House Calls

Am Fam Physician. 2011 Apr 15;83(8):925-931.

  Related letter: Additional Tips for Physicians Making House Calls

House calls provide a unique perspective on patients' environment and health problems. The demand for house calls is expected to increase considerably in future decades as the U.S. population ages. Although study results have been inconsistent, house calls involving multidisciplinary teams may reduce hospital readmissions and long-term care facility stays. Common indications for house calls are management of acute or chronic illnesses, and palliative care. Medicare beneficiaries must meet specific criteria to be eligible for home health services. The INHOMESSS mnemonic provides a checklist for components of a comprehensive house call. In addition to performing a clinical assessment, house calls may involve observing the patient performing daily activities, reconciling medication discrepancies, and evaluating home safety. House calls can be integrated into practice with careful planning, including clustering house calls by geographic location and coordinating visits with other health care professionals and agencies.

House calls were standard practice for physicians in 1930, when approximately 40 percent of patient encounters occurred in the patient's home. By 1950, this had fallen to around 10 percent, and by 1980, only about 1 percent of patient encounters were house calls.1 The 2008 American Academy of Family Physicians member survey reported that the average family physician conducted fewer than one house call per week.2 Renewed interest in house calls is evident in Medicare Part B billings, which increased from 1.4 million visits in 1999 to 2.3 million visits in 2009, in part because of changes in regulations and a 50 percent increase in reimbursement.3,4 This trend is expected to accelerate because of demographic changes. By 2030, 70 million U.S. citizens will be older than 65 years. A substantial number of persons will live at home with disabilities that prevent them from traveling to medical facilities.5 Approximately 15 percent of persons between 75 and 85 years of age report needing help with activities of daily living, such as bathing and toileting, and 36 percent of this age group report difficulty walking at least one block.6 Because the existing long-term care and assisted living infrastructure does not have the capacity for the projected numbers of patients requiring house calls,7 family physicians are likely to receive increasing demand for this service.

House calls can provide a unique perspective on a patient's life that is not available in an office visit or during hospitalization. A house call can foster the physician-patient relationship, and enhance the physician's understanding of the patient's environment and support systems. This article provides an overview of house calls, and suggests strategies to facilitate incorporation of this service into busy practices.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

Multidisciplinary home-based care may improve some outcomes in older adults.

B

811

Hospital at Home care is an effective alternative to hospital care for select patients with acute illnesses.

B

1518

Home care for patients with terminal illness is strongly associated with patient-preferred home death rather than death in a hospital.

C

26


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

Multidisciplinary home-based care may improve some outcomes in older adults.

B

811

Hospital at Home care is an effective alternative to hospital care for select patients with acute illnesses.

B

1518

Home care for patients with terminal illness is strongly associated with patient-preferred home death rather than death in a hospital.

C

26


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml.

Evidence of Effectiveness

Studies evaluating the effectiveness of house call programs for older adults have reached conflicting conclusions. Key difficulties in evaluating the literature include the degree of frailty of participants, the different outcomes measured, and the variation in composition of the clinical team, especially inclusion of a physician. One meta-analysis of 15 studies of care by specialized community nurses showed mortality benefit and reduction in long-term care admissions, but no decrease in hospitalizations.8 A systematic review of seven studies did not find outcome benefits in frail older adults.9 A review of 18 studies demonstrated benefit of interventions in young-old (low-risk) populations when the house call programs were multidimensional and included multiple visits.10 The U.S. Department of Veterans Affairs' Home Based Primary Care program, which uses a multidisciplinary care team to serve frail older persons in the home, has demonstrated fewer hospital admissions, shorter lengths of stay, reduction in readmission rates, and reduction in long-term care facility stays. Preliminary analysis suggests the experience of the multidisciplinary team and inclusion of a physician and nurse practitioner are important factors to reduce inpatient days.11

Although the focus of this article is on physician house calls for older adults and patients with chronic illnesses, there is also evidence that supports house calls in neonatal care to reduce rehospitalization12,13 and pharmacologist visits after hospitalization to resolve medication errors.14 Hospital at Home care for patients with certain acute illnesses can be as effective as hospital care in select patients.1518

Types of House Calls

The rationale for and objectives of house calls depend on the type of clinical encounter19  (Table 12022). Visits can be performed once (e.g., as part of a comprehensive assessment) or multiple times (e.g., to provide ongoing home care for patients with chronic or terminal conditions). Assessment visits may be appropriate for patients who are struggling with polypharmacy, multiple medical problems, excessive health care use (e.g., frequent emergency department use, preventable hospitalization), social isolation, frailty, or recent major changes in health. Assessment visits may also benefit patients in whom long-term care is being considered; those in whom abuse, neglect, or self-neglect is suspected; or those who need a family meeting. Patients may prefer treatment at home to hospital care if equivalent outcomes are likely. The choice of location of care is heavily dependent on the physician's opinion.23

Table 1.

