More and more, we are rediscovering what our predecessors practiced without a second thought: going to see our patients where they live. The modern twist is that they live not just in the family home but in the nursing home, assisted living center and hospice house. As the population ages, family physicians will increasingly have to make the choice between seeing patients where they live or transferring their patients' care to other doctors who will.

For me, the choice has been an easy one because I've seen that house calls lead to better patient care, a stronger practice and a more rewarding career in medicine. In addition, I've found a way to incorporate house calls into my work day without losing my shirt. Here's how and why you should too.

The risks and rewards

You might be thinking, "I don't have time to see all the patients in my office! Why would I want to make house calls?" While it's true that family physicians are under increasing time pressures, there are compelling reasons for making house calls a regular part of your practice.

Patient care. Very simply, house calls are good medicine. As family physicians, we often talk about our ability to provide high-quality, continuous, comprehensive care. House calls can help us fulfill that mission by keeping us in touch with our patients, even those who cannot come to the office. In addition, by visiting patients where they live, we can learn more about them and connect with them on a more personal level.

Marketing. Few things build the public's trust and the desirability of a doctor more than word-of-mouth advertising that "he makes house calls!" As we compete with other practices and other specialties in the managed care world, better service will build a practice. House calls are one of those rare value-added services that will make you outshine your competition.

A feel-good approach to medicine. As we have less and less time to spend with patients during office visits, it can become more difficult to feel personally rewarded for another ear infection well treated. Compared with this, when I go into my patients' homes and see them in the most personal and vulnerable state, I get a sense of walking on hallowed ground. Even visits for simple problems take on a meaningful hue.

Market share. The demographics are simple: America is aging. An estimated 13 percent of the U.S. population is over the age of 65, and by 2025 that age group will grow to nearly 20 percent, according to the U.S. Census Bureau. Many seniors can't get out of their homes, nursing homes or hospice centers. If you want to capture market share, go get it. You may even find that grandma's entire family will choose you as their physician when you impress them with grandma's care.

KEY POINTS: The modern house call means going to see patients where they live, whether it is the family home, nursing home, assisted living center or hospice house. House calls are good medicine, and they can increase a practice's market share and enrich a physician's career. New efficiencies can be learned to make house calls a viable part of any family practice.

Of course there are risks involved with expanding the scope of your practice to include house calls. Two of the greatest concerns are its effects on patient mix and practice efficiency.

If you enjoy a broad mix of patients, you may worry that by expanding your services through house calls you will end up with a disproportionate share of elderly patients in your practice. In my experience, house calls have certainly added some geriatric patients to my practice, but they have added even more adults and adolescents as the children and grandchildren of my elderly patients join my practice.

You may also worry about the implications of seeing one homebound patient at the expense of a half day of office patients. New efficiencies must be learned, but if you consider the care of your homebound patients an essential part of your practice, you'll find a way. The following tips will get you started.

When I go into my patients' homes, I get a sense of walking on hallowed ground.

How to manage a nursing home population

If you are making house calls to patients in a nursing home, keep in mind these suggestions, which will improve your efficiency:

Limit the number of nursing homes you attend. Your patients (or families) who are looking for a nursing home will most likely choose the one you are willing to visit. If you already go to more than one nursing home, consolidate your patients over time (e.g., by seeing new patients at one location only).

The black bag As you begin doing house calls, you will quickly customize your black bag to include those things that you find necessary and convenient. Here is a quick list of things to get you started: Street map, Stethoscope, Blood pressure cuff (regular and large), Pen light, Tongue depressors, Otoscope, Prescription pad, Phone numbers (offices, pharmacies, etc.), Cell phone, palm-held computer, etc. Dictaphone/forms/progress notes, Extra pens.

Don't admit patients to a nursing home you do not plan to visit. It is better to lose that patient to another doctor than to give telephone medicine when a monthly exam is more appropriate. Also don't rely on patients being transported to your office for monthly visits. This quickly leads to unhappy patients and families. If you don't believe me, ask my many patients who have transferred to my care over this very issue -- and who won't tell their former doctors why.

Make sure that you or a partner visits the nursing home once a week and sees every patient at least once a month. Block out the office schedule for the nursing home doc for that half day. Patients who become ill between visits with you can be seen by a partner on his or her turn at the nursing home.

