Bringing It Home: A Closer Look at Care Options for Aging Patients

“We’re harkening back to the true ‘Marcus Welby’ model.”

Dr. Pamela R. Miner, Medical Director of Housecall Providers in Portland, Oregon, is shaping the future of health care by keeping an eye on the past. Serving an increasingly elderly population whose members prefer to maintain control over their care and surroundings, Housecall Providers offers home-based medical care that’s proving to be beneficial for patients, families, and even payers.

“We fill the need for people who are in their home and unable to leave, except for very costly ER visits or ambulance rides, to get to the medical care they need in a crisis,” says Dr. Miner. “They may not be completely homebound, but there may be other reasons they struggle to get into a clinic setting.”

Housecall Providers brings a multitude of primary-care services directly to the patient. “Home-based medical practices diagnose and treat chronic medical conditions, and we can often prevent avoidable hospitalizations or other complications,” says Dr. Miner. “Technological advances mean that providers can now offer EKGs, ultrasound, X-rays, IV treatments, and other vital services. For a chronically ill person with limited energy, getting to and from a doctor’s office might be so taxing that it is all that they can do that day.”

In their model, Housecall Providers serves as the primary-care provider for its patients. Miner admits that it’s often difficult for clinic-based physicians to give up the responsibility for care when they’ve established a long-term relationship with their patients. “We’re saying to our partners in the community, ‘If you struggle to make good medical recommendations for your patients because you haven’t seen them for some time, we will go to them.’ We’re often approached by caseworkers, hospital social-work teams, patients, and families who recognize that trips to the hospital or other appointments are becoming burdensome. They’re reaching out to us and asking us to take over their care or their loved one’s care.”

“Think of a patient with increasing dementia: the thought of trying to get them into the car, and the stress and the anxiety they experience when moving and traveling in unfamiliar environments,” she adds. “When we’re able to visit them in an assisted-living facility or private home, the patient and family feel like they’re getting good quality care. Plus, they’re maximizing quality of life for their loved one each day, knowing time may be growing short.”

With America’s rapidly aging population, approximately two million people are homebound. Dr. Miner says that only 15 percent of those are getting home-based medical care, so the opportunity for physicians to work within this model is enormous. “This type of care allows you to take your training and best practices in diagnosis and treatment, and put the patient’s needs at the center of how you build a care plan,” she says. “You get to think critically about each and every intervention or step that might affect their complex medical conditions. It provides an extremely stimulating opportunity for physicians. For those who like medicine for its high-touch, high-communication, patient-centered focus, it’s extremely rewarding.”

Contrary to what some might think, Dr. Miner knows that the advantages of home-based medical care have economic benefits as well. “Medicare’s fee-forservice schedule only covers around 50 percent of the costs associated with delivering this kind of care,” she says. “We’re building a case to be reimbursed on a value-based structure.”

Housecall Providers is currently participating in the multi-year demonstration from the Centers for Medicaid and Medicare Services Innovation called Independence at Home. The project seeks to provide metrics surrounding home-based primary-care services. In its second year, Housecall providers showed a 26 percent savings in patient-health costs over a control group that did not receive home-based primary care—a savings of $830 per patient every month. 

“If we can convince the marketplace and payers to understand the value of what we do, some of our reimbursement challenges will slide away and it will become easier to attract high-quality clinicians to this environment,” Miner continues. “In order to be sustainable and to expand care for an aging population, homebased medical practices need new reimbursement models, different than the old fee-for-service.”

Still other providers specialize in delivering home-based nursing care and related services often ordered by primary-care physicians for their patients. Alyssa Goodrich, a clinical manager providing home-based care in Spokane, Washington, says that with hospital stays getting shorter, she and her team are able to help elderly patients with items such as wound care, catheter care, and various therapies. “We have many skilled clinicians including nurses, physical therapists, occupational therapists, speech therapists, and even medical social workers,” she says. She agrees that providing in-home care is particularly rewarding for any clinician: “You can connect with your patients on a different level, because it takes skill to go into someone else’s home—after all, it’s their territory,” she says. “You have to make them feel comfortable and confident in what you can provide for them.”

