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The Doctor Will See You Now, In Your Home

doctor house call medicine visit

The old-fashioned house call is back in a big way. Here’s how it works.

June, 2019  |  Harvard Health Newsletter  |

It’s hard to get to the doctor when you don’t drive anymore or you’re struggling with several chronic medical conditions. The result may be missed appointments and a lack of needed care.

But a growing trend makes it far easier for older adults to get medical attention, bringing routine exams and diagnostic tests to the patient’s doorstep. It’s called home-based medical care — when doctors, nurse practitioners, physician assistants, or other providers visit and treat older adults right in their homes.

Different from home health care

Home-based medical care isn’t the same as home health care, which sends skilled nurses and therapists to your home specifically to help you recover from illness, injury, or surgery, with the goal of helping you get better and regain your independence.

Instead, home-based medical care is more like a beefed-up house call. “These are their regular visits. The only difference is that we bring the equipment to them,” says Dr. Diane McMullin, a geriatrician with the House Calls program at Harvard-affiliated Mount Auburn Hospital.

In some cases, the house call provider can visit when you develop a sudden illness, like an infection. Some providers can bring mobile x-ray or ultrasound machines and equipment to draw blood and collect urine.

Is it covered?

“Medicare began recognizing home visits about 20 years ago,” says Brent Feorene, executive director of the American Academy of Home Care Medicine. And the number of Medicare-funded house calls has been increasing. For example, Medicare paid for 1.6 million home care visits in 2001. By 2015, the number was 2.6 million.

But Medicare won’t pay for a house call as a simple matter of convenience. “The expert must certify that the visit was medically necessary,” Feorene says.

What’s considered medically necessary? Coverage generally applies when an older adult has a condition that restricts the ability to leave home, making a visit to the doctor’s office considerably taxing. For example, the person might need the help of an assistive walking device or wheelchair, the assistance of another person, or medical transportation; or the person may have a cognitive, psychiatric, or emotional issue that makes it hard to get to an appointment.

Whether your private insurance will pay for a house call is a different story. That depends on your insurer.

Read the full article

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‘Eyes In The Home’: ACOs Use Home Visits To Improve Care Management, Identify Needs, And Reduce Hospital Use

Home visit from nurse practitioner

June, 2019  |

Authors: Taressa K. Fraze, Laura B. Beidler, Adam D. M. Briggs, Carrie H. Colla


Home visits are used for a variety of services and patient populations. We used national survey data from physician practices and accountable care organizations (ACOs), paired with qualitative interviews, to learn about home visiting programs. ACO practices were more likely to report using care transitions home visits than non-ACO practices were. Eighty percent of ACOs reported using home visits for some of their patients, with larger ACOs more commonly using home visits. Interviewed ACOs reported using home visits as part of care management and care transitions programs as well as to evaluate patients’ home environments and identify needs. ACOs most often used nonphysician staff to conduct home visits. Home visit implementation for some types of patients can be challenging because of barriers related to reimbursement, staffing, and resources.

More than a half-century ago, it was not unusual for physicians to make house calls. Modern medicine, however, transitioned care from the patient’s home to the provider’s office in an effort to improve efficiency.1,2 Still, there are advantages to house calls: to offer the patient convenience and safety, help providers build more personal relationships with patients, comprehensively assess patients’ needs, and identify issues related to the home environment.3 Moreover, many patients benefit from more intensive, home-based care,4,5 and evidence suggests that care provided in patients’ homes can both reduce costs and improve quality.47 Medicare has created new reimbursement models to support home visits for patients who are functionally unable to attend office-based visits.8

Home visits can improve the quality of care by easing transitions between care settings, enhancing care management, and helping older patients successfully age at home.3,9 Home visits can be used for a variety of services and patient populations, such as care management for patients with chronic disease, home-based primary or acute care, postdischarge care transitions, and support for frail patients. Home visits have the potential to reduce spending by preventing readmissions or by helping people with complex needs manage their conditions in lower-acuity (and lower-cost) settings.7,10 Home visits are particularly useful for addressing unforeseen challenges after discharge, such as those related to obtaining support from caregivers, understanding a care plan, understanding the full spectrum of medications a patient has at home, and making necessary adjustments to the home environment.4,10

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Blue Shield of California targets patients with complex needs in house call program

elderly womean in bed with walker

  |  by: Paige Minemyer |

Blue Shield of California has teamed up with Landmark Health to offer more house calls to members with chronic conditions—at no additional cost.

The insurer has enrolled 3,500 people in the program over the last year and has provided 15,000 in-home visits in that opening window, Blue Shield announced Wednesday. The key, the team told FierceHealthcare, is making sure both members and physicians understand that this is not meant to replace primary care providers (PCPs).

Instead, Landmark’s providers work alongside a patient’s existing PCP to provide care, particularly in the case of an urgent emergency to avoid a pricey, unneeded hospital admission. 

