Study: House Calls for Frail Elders Bring Savings

Ten or 12 times a year, Beatrice Adams' daughter would race her frail mother to the emergency room for high blood pressure or pain from a list of chronic illnesses.

Then Adams found a doctor who makes house calls, and the 89-year-old hasn't needed ER care in the nearly two years since.

"I'm not a wimpy female," Adams said as Dr. Eric De Jonge wheeled his medical bag into her dining room and sat down to examine her. "I have only 11 years to make 100, and I'm going to make it."

The old-fashioned house call is starting to make a comeback as part of an effort to improve care for some of Medicare's most frail and expensive patients.

While it may sound like a luxury, bringing team-based primary care into the homes of patients like Adams, according to a new study, actually could save Medicare money by keeping them from needing pricier specialty or hospital care.

"They have a lifeline," explained De Jonge, a co-founder of the medical house call program at MedStar Washington Hospital Center, who led the study.

Such elder care is rare, but is growing. Medicare paid for 2.8 million house calls in 2012, the latest data available, compared with 1.5 million about a decade ago.

There are different kinds of house call programs. De Jonge's aims to provide comprehensive care. Teams of doctors and nurse-practitioners make regular visits to frail or homebound patients whose needs are too complex for a 20-minute office visit even if simply getting there wasn't a huge hurdle.

They can use portable X-rays and do EKGs or echocardiograms right in the living room. They line up social workers for supportive care, spot preventable problems such as tripping hazards, arrange home delivery of medications, and offer round-the-clock phone consultations and same-day urgent visits.

Adams has multiple chronic conditions ranging from hard-to-control blood pressure to congestive heart failure and post-traumatic stress disorder stemming from an assault.

On a recent house call, De Jonge listened for about 10 minutes as Adams got some fears off her chest. "I just shake even thinking about it," she said of the attack that still triggers nightmares. A social worker was helping, she said.

Then came the physical exam. De Jonge already had cut in half the 17 medications other doctors had prescribed. Hhe said Adams' grogginess immediately disappeared.

"One of my favorite things as a geriatrician is eliminating unnecessary medications. You see people blossom," he said.

This visit, De Jonge opened every remaining pill bottle to make sure Adams was taking them properly. Her blood pressure and oxygen levels were fine. Severe swelling in her legs wasn't a sign of any heart trouble, he reassured Adams, just vein damage. She should put her feet up for a while each day.

Does all that effort pay off?

De Jonge and colleagues compared the cost and survival of 722 patients enrolled in their house call practice in recent years with Medicare claims records of 2,161 similarly ill patients who never received home medical care.

Death rates between these two groups were similar. But over a two-year period, total Medicare costs were 17 percent lower for the house-call patients, or an average savings of about $4,200 per person per year, the group reported last month in the Journal of the American Geriatrics Society. They used more primary care but used less hospital, specialty and nursing home care.

That could add up fast, De Jonge said. Five percent of Medicare patients account for about half of the government insurance program's spending, the kind of frail older people he typically sees.

But house-call providers can be hard to find, and reimbursement is one reason. A doctor can see - and be paid for - about three times as many patients in a day in an office than they can while making house calls because of the travel time, said Constance Row, executive director of the American Academy of Home Care Medicine.

Indeed, De Jonge said reimbursement doesn't completely cover his program's costs; it breaks even thanks to grants and some hospital funding.

Now Medicare has begun a major demonstration project designed to test how well the house-call approach really works - one that for the first time will allow participating providers to share in any government savings that result if they also meet quality-care requirements.

About 10,000 patients who receive home medical care from 17 programs around the country, including De Jonge's, are part of the three-year experiment. To qualify, patients must be among the frailest of the frail, people who probably would qualify for a nursing home if they didn't have some assistance at home, said Linda Magno, who oversees the project for the Centers for Medicare and Medicaid Services.

It's so difficult to get to the doctor's office that "they tend to cope as best they can until things go downhill and they call 911," Magno said. "Part of the goal is to provide that continuity (of care), that access, so that 911 isn't necessarily the first call you make."

Stay tuned. Two years into the project, Medicare is beginning to calculate which programs met the shared-savings criteria.