Rationale for and Types of House Calls

Rationale for house calls

Patient is homebound (Table 2)

Patient, family member, or member of the home health team requests a house call

Physician needs to negotiate care or clinical decision making with patient and caregivers

Physician needs to assess home environment, and patient and caregiver function

Physician needs to verify eligibility for third-party reimbursement for home health services

Types of house calls

Patient assessment (e.g., polypharmacy, multiple medical problems, excessive health care use, social isolation, frailty, suspected abuse, suspected neglect or self-neglect, need for family meeting, recent major change in health, consideration of long-term care admission)

Illness management for homebound patients (emergency, acute, or chronic conditions)

Dying patients (e.g., palliative/terminal care, death pronouncement, grief support)

Hospitalization follow-up

Concierge services (e.g., health promotion, disease prevention)


Information from references 20 through 22.

Table 1.   Rationale for and Types of House Calls

View Table

Table 1.

Rationale for and Types of House Calls

Rationale for house calls

Patient is homebound (Table 2)

Patient, family member, or member of the home health team requests a house call

Physician needs to negotiate care or clinical decision making with patient and caregivers

Physician needs to assess home environment, and patient and caregiver function

Physician needs to verify eligibility for third-party reimbursement for home health services

Types of house calls

Patient assessment (e.g., polypharmacy, multiple medical problems, excessive health care use, social isolation, frailty, suspected abuse, suspected neglect or self-neglect, need for family meeting, recent major change in health, consideration of long-term care admission)

Illness management for homebound patients (emergency, acute, or chronic conditions)

Dying patients (e.g., palliative/terminal care, death pronouncement, grief support)

Hospitalization follow-up

Concierge services (e.g., health promotion, disease prevention)


Information from references 20 through 22.

For frail older patients who are homebound, the goals of a house call are to preserve functional status and prevent or delay institutionalization or hospital admission. Table 2 provides the current Medicare definition of homebound.24 For patients with chronic conditions, such as heart disease, renal failure, or chronic obstructive pulmonary disease, the goals also include maximizing symptom control. For patients with advanced dementia, the goals may shift to emphasizing evaluation of home safety or the ability to live independently. Physicians can also evaluate caregivers' abilities to provide in-home care. For recently hospitalized patients, the goals include identifying the impact of functional decline, evaluating home safety, identifying medication discrepancies in the transition to home, and monitoring symptoms.

Table 2.

Medicare Definition of Homebound

To be eligible for home health services, a Medicare beneficiary must:

Need intermittent skilled nursing care; or physical, speech, or occupational therapy

Be confined to the home (e.g., normal inability to leave; requires considerable and taxing effort to leave; requires supportive devices like canes, wheelchairs, and walkers to leave; requires special transportation to leave; requires help from another person to leave; medical contraindication for leaving the home)

Be under a plan of care established and periodically reviewed by a physician

Receive the services from a Medicare-participating home health agency

Additionally, the following should not disqualify a person from being considered confined to the home:

Participation in therapeutic, psychosocial, or medical treatment in an adult day care program that is licensed or certified by the state

Any other absence from the home that is infrequent or of relatively short duration; any absence for the purpose of attending a religious service shall be deemed to be an absence of infrequent or short duration


Information from reference 24.

Table 2.   Medicare Definition of Homebound

View Table

Table 2.