Build a nursing home population of sufficient size so that your trips are fiscally worthwhile. If you would see 12 patients in half a day in the office, try to see at least 12 patients at each visit to the nursing home. For a practice of four physicians, the optimal nursing home population may be 40 to 50. (You can do just fine with half this number though.)

Manage phone calls proactively. This is perhaps the hardest part of nursing home medicine. There are several good strategies:

• Make sure that you or one of your partners goes to every nursing home you round on every week, as discussed previously. You can deal with all the paperwork and order-signing at that time.
• Use "care process models," "care plans" or "nursing protocols" to deal with trivial calls.
• Direct the nursing home staff to call your office with urgent medical problems and emergencies only, and establish a dedicated fax line for all other nursing home related messages and requests.
• Plan to spend at least six months training the nursing home staff on the difference between a request for a laxative and a medical emergency.

Give good service to the patients and treat the staff well. At least 20 percent of my nursing home patients have transferred to my care because of recommendations from nursing home staff and family members of nursing home patients. You can always say "no" to a new patient if your service is larger than you want.

Consider becoming the medical director of the nursing home. If you're going to be there anyway, why not make a little extra money and have a hand in controlling the quality of the services at the facility? As medical director, you can also institute policies, procedures and care plans that will improve patient care and minimize inefficiencies.

If you do become the medical director of the nursing home, do not fall into the trap of answering questions from staff about other doctors' patients, rounding on those patients when the other doctor won't, or taking nursing home call for doctors who won't take their own. In these cases, pick up the phone and do a little "teaching" with the other physician. If you start covering for doctors who won't practice acceptable medicine, you'll end up hating the nursing home. Your job is to improve the quality of the care at the nursing home, not to enable inappropriate behavior from other physicians.

Using forms to decrease work Physicians can create a variety of forms or templates to make house calls more efficient. Here is an example of a progress note form used for house calls to Medicare patients. The form guides you through the necessary home assessment, encourages accurate coding and will help you document the necessity of the home visit. This form can be downloaded as a Microsoft Word file or a PDF file. To access the PDF files, you will need Adobe Acrobat Reader, which you may download free of charge. HOUSE CALL -- Medicare Need for House Call: Pt home-bound O/V requires ambulance transport O/V requires excessive effort/pain CC HPI Physical Exam BP P R T HEENT Lungs Cor Abd Ext Skin Home Environment Patient Activity Support Smells: urine rotting musty OK Walks in home: no assist assist no Family visits: qwk Temp: x/s cold x/s hot OK Uses prescribed walker/cane: y n Friend visits: qwk Clean: clean messy dirty filthy Pt falling: y n freq:____________ Nurse visits: qwk Rugs: Exposed rug edges Pt dresses self: y n HH Aid visits: qwk Furniture: sturdy flimsy cluttered Pt bathes self: y n Meals on wls: qwk Toilet: accessible inaccessible Pt cooks for self: y n   toilet rails shower rails     Phone: accessible inaccessible     Food: healthy balance x/s canned     x/s junk food x/s salt/sugar     Food quantity: adequate scant x/s     Lighting: bright mod dim     Assessment/Plan     New Patient: 99341 99342 99343 99344 99345 Est Patient: 99347 99348 99349 99350 Patient Name: MR#: DOB: Date of Visit: _________________ Signature: ______________________________ Copyright © 2000 American Academy of Family Physicians. Physicians may photocopy or adapt for use in patients' charts. All other rights reserved.

How to manage a homebound or home-hospice population

To best manage your time and resources during visits to homebound or home-hospice patients, consider these tips:

Use home health nurses to their potential. They are free to you! Meet the home health nurse at the patient's home, and communicate care plans directly to the nurse, the patient and the family at the same time. Home health nurses will appreciate a doctor who is willing to work with them and talk to them as people. Add in a couple of house calls, and you will be forever in their hearts. Besides creating better working relationships, this will also bring you new patients.

Use care process models, care plans and nursing protocols with the home health nurses as you do with nursing home staff. This will save time and ensure that you're working toward the same objective.

Minimize travel time. There are several strategies for doing this:

• See both members of a couple at the same time;
• Make house calls when you plan to be in the car anyway (such as on your nursing home half day or on your way to another location);
• Make a group of house calls during the same half day;
• Make a house call at the end of each day (you could work in five house calls per week and make a bit more in production since house calls pay more than office visits).

