CHAPTER 10 HOME CARE
Practice of Geriatrics
CHAPTER 10 HOME CARE
George Taler, M.D. and Timothy J. Keay, M.D., M.A.-Th.
Benefits of Home Care
Developing an Office-Based House Call Program
Home care is the fastest growing sector of health services delivery in the United States.1 Medicare expenditures for home health care increased from $2.12 billion in 1988 to approximately $16 billion in 1995. Estimated national expenditures were $33 billion, or nearly one third of the total cost of long-term care services. The 1992 National Home and Hospice Care Survey conducted by the National Center for Health Statistics found that over 1 million patients receive in-home services on any given day.
Growth of home care services is stimulated by many factors and is expected to continue during the next several decades. Most patients (75%) who receive in-home services are over the age of 65; their average age is 70 years. For every resident in a nursing facility, there are three to four patients with conditions of equal medical complexity and debility residing in the community with the assistance of family, friends, and the intermittent services of home health care agencies. The swelling ranks of the elderly population, especially the oldest cohorts, will place increasing demands on supportive services.2 Changes in the hospital environment prompted by the prospective payment system and pressures from managed care organizations to reduce admissions and lengths of stay will dictate that most convalescence, rehabilitation, and terminal care be provided in post-acute care settings. But as restrictive policies imposed by state governments continue to limit the licensure of more post-acute care and long-term care beds, it is expected that an increasing proportion of these services will be delivered in the patient’s home.
Contrary to popular belief, a survey of primary care physicians shows that the majority make house calls, although they limit this practice to episodic visits to a few selected patients.3 However, a myriad of forces within the health care arena will probably lead to significant changes in the way home care is viewed by the medical community. Efforts to reduce the costs of care to the chronically ill are leading practitioners to explore increasingly more complex care in the home. Advances in technology resulting in miniaturization and automation of high-tech supportive equipment, such as ventilators, feeding pumps, dialysis machines, and medication delivery devices, coupled with a loosening of restrictions on location of service, have allowed patients with severe disabilities to remain in the community. Societal trends toward self-reliance, the financial implications of nursing home placement, and the increasing acceptance of long-term care insurance policies that include provisions for home care are stimulating the desire to gain access to these services.
BENEFITS OF HOME CARE
There are many advantages for both patient and physician in using home care. Patients who are appropriately included in home care benefit from the convenience of the physician’s visits. In addition, a house call obviates the costs of specialty transport and unwelcome public exposure. Furthermore, in-home supports improve overall health and both functional and cognitive status.4
Functional assessment is best accomplished in the environment in which the patient lives. Care-giver issues are more clearly recognizable, including the burdens of providing support, financial concerns, depression, and possibly abuse. The added costs and inconvenience of diagnostic testing and consultation promote a step-wise, algorithmic strategy that is generally more appropriate in geriatric practice. Finally, negotiating with patients on their own “turf” reinforces the importance of patient autonomy and ethical decision making and reaffirms the balance in the doctor-patient relationship.
House calls benefit the physician by adding an important dimension to the knowledge of the patient’s circumstances, by sharpening primary care skills, and by developing a greater appreciation for the costs and invasiveness of medical interventions in other settings. Ramsdell and colleagues5 found that an average of two new problems per patient were discovered among those who first underwent an interdisciplinary comprehensive geriatric assessment in the office and were subsequently evaluated at home. Twenty-three percent of these new problems involved potential mortality or significant morbidity and were distributed equally among medical, psychiatric, and safety concerns.
Another advantage is that the office practice is more predictable and more efficient when patients appropriate for house calls are seen at home. Physically impaired and behaviorally disruptive patients require additional office staff time to assist with dressing and mobility; it takes far more of the physician’s time to review a complex medical care plan (especially if the patient is not accompanied by the primary caregiver), to perform the examination, and to adjust the treatment regimen; diagnostic testing is more difficult; and problems frequently arise with continence. Following the visit, a stretcher-bound patient who occupies an examination room waiting for ambulance transport can seriously impede office flow. Also, a sizable home care practice can enhance the volume and efficiency of the group’s hospital practice. Homebound patients experience 0.5 hospital admission per patient per year, the highest rate among ambulatory patients and even higher than those in nursing homes.6 Once the acute illness has stabilized, familiarity with the range of in-home services and a willingness to visit the patient at home for follow-up care facilitates discharge planning. Also, home care may reduce hospitalizations among certain populations. Respiratory, cardiac, endocrine, and mental illnesses that result in repeat hospital admissions may all respond to intensive in-home monitoring and support.
DEVELOPING AN OFFICE-BASED HOUSE CALL PROGRAM
It is to the advantage of every primary care physician to develop the knowledge and skills that will enable him or her to manage patients at home. However, it is also necessary to develop a well-conceived and deliberate plan to run an efficient house call program.