Medicare Definition of Homebound

To be eligible for home health services, a Medicare beneficiary must:

Need intermittent skilled nursing care; or physical, speech, or occupational therapy

Be confined to the home (e.g., normal inability to leave; requires considerable and taxing effort to leave; requires supportive devices like canes, wheelchairs, and walkers to leave; requires special transportation to leave; requires help from another person to leave; medical contraindication for leaving the home)

Be under a plan of care established and periodically reviewed by a physician

Receive the services from a Medicare-participating home health agency

Additionally, the following should not disqualify a person from being considered confined to the home:

Participation in therapeutic, psychosocial, or medical treatment in an adult day care program that is licensed or certified by the state

Any other absence from the home that is infrequent or of relatively short duration; any absence for the purpose of attending a religious service shall be deemed to be an absence of infrequent or short duration


Information from reference 24.

The goals of house calls for palliative care focus on symptom assessment and management, as well as monitoring the support of caregivers. Visits to dying patients can occur in partnership with hospice services. Family physicians can provide valuable psychosocial support to patients and their families before and after death. Continued involvement in caring for patients with terminal cancer may improve end-of-life care and reduce the likelihood of death in the hospital.25 A systematic review demonstrated that home care, and the intensity of that care, is strongly associated with a patient-preferred home death rather than death in the hospital.26

Conducting House Calls

Advance planning is necessary to develop the anticipated agenda of a house call. This may include logistics (e.g., supplies, patient education materials), obtaining directions and patient contact information, confirming the visit with the patient and caregivers, and coordinating with other home health care professionals.

The INHOMESSS mnemonic (impairments/immobility, nutrition, home environment, other people, medications, examination, safety, spiritual health, services) addresses the components of a comprehensive house call. A sample checklist that incorporates these items is provided in Figure 1.20 Specific elements of the INHOMESSS assessment can be conducted independently based on the needs of the patient and the physician's agenda. The comprehensive evaluation begins with an assessment of the patient's neighborhood and exterior of the home, specifically the ease of entering or exiting the home. Home modifications to assist older adults with disabilities are described in a previous article in American Family Physician (http://www.aafp.org/afp/2009/1101/p963.html).

Sample House Call Checklist (Based on the INHOMESSS Mnemonic)

Figure 1.

Sample house call checklist. (INHOMESSS = impairments/immobility, nutrition, home environment, other people, medications, examination, safety, spiritual health, services.)

Adapted from Unwin BK, Jerant AF. The home visit. Am Fam Physician. 1999;60(5):1487.

View Large

Sample House Call Checklist (Based on the INHOMESSS Mnemonic)


Figure 1.

Sample house call checklist. (INHOMESSS = impairments/immobility, nutrition, home environment, other people, medications, examination, safety, spiritual health, services.)

Adapted from Unwin BK, Jerant AF. The home visit. Am Fam Physician. 1999;60(5):1487.

Sample House Call Checklist (Based on the INHOMESSS Mnemonic)


Figure 1.

Sample house call checklist. (INHOMESSS = impairments/immobility, nutrition, home environment, other people, medications, examination, safety, spiritual health, services.)

Adapted from Unwin BK, Jerant AF. The home visit. Am Fam Physician. 1999;60(5):1487.

One approach to assessing the patient's functioning at home is to observe the patient performing daily activities. Activities of daily living (especially transfer skills) are demonstrated by getting in and out of bed, on and off of the toilet, and in and out of the bathtub or shower. Other self-care skills include performing hygiene tasks, getting dressed, taking medications, doing housework, and preparing food. Observing the patient-caregiver interaction can provide insight into the relationship.

After the functional assessment, a directed physical examination or home safety assessment can be performed as needed. Some elements of the home safety assessment can be performed during the functional assessment (Table 320).

Table 3.

Home Safety Assessment

Bathroom

Are handholds sturdy and in appropriate places?

Can the toilet seat be raised?

Does the bathtub/shower have a nonslip surface?

Is the bathroom floor slick?

Electrical cords/appliances

Are cords frayed or damaged?

Do cords cross walking paths?

Emergency actions/evacuation route

Are emergency numbers available?

Are there means of egress from home?

Firearms

Are firearms present?

If yes, are they secured? (e.g., gun lock, locked case/cabinet, weapon and ammunition separated)

Fire extinguishers

Are fire extinguishers present?

If yes, are they accessible and in working order?

Is the patient or caregiver able to use them?

Heating and air-conditioning

Are controls accessible and easy to read?

Is the home an appropriate temperature year-round?

Hot water heater

Temperature set below 120° F (49° C)?

Kitchen safety (especially gas stoves)

Is it easy to tell if burner or oven gas is on?

Does the patient wear loose garments while cooking?

