds you think they are 10. A trip to the pantry to find the salt is as effective as 20mg of lasix/d The Future Changing demographics will increase demand Need for more clinicians doing housecalls Need for more housecall education Reimbursement issues Websites: Independence at Home: IAHNow.com AAHCP.org Questions? 10