Choosing Appropriate Patients for House Calls
The best candidates for house calls are chronically or terminally ill patients who have impaired mobility or disruptive behaviors (Table 10-1). Patients with dementia, terminal illness, or severe psychiatric disorders may decompensate in a public waiting room, causing discomfort for all involved. Terminally ill patients often find it a hardship to come to the office and are more effectively seen at home to address their physical and emotional needs. Bereavement issues may require more time than is convenient in the office and may have more meaning for the family when they are addressed at home. Other patients who could be considered for house calls are those with functional and caregiving problems that need to be addressed at each visit. Also to be considered are those patients to whom the physician is committed but who are chronic “no-shows” and thereby disrupt office scheduling.
TABLE 10-1 PATIENTS APPROPRIATE FOR HOME CARE
For some patients, house calls are indicated for only one or two visits. For example, when an illness has resulted in a significant change in function, a home visit following hospital discharge will highlight the appliances and services needed for support during convalescence and rehabilitation. Patients who fail to respond to what should be adequate therapy or whose response is inconsistent may benefit from a diagnostic home visit. In these perplexing situations, a house call will often elucidate nutritional problems or indiscretions, verify the purchase of prescribed medications, or reveal the presence of medications from other sources that interfere with the expected response. Situations in which there is suspected caregiver burnout or elder abuse are usually better assessed by a diagnostic house call.
Establishing an Office Organizational Structure
Two components are necessary to establish a successful house call program based in a private office setting. First is organizing the information flow, and second is establishing a house call team from community resources. The house call team is composed of the physicians who make house calls, the house call coordinator, representatives from the home care agency, and other health care professionals with whom the program has an informal working arrangement. The objective is to manage this aspect of the service spectrum with maximum efficiency and minimum disruption of the ambulatory practice.
HOUSE CALL COORDINATOR
A house call coordinator is the pivotal individual around whom the home care practice is organized. All calls are channeled through the coordinator, including those from patients and their families, home care agency staff, pharmacists, and vendors. Providing a central focus through which all information flows facilitates communication, saves everyone a great deal of time on the telephone, and assists in documentation. Emergency triage is managed through simple algorithms. The coordinator may offer the patients and their caregivers emotional support, encouragement, and practical advice from a lay perspective. Home care nurses can leave messages and updates, reassured that there will be a written note documenting their report and that true emergencies will be conveyed promptly. Telephone consultations between team members and the physician can be coordinated, ensuring that the parties will be available at the designated time and that the chart information for an efficient interchange will be accessible. The coordinator also organizes the correspondence, charting, and scheduling arrangements for diagnostic testing, delivery of medications and supplies, special clinic appointments, and consultations.
HOME CARE NURSING
The practice should align itself with a limited number of home care agencies—preferably just one. The choices are based on several factors, which include the service area involved, affiliation with the major hospital or hospitals where the physicians have privileges or nurse liaison services that facilitate discharge planning and communication with the agency, adequate size to provide timely services, and a solid reputation. For larger house call practices, the agency should be willing to assign the patients to a small pool of nurses, social workers, and therapists who may also participate in team meetings. This gives the physicians sufficient experience to learn the capabilities of the agency staff, and the agency can become more comfortable with the style of the physicians and their office routines. Likewise, the physicians and practice administrators can influence the policies and procedures of the agency to better coordinate their services.
Subacute problems that arise between visits can be managed effectively by initiating a nursing visit and in-home laboratory or radiographic tests, according to the history. The nurse can usually examine the patient within 24 hours and can provide an assessment. The information gathered through these sources provides a reasonably accurate basis for diagnosis and therapy. Subsequent nursing visits can be scheduled as often as twice daily for a short time. However, house calls are generally not appropriate for a patient with an acute and serious illness. An emergency department is better suited to evaluate efficiently a patient with unstable vital signs, acute delirium, or significant trauma. One exception is the patient with an imminently terminal disease who has elected to forego hospitalization. Because the medical care plan in such cases requires careful consideration and negotiation with the family, an intercurrent house call often results in more humane care for the dying.
OTHER TEAM MEMBERS
The physician should recruit the other members of the house call team and encourage them to attend regularly scheduled meetings. A community pharmacist can work in consultation with the physician to review drug profiles, monitor regimens through a drug-drug interaction program, and alert the team to the availability of new medications and formulations. By delivering medications and disposable supplies to the home, the pharmacist is more likely to increase the number of referrals to the business; by assuming responsibility for oversight of patient compliance as part of the team, account retention is ensured. Pharmacists who have earned a Pharm D degree can assume the management of selected regimens—for example, anticoagulation, pain control for hospice patients, and adjustment of insulin dosage for new-onset diabetics. Affiliation with the house call program can increase referrals from the practice as a whole. Similarly, a durable medical equipment vendor benefits by new referrals and by the built-in forum for marketing new products at team meetings. Regular meetings with the physicians and their staff greatly facilitates completion of the often complex and arcane certificate of medical necessity forms required for the vendor’s billing procedures.