Lighting and night-lights

Is lighting present and sufficient?

Loose carpets and throw rugs

Are carpets and throw rugs present?

If yes, do they need to be secured or removed?

Pets

Are pets present?

If yes, are they easy to care for?

Smoke and carbon monoxide monitors

Are they present?

If yes, are they functioning and monitored?

Stairs

Does the home have stairs?

If yes, are they carpeted and is the carpeting secure?

Are stairs well lit?

Are there railings?

Tables, chairs, furniture

Is furniture sturdy, balanced, and in good repair?

Utilities (gas or electric)

Are the systems monitored and maintained?

Water source

Is water from a public source or a well?

Is the source functioning and safe?


Adapted from Unwin BK, Jerant AF. The home visit. Am Fam Physician. 1999;60(5):1486.

Table 3.   Home Safety Assessment

View Table

Table 3.

Home Safety Assessment

Bathroom

Are handholds sturdy and in appropriate places?

Can the toilet seat be raised?

Does the bathtub/shower have a nonslip surface?

Is the bathroom floor slick?

Electrical cords/appliances

Are cords frayed or damaged?

Do cords cross walking paths?

Emergency actions/evacuation route

Are emergency numbers available?

Are there means of egress from home?

Firearms

Are firearms present?

If yes, are they secured? (e.g., gun lock, locked case/cabinet, weapon and ammunition separated)

Fire extinguishers

Are fire extinguishers present?

If yes, are they accessible and in working order?

Is the patient or caregiver able to use them?

Heating and air-conditioning

Are controls accessible and easy to read?

Is the home an appropriate temperature year-round?

Hot water heater

Temperature set below 120° F (49° C)?

Kitchen safety (especially gas stoves)

Is it easy to tell if burner or oven gas is on?

Does the patient wear loose garments while cooking?

Lighting and night-lights

Is lighting present and sufficient?

Loose carpets and throw rugs

Are carpets and throw rugs present?

If yes, do they need to be secured or removed?

Pets

Are pets present?

If yes, are they easy to care for?

Smoke and carbon monoxide monitors

Are they present?

If yes, are they functioning and monitored?

Stairs

Does the home have stairs?

If yes, are they carpeted and is the carpeting secure?

Are stairs well lit?

Are there railings?

Tables, chairs, furniture

Is furniture sturdy, balanced, and in good repair?

Utilities (gas or electric)

Are the systems monitored and maintained?

Water source

Is water from a public source or a well?

Is the source functioning and safe?


Adapted from Unwin BK, Jerant AF. The home visit. Am Fam Physician. 1999;60(5):1486.

Medication review and reconciliation is a necessity at every house call. Approximately 14 to 50 percent of older patients may experience medication discrepancies, which are associated with increased rates of rehospitalization.14,27 Discrepancies may be related to patient factors, such as nonadherence or problems obtaining prescription medications. Other factors may also play a role, including prescriptions for different doses of the same medication, errors in discharge medication lists, incorrect labeling, or prescriptions for medications to which the patient is allergic.14,27

Incorporating House Calls into Practice

Incorporating house calls into regular workflow can be challenging. The biggest barriers are travel time, disruption of the office schedule, and a perception of lost revenue. With careful planning, house calls can be a rewarding patient encounter and a refreshing change from clinical routine. Strategies to incorporate house calls into practice include scheduling visits before or after office hours, or incorporating a visit into other business or personal travel. Some physician practices have developed mobile office vehicles for home care services.

Efficient scheduling and coordination of care is essential. Patients are often frail or cognitively impaired, and are at increased risk of becoming lost to medical follow-up; therefore, a dedicated system for tracking is helpful. Working with a chronic disease nurse may help with tracking and coordinating care. Because most visits involve chronic disease management, they can be scheduled in advance and planned by geographic areas, such as by zip code, to minimize driving time between visits. Trip planning software can help avoid delays from poor directions. Table 4 lists suggested supplies for routine house calls.20

Table 4.

