It's Oct. 18, 1993, and Thomas Cornwell, M.D., a family physician not too many years out of residency, is on call at an urgent care clinic in Chicago. Unbeknownst to his colleagues, he's also agreed to help launch a home-based primary care model in the Chicago area.
Thomas Cornwell, M.D., visits patient Josh Bowler at the Bowler family home. Josh, a quadriplegic patient, has been in Cornwell's care for nine years.
The clinic phone is ringing and, against all odds (and clinic protocol), Cornwell takes the call. After listening to the caller complain about abdominal pain, he tells her to go the ER. He still remembers her response: "Doesn't anyone make house calls?"
Cornwell tells AAFP News he went to see the patient after he finished his shift. "She was my first patient; she averted a hospitalization." Now, more than two decades later, Cornwell's house call count has reached nearly 32,000 visits to more than 4,000 patients.
Defining Home-Based Primary Care
Cornwell describes house call medicine as "bringing primary care to a mostly elderly population with multiple chronic problems."
The average age of his patients is 80, and one-third are older than 85. "About 8 percent of our patients are under the age of 65," says Cornwell, and most of them suffer from neuromuscular diseases.
- Family physician Thomas Cornwell, M.D., of Wheaton, Ill., has been delivering house call medicine to mostly elderly patients for nearly 20 years.
- Cornwell says house call medicine is seeing a resurgence and can provide home-bound patients with more comprehensive care for far less cost than ER visits and hospital admissions.
- Cornwell's patients and their caregivers appreciate medical care that is fast and efficient and avoids having to transport patients with serious mobility issues.
All of his patients have serious mobility issues that make leaving the house for an office visit difficult on the patient and caregivers alike; hospitals stays are avoided whenever possible.
"You just can't get more patient-centered than when your patients can't leave the home and you show them so much dignity and respect by bringing wonderful care to them," says Cornwell.
Take Tom and Trudy Bowler, who have been providing full-time home care for their son Josh for nine years. A fall from a building left the now 40-year-old with a cervical spine injury and paralysis from the base of his skull down.
"Dr. Cornwell is our lifeline," Trudy tells AAFP News. "He's a godsend. Dr. Cornwell is always at the other end of the phone; we call if we need something and he's always there for us. I can't tell you how many times he's saved us from having to pack Josh up" for an ER visit.
Today, Cornwell stopped by to drain an abscess, says Tom. Earlier in the week, Tom texted the family physician at 7 a.m. with a concern. "He called me at 7:30 a.m. from Washington, where he was receiving an award. He ordered an X-ray, and the tech came here to do it."
Transporting Josh to the hospital for the procedure would have been an eight-hour ordeal, says Tom, but the house call was "fast, efficient and much less stressful" for all involved. Tom and Trudy appreciate that Cornwell considers them partners in taking care of their son. A full-on advocate for house call medicine, Tom says it should be part of the standard discharge procedure for any severely compromised patient.
Thomas Cornwell, M.D., examines Stephanie Klein during a house call visit to her daughter's and son-in-law's home.
Crunching the Numbers
Cornwell describes today's health care climate as setting up a "perfect storm" for the resurgence of house calls. He points to factors such as an aging population, the Medicare and Medicaid fiscal crisis, and health care reform that have spurred CMS to call for a reduction in hospital readmissions and a shift from volume-based to value-based payment.
Cornwell is convinced that shared-savings programs and similar initiatives will demonstrate the value and cost savings achieved when home-bound patients are cared for in their homes. He notes that quality end-of-life care reduces costs and decreases hospital mortality rates, important to hospital administrators looking to avoid CMS penalties.
It's the unaffordable cost of care for the rising tsunami of aging patients that will help drive home-based primary care, Cornwell insists. For instance, according to 2014 statistics from the National Institute for Health Care Management Foundation,(www.nihcm.org) 1 percent of the U.S. population accounted for nearly 23 percent of overall health care spending; the top 5 percent of spenders accounted for 50 percent of all health spending.
House call visits are also a social time for patient Stephanie Klein, who's happy to pose for a picture with Thomas Cornwell, M.D., after he brings her Valentine's Day gifts.
"We've heard for years about providing the right care at the right time in the right place, but no one was thinking the right place was the home," says Cornwell. He notes that in 1930, as much as 50 percent of all medical care occurred in the home. "That decreased to less than 0.6 percent in the 1990s," he says.