HOUSE CALL TEAM MEETINGS
The house call team meetings are important for communication, interdisciplinary consultation, and timely completion of required documentation. A regular agenda facilitates the flow of information. While one physician reports on recent patient encounters, the others review paperwork associated with their house call patients and listen for information that may be pertinent for cross-covering. The nurse reports on the patients who require skilled services; the home care liaison supervisor conveys information from the physical therapists, occupational therapists, or other nurses who have seen patients under the practice’s care. The pharmacist reports on compliance issues and reviews any intercurrent changes in the medical regimen. Should new orders for nursing, medications, equipment, or other services be issued during the presentations, these can be written and signed immediately. Weekly meetings generally last an hour for programs that cover 100 patients.
Financial viability is essential to the success of the program. The first issue involves determining the size of the home care practice to ensure an appropriate number of calls to warrant the time commitment. The second pertains to ensuring appropriate remuneration for the services rendered.
TIME MANAGEMENT AND DETERMINING PRACTICE SIZE
Specific half-day sessions should be set aside for house calls, preferably at the same time of the week and during daylight hours. Coordination of the office schedule with staff and other practitioners minimizes overhead expenses. House calls made during normal working hours ensure ready telephone access to other providers and support personnel as well as safety. Recent surveys of physicians who are active in house call practice have found that the typical house call takes approximately 20 to 30 minutes in the home. Travel time should be minimized by defining a geographic radius divided into quadrants, each visited monthly, or by clustering patients along specified routes. The physician should have a copy of the calendar and plan the return visit at the conclusion of each house call. This allows the flexibility to see the patient as often as appropriate for his or her condition, coordinate the visit with other house calls in the neighborhood, fit the visit into the family’s schedule, and prevent physician overscheduling.
Five to seven patients can be seen in their homes in a half-day session; 10 to 12 patients can be seen when multiple visits can be scheduled in a few locations. Therefore, the size of the practice is determined by either the number of available half-day sessions or the number of patients available to the practice. Generally, a half day per week is sufficient to manage 60 to 80 patients who are seen quarterly for routine visits and as needed when their condition is less stable.
ENSURING APPROPRIATE REMUNERATION
The current procedural terminology (CPT) descriptions for house call services are listed in Table 10-2. Because homebound patients are most similar to those in nursing homes (i.e., they have multiple concurrently active diagnoses), the higher code numbers are most often applicable. Documentation is the key to verifying the requested remuneration. Records of telephone contacts with patients, family, and home care staff, as well as team meetings are advisable. Progress notes should include historical data, physical examination findings, pertinent diagnostic test results, a therapeutic reassessment reflective of all active diagnoses, an evaluation of the patient’s functioning, caregiver issues, and evidence of a medical care plan for the ensuing period. There are no Medicare restrictions on the number of visits as long as there is sufficient justification in the progress notes.
TABLE 10-2 CPT CODES FOR HOME VISITS
As of 1995, Medicare has agreed to pay on a monthly basis for care plan oversight (CPO) at a rate comparable to that allowed for a high-level, established-patient home visit. Criteria defining eligibility for remuneration under the CPO code are different than those used for any other evaluation and management service; early experience suggests that approximately one quarter of the home care case load may be eligible. The patient must be under the active care of the physician as demonstrated by a face-to-face encounter within the 6 months prior to the initiation of CPO billing and must be under the care of a Medicare-certified home care agency for a Medicare-covered service (for example, home infusion therapy is excluded under Medicare, and so is excluded under CPO as well). A minimum of 30 minutes per calendar month of documented time devoted exclusively to the coordination, monitoring, and adjustment of the medical care plan is needed.
Billable time includes only interactions with other health professionals through meetings, telephone calls, or review of correspondence and medical records beyond that needed for routine care. Services usually provided as part of follow-up care after office or home visits do not contribute to CPO time. Therefore, telephone calls with the patient or family, contacts with other office staff, and routine matters, such as prescription renewals or signing home care agency orders, may not be counted. CPO may not be billed for care covered under a global fee arrangement, such as for follow-up of a surgical procedure or services provided by the medical director or an employee of a Medicare hospice. Finally, certain professional relationships may exclude physicians from billing under the CPO code. Physicians who hold a 5% or greater ownership share in the home care agency providing services or receive more than $25,000 in compensation from the agency are not eligible to bill for CPO provided through that agency. Because CPO is a new code with a novel set of criteria, the Medicare intermediaries are likely to scrutinize carefully the documentation supporting the charges, underscoring the importance of maintaining comprehensive medical records.
