House Calls

 

Am Fam Physician. 2020 Aug 15;102(4):211-220.

Related Editorial: The Promise and Challenge of Home Health Services during the COVID-19 Pandemic

Related Blog: Guest Post: Providing House Calls During the COVID-19 Pandemic

The demand for house calls is increasing because of the aging U.S. population, an increase in patients who are homebound, and the acknowledgment of the value of house calls by the public and health care industry. Literature from current U.S. home-based primary care programs describes health care cost savings and improved patient outcomes for older adults and other vulnerable populations. Common indications for house calls are management of acute or chronic illnesses, coordination of a post-hospitalization transition of care, health assessments, and end-of-life care. House calls may also include observation of activities of daily living, medication reconciliation, nutrition assessment, evaluation of primary caregiver stress, and the evaluation of patient safety in the home. Physicians can use the INHOMESSS mnemonic (impairments/immobility, nutrition, home environment, other people, medications, examination, safety, spiritual health, services) as a checklist for providing a comprehensive health assessment. This article reviews key considerations for family physicians when preparing for and conducting house calls or leading teams that provide home-based primary care services. House calls, with careful planning and scheduling, can be successfully and efficiently integrated into family medicine practices, including residency programs, direct primary care practices, and concierge medicine.

House calls, also referred to as home visits, are increasing in the United States.1 Approximately 40% of patient visits in the 1930s were house calls.1,2 By 1996, this decreased to 0.5% because insurance reimbursements for house calls decreased.1,2 The pendulum in the United States is swinging again to house calls because of the need to develop care models for the growing aging population.1,3,4 The proportion of house calls to outpatient clinic visits conducted by family physicians in the United States is unlikely to reach the 1930s levels; however, the number of house calls conducted from 1996 to 2016 doubled.3 Medicare Part B billing and reimbursement for house calls are also increasing, with nearly 2.6 million house calls paid in 2015.5

WHAT'S NEW ON THIS TOPIC

House Calls

There were more than 1,100 direct primary care practices in the United States in 2019, and 68% of these practices offered house calls, including eight practices that were completely mobile (i.e., had no actual office).

A systematic review of nine studies (N = 46,156) evaluating home-based primary care outcomes for homebound older adults reported fewer hospitalizations, hospital bed days of care, emergency department visits, long-term care admissions, and long-term bed days.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Family physicians should refer eligible older adults with frequent hospitalizations to home-based primary care programs because of decreased hospitalization rates and 30-day hospital re-admissions.612

B

Large-scale patient-oriented evidence including systematic review of observational studies and a randomized controlled trial from the U.S. Department of Veterans Affairs home-based primary care program and the report to Congress on Medicare's Independence at Home Demonstration Year 3

For patients with terminal cancer, the patient's goals for end-of-life care and preference for dying at home vs. in the hospital should be assessed.18,2628

B

Limited patient-oriented results from an international systematic review and cross-sectional data

Family physicians should consider using a house call checklist, such as INHOMESSS or similar mnemonics, to prepare for and guide the geriatric assessment of older adults in their home.18

C

Clinical review and expert opinion, recommendations from the American Geriatrics Society

A house call supply bag should include equipment to check vital signs, supplies to take samples for laboratory tests and perform minor procedures, personal protective equipment for the physician, and digital or paper records for documentation.18

C

Clinical review and expert opinion


INHOMESSS = impairments/immobility, nutrition, home environment, other people, medications, examination, safety, spiritual health, services.

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 https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Family physicians should refer eligible older adults with frequent hospitalizations to home-based primary care programs because of decreased hospitalization rates and 30-day hospital re-admissions.612

B

Large-scale patient-oriented evidence including systematic review of observational studies and a randomized controlled

The Authors

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CAITLYN M. RERUCHA, MD, MSEd, FAAFP, is an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md., and is a military physician stationed at Fort Bragg, N.C....

RUBEN SALINAS, JR., MD, FAAFP, is a geriatrician and faculty family physician at the Carl R. Darnall Army Medical Center Family Medicine Residency Program, Fort Hood, Tex.; an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences; and an assistant professor at Texas A&M Health Science Center College of Medicine, Temple.

JACOB SHOOK, DO, is a military physician at Fort Richardson, Alaska. At the time this article was written, he was a senior resident in the Carl R. Darnall Army Medical Center Family Medicine Residency Program.

MARGUERITE DUANE, MD, MHA, FAAFP, is an adjunct associate professor in the Department of Family Medicine at Georgetown University, Washington, D.C.; an associate physician at Modern Mobile Medicine, a direct primary care house call–based practice, in Washington, D.C.; and the cofounder and executive director of Fertility Appreciation Collaborative to Teach the Science, a collaborative project of the Family Medicine Education Consortium, Dayton, Ohio.

Address correspondence to Caitlyn M. Rerucha, MD, MSEd, FAAFP, Battalion Surgeon, Bldg. X-4836 Chaos Lane, Fort Bragg, NC 28310 (email: cmreruchamd@gmail.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

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