House calls may help frail elderly

Michelle Andrews, Kaiser Health News

From the back window of his rowhouse, Karl Schwengel can see the U.S. Capitol. But the 11 blocks might as well be so many miles, because he can barely walk across his bedroom, let alone go for a stroll.

Schwengel, 79, has congestive heart failure and arthritis. And though he lost 60 pounds during a recent hospital stay, he still weighs in at 260 pounds.

Last year, he was retaining so much fluid that his calves were "almost the size of basketballs," he says, and walking became nearly impossible. When he traveled to a clinic or the hospital for medical treatment — an ordeal in and of itself — he relied on neighbors and an unofficial godson to take him.

All that began to change about six months ago when a local community group put him in contact with the Medical House Call Program at Washington Hospital Center. Now a doctor or nurse practitioner visits him every month to check his vital signs and medications and work with him to improve his health. A physical therapist recently joined the Schwengel team, and now he's practicing using a walker at home. "The doctor says we’re going to work on one problem at a time," he says.

In this era of assembly-line appointments, when you're lucky to get 10 minutes of face time with a physician, the idea of doctors making house calls seems old fashioned. But for frail, elderly people with multiple health problems, bringing the medical establishment to the patient makes sense.

Because it's hard for these patients to get to the doctor, small problems languish and turn into larger ones. Eventually they land in the emergency room or hospital. They recover — but then, all too often, the cycle starts over again.

Home visits make financial sense as well, notes Jim Pyles, a Washington lawyer and member of the board of directors of the American Academy of Home Care Physicians. "We found that you could afford to treat a patient for a whole year at home by avoiding just one hospitalization," he says.

Washington Hospital Center’s program, which started 11 years ago and serves roughly 600 patients, has reduced expected hospitalizations among participating patients by almost two thirds, says gerontologist George Taler, co-director of the program.
Now that program and similar ones may get their turn on a national stage.

The health care overhaul creates a three-year Medicare demonstration project to test the home visit concept on 10,000 of the sickest, most-expensive-to-treat Medicare enrollees. To be eligible for the project, called Independence at Home, patients must have multiple chronic conditions and be unable to perform normal daily activities like bathing and dressing. They must also have been hospitalized or needed other high- cost care in the last year.

Health care organizations that participate in the project won't receive any money up front. If they succeed in cutting treatment costs by 5 percent, improving health outcomes and getting positive patient reviews, the groups share in any further savings. The program is slated to begin by January 2012, but some supporters are pushing for a faster start.

Supporters say the project is a recognition of the increasing importance placed on growing old at home, rather than in institutions. "It will help expand these programs and acknowledge Medicare’s role in them," says Elinor Ginzler, a senior vice president at AARP.

But making a success of these program is no simple task. Although Medicare pays practitioners more for home visits than for clinic visits, it doesn't pay for time spent traveling or for coordinating patients' care.

Clinicians working for Chicago-based Home Physicians see just 10 or 11 patients a day, far fewer than the 30 or more patients an office-based doctor would typically see, says Craig Reiff, CEO of Home Physicians, a 15-year-old private company whose 60 clinicians — including primary care doctors, podiatrists, nurse practitioners and physician assistants — serve 12,000 patients in Chicago and Baltimore.

To make the visits pay, Reiff says he has to schedule his clinicians' visits carefully. And he notes that they make calls in tight geographic areas: "It could be very difficult to make it work in rural areas," he says.

Practitioners have had no trouble reaching Karl Schwengel's home in Washington.

"They've done everything in the world for me," he says. With their help, he hopes to keep losing weight and learn to walk again. "There are so many things I want to do," he says. "I want to take my dog for a walk across the park."

Or maybe, to the Capitol.