A medical director contract with a home care agency is a different way to enhance practice revenue. Such contracts require approximately 4 to 8 hours a week for chart reviews for quality assurance purposes, in-service training for the agency staff, liaison with other physicians, and policy review and development. Criteria must be met to ensure compliance with certain “self-referral” statutes enacted in many states. It is prudent not to own stock in the home care agency or any other entity that is financially aligned with it. No more than 25% of the home care agency’s revenues may be derived from affiliation with the practice, and the services rendered must not be either those that would normally be given without compensation or those that are reimbursable through patient care. Under no circumstances can the physician accept remuneration for referrals.
Conducting a Home Visit
The house call presents an array of professional challenges for which the physician must be prepared, mostly through self-study. Few residency training programs incorporate adequate home care experiences, and there are few role models in the academic world from whom to learn. Physicians have a natural sense of trepidation in venturing outside the familiar surroundings of the hospital or ambulatory setting without the immediate support of the nursing staff, availability of diagnostic facilities, and easy accessibility of colleagues and consultants. Practicing in the patient’s home tests one’s bedside clinical skills in obtaining a history, performing a physical examination, and developing a diagnostic differential on which to base therapy. Seeing the patient in the home also uncovers situations that require knowledge that is usually in the province of other health professions, such as family counselling, financial planning, home safety, assessment for the use of rehabilitative equipment, and linkage with community resources. As advances in miniaturization and technology allow life-support equipment to be used in the home, practitioners will be called on to deal with devices previously encountered only in the hospital. Mastering patient management in this setting opens the door to some of the most personally rewarding experiences in all of primary care.
For patients new to the practice who will be managed under the house call program, the physician should give and get as much information before the visit as practicable. An “advance packet” of information about the services available through the program and selected questionnaires and requests for copies of recent medical records, including hospitalizations, will streamline the first visit (Table 10-3). An Advance Directive form will encourage the patient and family to express their values and opens a discussion about the nature and extent of care desired and expected.
TABLE 10-3 THE “ADVANCE PACKET”
The appointment should be scheduled to allow adequate time (usually at least 1 hour is needed) and with assurances that responsible family members will be present. Clear directions to the home and any special travel information are essential. Observation begins with the neighborhood, its cleanliness, access to convenience stores, pharmacy, and so on, and the condition of the other houses in relation to the patient’s home. Disparities between the patient’s house and those surrounding it offer clues to the level of functioning of the patient, his financial status, and the likely availability of friendly neighbors for assistance. After reviewing the “advance packet” materials, the priorities on the initial visit are to obtain a working history based on the chief complaints and current problems, to perform a targeted physical examination, to assess mental function and the ability to perform activities of daily living and instrumental activities of daily living, to review home safety, and to evaluate the capabilities and emotional well-being of the caregiver. Documentation should include a problem list, a medication list, and decisions concerning the advance directives. This information helps to develop the management goals (e.g., to provide maintenance care or terminal care) and to determine the need for further laboratory tests and consultations. A scheduled follow-up appointment completes the visit.
On subsequent visits, a review should encompass the ongoing problems (check the problem and medication lists and monitoring parameters), any intercurrent problems, the functional status, and health maintenance (e.g., vaccinations). Some time should be set aside with the caregiver to answer questions, clarify monitoring parameters, and provide emotional support.
The tasks entailed in the house call are more readily performed if the proper instruments and forms have been brought to the home (Table 10-4 and Table 10-5). It is better not to carry any medications, needles, or syringes except as needed for vaccinations. Bring all “sharps” back to the office for proper disposal.
TABLE 10-4 HOUSE CALL BAG: EQUIPMENT
TABLE 10-5 HOUSE CALL BAG: STATIONERY
Care in the home presents many issues that are outside the usual practice of medicine in the hospital, office, or nursing home. Special issues beyond the scope of this chapter include detailed consideration of the ideal site of medical care for particular patients, safety in the home, family dynamics (especially the role of caregiver [Table 10-6]), detection and treatment of elder abuse, functional supports and knowledge of available durable medical equipment, and the use of high-tech options in the home setting. The knowledge gained from house call experiences broadens the scope of concerns that are included in the primary care considerations of patients with multiple impairments and generally lead to the most appropriate care in the least restrictive environment.
TABLE 10-6 THE PHYSICIAN’S ROLE IN CAREGIVER SUPPORT
Home care is a useful option for medical management of a particular group of functionally impaired people. The population for whom this type of care is most appropriate is burgeoning, as is the home care industry. These patients are often very ill with progressive debilitating diseases that frequently lead to death, yet they receive great benefit from care given in their homes. Physicians who are contemplating incorporating a house call component into their practice need to acquire the knowledge and skills that aid in providing effective care in the home and work within an organized, interprofessional supportive system that maximizes team efficiency.
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