“We see this as a real strategy—comprehensive, coordinated care for a physically vulnerable population,” said Malaika Stoll, M.D., senior medical director at Blue Shield of California.  Read the full article

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A Large-Scale Advanced Illness Intervention Informs Medicare’s New Serious Illness Payment Model

holding hand of elderly patient

Brad Stuart, Elizabeth Mahler and Praba Koomson


Patients with advanced illness receive fragmented, hospital-based care that is unaligned with their preferences near the end of life. We describe a team-based intervention that provides home-based, coordinated care to more than 2,000 seriously ill patients daily in nineteen urban, suburban, or rural counties in California. In the last month of life, compared to matched Medicare beneficiaries in similar counties, this program reduced hospital days by 1,361 per 1,000 beneficiaries, hospital deaths by 8.2 percent, inpatient payments by $6,127, and the total cost of care by $5,657 per beneficiary. The Centers for Medicare and Medicaid Services (CMS) has announced a new Medicare payment model for serious illness care, based in part on this program. To inform model development and implementation, we describe lessons learned about changing the focus of care for advanced illness from hospital to home, broadening care coordination to achieve system integration, and developing methods for payment and quality accountability that transform care delivery.

Beneficiaries with advanced illness (also called “serious illness”) account for 4 percent of the Medicare population but 25 percent of its costs. Advanced illness refers to late-stage chronic illness, when one or more conditions become serious enough that general health and function decline and treatments begin to lose their impact—a state that progresses to the end of life.1 Patients with advanced illness often undergo unwanted, avoidable, and costly hospitalizations near the end of life.

Neither current Medicare reimbursement nor the present portfolio of the alternative payment models of the Centers for Medicare and Medicaid Services (CMS) adequately finances home-based care to remedy this, and available services are underused and overstressed. Medicare pays for home hospice care, but many enrollees don’t benefit from its services because they are not admitted until days before death, often following intensive hospitalizations.2 Lacking a major expansion initiative, palliative care fellowship training programs will not meet the burgeoning demand as the US population ages.3

New clinical and payment models are needed, particularly for the two-thirds of beneficiaries enrolled in fee-for-service Medicare, to integrate fragmented delivery systems and incentivize providers to create team-based care at home for patients and their families and caregivers. The Coalition to Transform Advanced Care (C-TAC), a not-for-profit organization representing over 150 US health systems, health plans, hospices, community-based organizations, and leading consumer and patient advocacy organizations,4 has proposed such a delivery and payment model for patients with advanced illness5 to the Center for Medicare and Medicaid Innovation (CMMI). The model, called Advanced Illness Management (AIM), was developed at Sutter Health, a large integrated health system in California. CMMI has announced a new serious illness payment model based on C-TAC’s proposal and another from the American Academy of Hospice and Palliative Medicine.6

In this article we describe the piloting, scaling, and testing that formed the backbone of C-TAC’s model. Based on that experience, we share lessons learned that could inform CMMI’s efforts to improve care for Medicare beneficiaries with advanced illness.

Read the full article


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CMO Dr. William Shrank on Humana’s physician strategy, ‘Medicare for All’ and home care as the Netflix of healthcare


Morgan Haefner  |  June 4, 2019  |  Beckers Hospital Review

Humana wants to do for healthcare what Netflix did for home entertainment.

Humana’s CMO William Shrank, MD, said the insurer’s strategy for its 16 million members, most of whom are Medicare Advantage enrollees, is to meet patients where they are — at home.

“If you look at the movie industry, you see there was a time when people used to go to the retail outlet to buy or rent their DVDs, and now there’s a better service that’s more convenient. It’s more personalized in the home,” Dr. Shrank told Becker’s Hospital Review during an in-person interview June 4. “That’s our goal. Our goal is to be that more progressive solution that is patient-focused, convenient, integrated and meets patients where they are. It’s more of a Netflix kind of thing.”

For Humana, this means better leveraging data, technology and analytics to be proactive, and reaching out to patients before medical issues arise to provide appropriate services in their bedrooms, kitchens and living rooms.

It’s a different tactic than competitors like CVS Health/Aetna and UnitedHealth Group have used, but Dr. Shrank said that to Humana, home-based care is the future of healthcare. The insurer’s investments are evidence: Humana and two private equity firms bought Louisville, Ky.-based post-acute care provider Kindred Healthcare in a $4.1 billion deal, with the trio also buying hospice operator Curo Health Services for $1.4 billion.

Here, Dr. Shrank further discusses Humana’s at-home strategy and answers questions on the payer’s primary care moves, its partnerships with hospitals and the possibility of “Medicare for All.”

Editor’s note: Responses have been lightly edited for clarity and length.

Question: CVS/Aetna just announced plans to open 1,500 “HealthHubs.” UnitedHealth’s Optum is acquiring physicians. Amid these moves from competitors, what’s your physician strategy?