Equipment and Documents for a House Call

Physician-supplied

Recommended

Bandage scissors

Cell phone

Cerumen spoons

Gauze/tape/packing

Gloves (sterile and nonsterile)

Glucometer

Lubricant

Maps or global positioning system (GPS)

Otoscope/ophthalmoscope

Phlebotomy equipment

Sharps container

Sphygmomanometer (variety of sizes)

Sterile specimen cups

Stethoscope

Tape measure

Thermometer

Tongue depressors

Tuning fork

Optional

Computer (portable printer and fax, wireless card, electronic health record)

Dictaphone

Externally worn hearing amplifier

Personal digital assistant (PDA)

Portable electrocardiograph

Pulse oximeter

Vaccines (properly stored)

Patient-supplied (as needed)

Glucometer

Home blood pressure monitor

Nebulizer

Peak flow meter

Scale

Documentation

“Advance packet” (names, phone numbers, policies, scope of services, questionnaires and patient forms)

Assessment tools (e.g., Mini-Mental State Examination, Geriatric Depression Scale, Screen for Caregiver Burden)

Billing documentation

Business cards/appointment cards

Patient record

Phonebook of essential community numbers and services

Prescription pad


Adapted from Unwin BK, Jerant AF. The home visit. Am Fam Physician. 1999;60(5):1484.

Table 4.   Equipment and Documents for a House Call

View Table

Table 4.

Equipment and Documents for a House Call

Physician-supplied

Recommended

Bandage scissors

Cell phone

Cerumen spoons

Gauze/tape/packing

Gloves (sterile and nonsterile)

Glucometer

Lubricant

Maps or global positioning system (GPS)

Otoscope/ophthalmoscope

Phlebotomy equipment

Sharps container

Sphygmomanometer (variety of sizes)

Sterile specimen cups

Stethoscope

Tape measure

Thermometer

Tongue depressors

Tuning fork

Optional

Computer (portable printer and fax, wireless card, electronic health record)

Dictaphone

Externally worn hearing amplifier

Personal digital assistant (PDA)

Portable electrocardiograph

Pulse oximeter

Vaccines (properly stored)

Patient-supplied (as needed)

Glucometer

Home blood pressure monitor

Nebulizer

Peak flow meter

Scale

Documentation

“Advance packet” (names, phone numbers, policies, scope of services, questionnaires and patient forms)

Assessment tools (e.g., Mini-Mental State Examination, Geriatric Depression Scale, Screen for Caregiver Burden)

Billing documentation

Business cards/appointment cards

Patient record

Phonebook of essential community numbers and services

Prescription pad


Adapted from Unwin BK, Jerant AF. The home visit. Am Fam Physician. 1999;60(5):1484.

To enhance communication and improve efficiency of care, physicians should coordinate house calls with other health care professionals, such as hospice team members. Examples of health care professionals whose visits can be arranged through a home health agency include the following: dietitian, home health aide, licensed practical nurse, occupational therapist, physical therapist, psychiatric nurse, registered nurse, social worker, speech therapist, and wound care nurse. Wound care can be more efficiently evaluated and managed in conjunction with a nurse partner, and joint visits minimize the need for dressing removals. Hospice visits can include completion of necessary controlled substance refills to avoid delays. Home health and hospice documentation can also be completed.

Providing urgent care for homebound patients is challenging, but possible. Partnering with nurse practitioners can be effective in providing emergent care with minimal disruption to office practice, and can help to avoid the need to transfer the patient out of the home. Advanced planning can mitigate some of the problems associated with home care for acute conditions. An emergency kit of likely medications and supplies can be maintained in the patient's home for use by caregivers, home health nurses, or other clinicians (Table 5).

Table 5.

Suggested Medications for House Call Emergency Kit

Condition Medication

Agitation

Haloperidol (2 mg) for subcutaneous or intramuscular administration

Dehydration

Supplies for hypodermoclysis, including intravenous fluids, infusion set, butterfly needles (21 gauge), tape, occlusive dressing

Dyspnea

Benzodiazepine for subcutaneous or sublingual administration

Opioid for subcutaneous or sublingual administration

Heart failure

Furosemide for subcutaneous administration

Pain

Opioid for subcutaneous or sublingual administration

Seizure

Diazepam (Diastat; 10 mg) for rectal administration

Table 5.   Suggested Medications for House Call Emergency Kit

View Table

Table 5.