"You know, technology is what drove patients to doctors' offices and hospitals, but now, we can have X-rays, ultrasound and any lab we want drawn in the home, and so technology is no longer a barrier.
Happiness at Home
Susan Klein-Weiner says Cornwell has been taking care of her mother, Stephanie Klein, for the past three years. "She has congestive heart failure and has a tremendous amount of arthritis and pain and mobility problems. Dr. Cornwell manages it all," says Klein-Weiner.
"My mother is stable because of Dr. Cornwell, and she is pain-free because of Dr. Cornwell," she adds.
Then there's the equally important caregiver piece. "I am so relieved to have him available to me. I have peace of mind, and I don't have to worry about being the case manager and knowing all this medical stuff that I'm not trained in," says Klein-Weiner.
Health is Primary Panelist Honored by American Geriatrics Society
On May 19, Thomas Cornwell, M.D., of Wheaton, Ill., joined a panel of health care experts to discuss market-specific initiatives and new models of care that are improving patient and community health.
Cornwell, a family physician who is on the front lines of a national movement to revive primary care house calls for home-bound patients, delivered his remarks in Chicago during the third stop of the Health is Primary city tour. The city tour concludes this fall with stops in Denver on Oct. 2 and Detroit on Oct. 21.
The Health is Primary campaign is a product of Family Medicine for America's Health, a partnership of the AAFP and seven other family medicine organizations that is designed to demonstrate how a strong primary care system will enable family physicians to achieve the triple aim of better health, better care delivery and lower costs.
Just days before Cornwell's appearance as a panelist in Chicago, he was honored during the annual meeting of the American Geriatrics Society as the recipient of the 2015 Arnold P. Gold Foundation Humanism in Medicine Award for Practicing Doctors. According to a March 9 press release in which the award was first announced, Cornwell was chosen for his work as a house call physician who exemplifies "compassionate and respectful concern for patient well-being."
Cornwell counts as major successes the fact that more than 90 percent of his patients complete an advance directive document during his first visit and that he's able to gently coax every patient nearing the end of life to agree that "comfort" medications -- like morphine -- be available in the home to avoid any potential suffering.
"I tell patients, 'I hope you don't need it. But if you have suffering at two o'clock in the morning, I want these medications here as insurance -- to make whatever time you have left comfortable.'"
Cornwell also reports that as many as 25 percent of patients in the practice die each year. But remarkably, in 2013, 80 percent of those patients passed away at home. "And it's not because we encourage it, but it's because we talk about it," he says.
Training the Masses
Statistics show that the number of house-call visits by physicians is increasing. For instance, the New England Journal of Medicine reported in 1997(www.nejm.org) that physicians provided 984,000 house calls to Medicare beneficiaries in 1996.
Fast forward to a 2005 letter to JAMA(jama.jamanetwork.com) in which the authors noted that the number of house calls made rose by 43 percent between 1998 and 2004 to more than 2 million visits annually.
But is the tide turning quickly enough?
Payment is the biggest obstacle. "My most common payment in 1997 was $59.37; that was a level two follow-up visit," says Cornwell. Then in the early 2000s, CMS added new codes and increased the relative value units associated with those codes.
"My payments doubled, meaning my most common bill now is $130," but that is still not enough to entice loan-strapped medical students and residents into the house call arena, says Cornwell.
"There are examples all around the country where doctors are going to do well -- and health care systems are going to do well -- by paying doctors fairly to delivery all these cost savings" to the system, he says.
On Oct. 18, 2013, exactly 20 years after making his first house call, Cornwell received $15 million in private funding to, as he puts it, "spread this model of care."
Cornwell is tasked with using the bulk of that money to teach others how to do what he does so well. He notes that educational programs about house call medicine are sprouting up at institutions such as Johns Hopkins School of Medicine in Baltimore and the University of Illinois College of Medicine in Chicago.
Back to the Beginning
Cornwell's foray into house call medicine almost didn't happen. Back in 1986, after being named the outstanding graduate of his medical school class, "I was so dissuaded from going into family medicine -- as if I was throwing away all of my potential," he remembers.
But ultimately, Cornwell completed his residency training at Advocate Lutheran General Hospital in Park Ridge, Ill., and now he stands on the brink of changing the way thousands upon thousands of home-bound Americans are cared for.
"What I love about family medicine is that it's so challenging. And it was my family medicine training that gave me the tools to really take care of such complicated patients," he says.
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