Dictate your notes in the car. Don't wait until you return to the office or your home. Dictate while the visit is fresh in your mind, and you'll get through it more quickly. In fact, you can dictate on your way to the next visit and waste no time at all.

Be willing to make an unexpected house call now and then when the patient really needs you. You'll find a way to work it in if you think of it as an "admission," but skip the hospital. Your patients, their families and your community will grow to love you, and your practice will thrive.

Coding house calls The table below compares the CPT codes for house calls to similar office-visit codes. House call requirements House call CPT code Approx. time for house calls Similar office-visit code Office visit requirements New patient Problem-focused history and exam Straightforward medical decision making 99341 20 99201 Problem-focused history and exam Straightforward medical decision making Expanded problem-focused history and exam Medical decision making of low complexity 99342 30 99202 Expanded problem-focused history and exam Straightforward medical decision making Detailed history and exam Medical decision making of moderate complexity 99343 45 99203 Detailed history and exam Medical decision making of low complexity Comprehensive history and exam Medical decision making of moderate complexity 99344 60 99204 Comprehensive history and exam Medical decision making of moderate complexity Comprehensive history and exam Medical decision making of high complexity 99345 75 99205 Comprehensive history and exam Medical decision making of high complexity Established patient Problem-focused interval history and exam Straightforward medical decision making 99347 15 99212 Problem-focused history and exam Straightforward medical decision making Expanded problem-focused interval history and exam Medical decision making of low complexity 99348 25 99213 Expanded problem-focused history and exam Medical decision making of low complexity Detailed interval history and exam Medical decision making of moderate complexity 99349 40 99214 Detailed history and exam Medical decision making of moderate complexity Comprehensive interval history and exam Medical decision making of moderate to high complexity 99350 60 99215 Comprehensive history and exam Medical decision making of high complexity

How to manage an inpatient hospice population

For "house calls" to an inpatient hospice population, here's what to expect:

Hospice patients need routine visits for months, which can be scheduled ahead of time. Eventually, they will require unscheduled visits as symptoms worsen. You can use all the above techniques to manage the care of these vulnerable, special patients. But here, you have one additional advantage: the hospice nurse (another free nurse for you). These well-trained professionals will do all they can to make your job easy. They will almost certainly already have standing orders for you to approve, and they are highly autonomous at managing patients' symptoms. You will almost never receive a trivial phone message or a needless request from a hospice nurse. Care of the hospice patient in the home or in the hospice house combines the best of home care and nursing home care. This is a good model to apply to all your homebound and nursing home patients.

What about coding and documentation?

For documentation, the short answer to what works best is whatever works for you. I recommend doing the documentation immediately after the visit, using a one-page progress note form specifically designed for house calls (see page 51) or a dictating machine. Either way, I finish my documentation in my car before I leave the patient's residence.

Remember that house calls pay more than office visits. To be reimbursed at the higher rate by Medicare, you must document the reason a house call was necessary. Reasons include "the patient is home-bound," "an office visit requires ambulance transport" or "an office visit requires excessive physical effort or pain."

House call CPT codes are similar to office visit codes, but there are two major differences. First, the typical face-to-face time is longer with house calls. Second, for house calls to established patients, the lowest code is essentially equivalent to a 99212. (See the comparison on page 53.)

Bottom line

I like house calls. If I hated them, I wouldn't do them even if they were profitable. I suspect you wouldn't either. The biggest obstacle to incorporating house calls into regular practice isn't inadequate reimbursement; it's inadequate training. When we don't have a good, thorough experience with a particular aspect of medicine as residents, we tend not to gravitate toward those things in our practices. Comfort comes from experience. Without comfort in making house calls, we don't do them even though we can and should.

My advice is to do just six house calls. You'll work out the logistics after the first two or three and, by the end of the sixth, have a sense of their value to you as a physician and as a person. If you don't like them, no sweat. Do them when you have to, but otherwise leave them to your colleagues. If you like them, don't look back. It may be the most rewarding experience you have as a doctor.

Editor's note: Please keep in mind that CPT and ICD-9 codes change annually. For the most detailed and up-to-date information, refer to the current CPT manual, the related "Documentation Guidelines for Evaluation and Management Services" and the ICD-9 manual.

Dr. Giovino is director of the Mercy Health System Family Practice Residency Program in Janesville, Wis., and is medical director of Mercy Hospice. He is also a contributing editor to Family Practice Management.

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