When I told our hospital vice president I was making home visits with the residents, he gave me a polite smile that said “how quaint.” He then told us how the hospital was developing important new things like a joint replacement program, with concierge service and wood paneled patient rooms. They’re recruiting orthopedists. Like most hospital administrators, consultants keep him well informed on health care reform and other emerging trends. Home visits by family physicians are not part of the conversation. This is curious because of all the talk in health policy circles about the “Patient-Centered Medical Home” as a means to improve quality and decrease cost. In the latest set of standards for the Patient-Centered Medical Home developed by the National Center for Quality Assurance, there is no mention of the patient’s home as a locus of care. There is, however, a great deal about information technology. Information technology is a major concern of our national health policy experts.
The idea of physicians going to patients’ homes calls up nostalgic Norman Rockwell images of a simpler time. For the past two generations home health services have been the province of visiting nurses and other health care workers, not physicians. It’s simply economics. Medicare pays home health agencies enough to make it worth their while, but the overhead of a physician office is so great that making home visits is a money loser. And inconvenient. It’s possible to have a practice that entails only home visits, and a few physicians have done it. But most doctors who still go to patients’ homes squeeze in visits before or after office hours. It’s easy to see why it’s not popular.
I made my first home visits as a family medicine resident in Brooklyn. It didn’t take long to realize I could learn more about my patients in five minutes of a house call than a year’s worth of visits to the office. You see the family photos, the clutter, the pill bottles, the pets, the family dynamics all laid out in front of you. Like one visit to an elderly couple in Flatbush to check on the husband’s diabetic foot ulcer. He was a retired cab driver with Alzheimer’s disease who had finally stopped driving after he ran over the curb and smacked into a street sign. We went over instructions for wound care and then witnessed a shouting match between his wife and their adult son. When I went to say good-bye to the husband I found him washing his feet in the toilet bowl.
Our home visits are not house calls. We only get paid for seeing patients who meet criteria for being “home bound.” Insurance won’t pay for us to visit a child with fever. Still, there are plenty of frail elderly or patients with long-term disabling illnesses who qualify. When we added a required home care rotation to our residency training program we had a few simple goals-to learn more about our community, to see the different types of settings where our patients live (not just houses and apartments, but assisted living facilities, group homes, etc.), to assess their social support and the safety of the home environment, and to learn more about the role of other health care professionals in providing care in the home. In addition to making visits to their own patients, residents go out with home care and hospice nurses, physical therapists and advanced practice nurses. These other health care professionals seem happy to have a physician join in.
Our family medicine program is in a fairly typical small American city. It has a university, some large employers-a middle class and blue-collar community with its share of new immigrants, poverty, mental illness, drugs, and homelessness. If there’s anything that has emerged from our visits, it’s the awareness of how so many of our patients and families-even those we would call middle class-struggle to get by, each in their own way. When they come to the office we hear it in their voices but we don’t see it. The home care nurses know. We visit an 89-year-old woman in a moderate-sized Cape on a quiet suburban-like street. This is not the ghetto. The paint is peeling and old cars are parked in the driveway and the front lawn. Our patient walks from room to room holding on to furniture to keep from falling. The rooms are too cluttered for her to pass through with her walker. She’s taking medicine that makes her a bleeding risk if she falls and injures herself. Her bed is downstairs in the living room. Her daughter sleeps on a mattress on the floor next to her. Her three adult sons have the three bedrooms upstairs. There are family photos everywhere-filling the walls and cabinets, propped up on the backs of sofas, left on chairs. Her calcium tablets expired a year ago. Her out-of-pocket medication cost is $150.00 a month.
A mental health patient is morbidly obese from her anti-psychotic medication. She chain-smokes and uses home oxygen. Dust is everywhere and the room smells of cat urine. She is taking courses at the community college, transported to class by the Red Cross. She says she doesn’t want to live but hasn’t given up yet. When she needs a knee replacement she’ll get a wood paneled hospital room for a few days, maybe a few more if she has complications. At another home a daughter is taking care of her elderly demented mother and her deaf 90-year-old father-in-law between shifts at the family owned restaurant. She serves us Chinese food she brought from work. We see an elderly Italian-speaking man whose son, a local police officer trained for the SWAT team, comes over to translate. It takes fifteen minutes just to go over his medication. His wife serves us Italian Christmas pastries. It’s easy to gain a few pounds doing home visits. An overweight 84-year-old woman with bad arthritis lives alone. She has a walker but has fallen twice in the past several months. The firemen come and pick her up. Her house had structural damage from the heavy snow this past winter, but the insurance company is refusing to cover repairs. The resident sees why it takes her an hour in the winter to get from her house to a car to the office a mile away.
I’m impressed by how well the residents know their patients and their families, and how well liked they are in return. The patients are amazed and appreciative that their doctor is actually coming to their home, just like in the old days. In fact they have trouble believing it. If the system supported them, these young physicians would be happy to make home visits a regular part of their practice. Maybe then our patients wouldn’t have to go to the emergency department or be hospitalized quite so often. Maybe their lives would be a little more manageable. Maybe then we’d really be doing patient-centered care.