Yet there can be a disconnect in the coordination of these services—which is why it’s crucial for the ordering physicians to let their patients know specific details. Says Goodrich, “Sometimes patients believe they’re getting an in-home caregiver to do basic household chores, and that’s not the case.” In such instances, it’s important that the ordering physicians—and their patients—understand exactly what services those providers are delivering.

“Hospice care is much more familiar to people than it has been in the past. It’s not as scary a word as it used to be,” says Kim Ransier, Executive Director of Hospice of North Idaho. “One thing we’re also noticing is that people are calling us and getting referred to us later in their illness than they were 20 or 30 years ago. That’s largely due to the advent of so many new treatments, and more education on the part of the consumer to try and seek out treatment options.” According to Ransier, the average length of hospice care nationally is approximately 60 days. At Hospice of North Idaho, it’s about 40 days.

One common misconception is that hospice care is only for elderly patients and their families to think about. “We have a 25-year-old right now who was diagnosed with leukemia six months ago and now only has a few days to live,” says Ransier. “We had a meeting with his family only just yesterday. While he had been referred to all sorts of specialists during treatment, at no time did anyone say his disease could end his life. No one told him or his family during these months that hospice could be an eventual possibility.”

All families need to be prepared when treatments are no longer effective and a loved one is facing hospice care. “One of the biggest challenges we face are the late referrals,” says Ransier. “We like to work with families and provide time for them to process what’s happening. But when we have someone for five days, the family doesn’t have time to adjust or visit and say goodbyes.”

On a positive note, technology and connectivity have helped families better navigate hospice issues. “We’ve coordinated family conversations over Skype,” Ransier continues.

“It especially helps when there are some family members who are local and others who are far away. For example, one might say, ‘Dad’s in really bad shape, and you should come home.’ And another family member replies, ‘I just saw him last month and he was fine.’ The answer is, ‘Well, let’s Skype and you can see what he’s going through.’”

It’s still very difficult for physicians to bring up end-of-life issues, says Ransier. “‘How to have the conversation’ is something that needs to be taught earlier in medical school and among primary-care physicians,” she says, and adds that she thinks it’s never too early to begin the discussion. 

“What we know is that the patients will talk about this. But they often need someone to bring it up. Most of the time, the patient has a long-term relationship with the primary-care doctor. And once the doctor brings it up, patients will respond. Most people still feel that their physicians ‘know all,’ so it stimulates the conversation and strengthens the relationship.”

Many patients with chronic conditions such as cancer, congestive heart failure, or Parkinson’s experience a range of symptoms and stresses from the treatments they receive. This is where palliative care comes in.

“We talk about palliative care as a wraparound of all the comfort and services patients need while they’re navigating chronic illness,” says Dr. Miner. “Unlike a hip fracture or cold, these are conditions they’ll be managing their entire life. The longer the chronic illness goes on, the less effective our tools are at keeping patients as functional as they want to be. Nurses, social workers, and even spiritual counselors are vital to helping people with the changes they’re facing because of the nature of their condition.”

At Hospice of North Idaho, more patients receive palliative care at any given time than there are patients in hospice care. “We have a nurse who calls and does a home visit,” says Dr. Ransier. “Based on that, she comes up with a plan of care—a call every two weeks, a home visit once a month.”

Much like with home-based medical care, the value is clear to see, yet still needs to be quantified. “The challenge is, there is no reimbursement unless the care is provided by a licensed provider like a nurse practitioner or physician,” Ransier continues. “We can prevent costly ER visits, and we can connect patients to a lot of social services, which also keeps them out of the hospital.”

For seniors, getting the right care where and when it’s needed most can be critical. The growth of these niches of care delivery is good news for the senior population in particular. Whether homebound, facing a chronic condition, or in the final stages of life, there are care givers and physicians who can join them on the journey.