Dr. William Shrank: The large payers — at least the three of us focused heavily on Medicare Advantage — are blurring the lines between payer and provider. We’re thinking more holistically about how we manage a population rather than figuring out how to pay claims. We are all taking a little bit of a different tactic. Ours is focused on the home, on meeting patients where they are. United is going to buy more and more primary care docs, and CVS is doing more in the retail space. We think the future of healthcare is going to be in the home.  Read the full article

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ACOs Commonly Use Home Visits for Complex Patients During Care Transitions

house call doctor at door

Authors: Taressa K. Fraze, Laura B. Beidler, Adam Briggs, and Carrie H. Colla

The Issue

Years ago, it was not uncommon for physicians to make house calls. But in the past 50 years, care has largely transitioned to physicians’ offices. Office-based visits are more efficient, and reimbursement for home visits can be challenging under fee-for-service payment. However, there are advantages to home visits: they can improve health outcomes, and they can decrease spending on patients with complex needs, including patients with chronic conditions and those recently discharged from the hospital. With support in part by a six-foundation collaborative that includes the Commonwealth Fund, Peterson Center on Healthcare, Robert Wood Johnson Foundation, SCAN Foundation, John A. Hartford Foundation, and Milbank Memorial Fund, researchers looked at whether health care providers contracted with accountable care organizations (ACOs) were more likely than non-ACO practices to employ home visits. The study, published in Health Affairs, used 2017–2018 survey results as well as data obtained from interviews with 18 ACO leaders.

What the Study Found

  • ACO physician practices were more likely than non-ACO practices to conduct home visits for complex patients within 72 hours of hospital discharge (25.7% vs. 18.8%).
  • ACOs using home visits tended to be larger (include a hospital or contract with more physicians) and more likely to be part of an integrated delivery system than ACOs that did not use home visits.
  • More than 50 percent of ACOs that participated in risk-bearing payment arrangements, such as episode-based bundled payment, employed home visits. In comparison, only 30.2 percent of ACOs that did not have risk-bearing contracts used home visits.
  • In addition to using home visits as part of a care management or care transitions program for complex patients, ACOs used home visits for patients who were noncompliant or nonresponsive with office-based care.
  • Postdischarge visits were common, but some ACOs also used home visits on an as-needed basis, such as when care teams sense something is not right with a patient or a patient cannot be reached by phone or other means.
  • Care team members who conducted home visits included care management staff, nurses, social workers, health coaches, and pharmacists.
  • Looking at only Medicare ACOs, the researchers saw no significant differences in quality scores or likelihood of achieving shared savings between ACOs that used care transition home visits and those that did not.

Read the full article

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York Hospital Increases Services for Older Adults



YORK — In order to increase services for elders in its coverage area, York Hospital has created the Center for Older Adults with geriatric specialists providing comprehensive care in its new clinic and house calls to those who cannot make the trip to see their primary care physician for a variety of reasons.

The Center for Older Adults opened in February and soon will be increasing clinic hours to two days a week, said Dr. Elizabeth Castillo, a hospitalist and geriatric specialist working with geriatric Nurse Practitioner Barbara Roberge and Nurse Practitioner Erin Morgan, who has been conducting home visits for the Older Adults House Calls Program since November.

“This home visit program is something old that is new again,” said Morgan. “I know in the past doctors often made house calls and it may have been the majority of their work. Now there is a focus on having physicians and nurse practitioners to get back in the home. It’s a bit of a trend.”

There is an important distinction between this program’s house calls and home nursing visits that have existed for decades for those patients being released from the hospital. Morgan, as a nurse practitioner, can diagnose, prescribe, order laboratory tests, similar to the services doctors and nurse practitioners offer in office and clinic settings.

“So, it’s like they are going in to see their physician or nurse practitioner in the office but I’m coming to their home instead,” Morgan said. “I work in collaboration with the primary care physicians, working on the same medical record and working together on a plan of care for the patients.”

Patients are referred to Morgan by their primary care physicians when they have some acute medical concern, but it is difficult to physically get into the doctor’s office due to a fall, trouble walking or mental or memory challenges.

“We do not handle urgent care situations because patients need to wait 24 to 48 hours to be seen. If it’s an emergency, they need to go to the ER,” said Morgan, who has been doing home visits in Massachusetts as a geriatric nurse practitioner and is thrilled to work in York, where she grew up.

The focus on elder care is new to York Hospital and is a result of Dr. Castillo’s arrival last fall. She moved to York from North Carolina with extensive training and experience in geriatric medicine, said Jody Merrill, York Hospital’s lead of marketing.

“Leadership recognized that there is a significant need in the area for specialists in geriatric care,” Merrill said.

The Center for Older Adults provides comprehensive outpatient consultations for older adults who need more time or more frequent visits than a regular primary care visit. Castillo and Roberge stay in close contact with the patient’s primary care provider while an interdisciplinary team of medical, nursing, rehabilitation, nutrition, pharmacy and behavioral medicine is available for those older adults who have experienced some decline in the past year and have been referred for this service.  Read the full article