Suggested Medications for House Call Emergency Kit

Condition Medication

Agitation

Haloperidol (2 mg) for subcutaneous or intramuscular administration

Dehydration

Supplies for hypodermoclysis, including intravenous fluids, infusion set, butterfly needles (21 gauge), tape, occlusive dressing

Dyspnea

Benzodiazepine for subcutaneous or sublingual administration

Opioid for subcutaneous or sublingual administration

Heart failure

Furosemide for subcutaneous administration

Pain

Opioid for subcutaneous or sublingual administration

Seizure

Diazepam (Diastat; 10 mg) for rectal administration

Documenting house calls is similar to documenting an outpatient clinical visit, but the chief complaint must include justification of the reason for the visit to occur in the home (e.g., patient immobility or other cognitive or emotional inability to go to the office; need for the physician to assess home environment or caregivers). Using a structured visit template can help physicians consistently document common issues encountered during visits. House call billing codes are listed in Table 6.28 A health care professional communication log may be maintained at the patient's home to briefly record visits and care plan changes performed by various home care services. Copies of the visit note may be left with the patient if needed. Some electronic health records can document the house call and bill Medicare wirelessly for the service. Portable printers can also be used to print necessary documents and patient education materials.

Table 6.

CPT Codes for House Calls and Domiciliary Care

CPT code Description

Home visits: new patients

99341

Low severity

99342

Moderate severity

99343

Moderate to high severity

99344

High severity

99345

Unstable

Home visits: established patients

99347

Minor

99348

Low to moderate severity

99349

Moderate to high severity

99350

High severity

Domiciliary or rest home visits: new patients

99324

Low severity

99325

Low to moderate severity

99326

Moderate to high severity

99327

High severity

99328

High complexity

Domiciliary or rest home visit: established patients

99334

Self-limited or minor

99335

Low to moderate severity

99336

Moderate to high severity

99337

Unstable or significant new problem

Care plan oversight

99339

Supervision of patient requiring complex/multidisciplinary care (15 to 29 minutes)

99340

Same as above, 30 minutes or more


CPT = current procedural terminology.

Information from reference 28.

Table 6.   CPT Codes for House Calls and Domiciliary Care

View Table

Table 6.

CPT Codes for House Calls and Domiciliary Care

CPT code Description

Home visits: new patients

99341

Low severity

99342

Moderate severity

99343

Moderate to high severity

99344

High severity

99345

Unstable

Home visits: established patients

99347

Minor

99348

Low to moderate severity

99349

Moderate to high severity

99350

High severity

Domiciliary or rest home visits: new patients

99324

Low severity

99325

Low to moderate severity

99326

Moderate to high severity

99327

High severity

99328

High complexity

Domiciliary or rest home visit: established patients

99334

Self-limited or minor

99335

Low to moderate severity

99336

Moderate to high severity

99337

Unstable or significant new problem

Care plan oversight

99339

Supervision of patient requiring complex/multidisciplinary care (15 to 29 minutes)

99340

Same as above, 30 minutes or more


CPT = current procedural terminology.

Information from reference 28.

Personal Safety

Physicians may be concerned about personal safety while conducting house calls. Common sense practices include keeping staff informed of planned departure and return times, not carrying narcotics or other controlled substances, and avoiding unsafe areas. It may be advisable to avoid carrying a doctor's bag or wearing a white coat so as not to stand out as a physician in neighborhoods where personal safety is an issue.

Potential Impact of Health Systems Innovation

House calls can be an important component of the patient-centered medical home. The joint principles of the patient-centered medical home state that each patient should have a personal physician, physician-directed care, and expanded access to care.29 For the homebound, frail older patients, house calls are essential to manage care and enhance its quality. The joint principles also emphasize that payments should reflect the value of care management. The Patient Protection and Affordable Care Act will create a demonstration project based on the Veterans Affairs' Home Based Primary Care model, and will reimburse physicians for the comprehensive oversight of vulnerable older patients.

The Authors

BRIAN K. UNWIN, COL, MC, USA, is an assistant professor of family medicine and geriatrics at the Uniformed Services University of the Health Sciences, Bethesda, Md.

PAUL E. TATUM III, MD, MSPH, CMD, FAAHPM, is an assistant professor of family medicine at the University of Missouri–Columbia School of Medicine.

Address correspondence to Brian K. Unwin, COL, MC, USA, Uniformed Services University of the Health Sciences, 10405 Stallworth Ct., Fairfax, VA 22032 (e-mail: bunwin@usuhs.mil). Reprints are not available from the authors.

Author disclosure: Nothing to disclose.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Army Medical Department or the U.S. Army Service at large.

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