Am Fam Physician. 1999;60(5):1481-1488
With the advent of effective home health programs, an increasing proportion of medical care is being delivered in patients' homes. Since the time before World War II, direct physician involvement in home health care has been minimal. However, patient preferences and key changes in the health care system are now creating an increased need for physician-conducted home visits. To conduct home visits effectively, physicians must acquire fundamental and well-defined attitudes, knowledge and skills in addition to an inexpensive set of portable equipment. “INHOMESSS” (standing for: immobility, nutrition, housing, others, medication, examination, safety, spirituality, services) is an easily remembered mnemonic that provides a framework for the evaluation of a patient's functional status and home environment. Expanded use of the telephone and telemedicine technology may allow busy physicians to conduct time-efficient “virtual” house calls that complement and sometimes replace in-person visits.
In 1990, the American Medical Association (AMA) reported that approximately one half of primary care physicians polled in a national survey indicated that they performed home visits.1 Although most of the physicians surveyed perceived home visits to be an important service, the majority performed only a few such visits per year.1 Consistent with these self-reported behaviors are data indicating that only 0.88 percent of Medicare patients receive home visits from physicians.2 In addition, the Health Care Financing Administration reported charges for only 1.6 million home visits in 1996, an extremely small percentage of the total number of annual physician-patient contacts in the United States.3 These statistics stand in sharp contrast to medical practice before World War II, at which time about 40 percent of patient-physician encounters were in the home.4
The low frequency of home visits by physicians is the result of many coincident factors, including deficits in physician compensation for these visits, time constraints, perceived limitations of technologic support, concerns about the risk of litigation, lack of physician training and exposure, and corporate and individual attitudinal biases. Physicians most likely to perform home visits are older generalists in solo practices. Health care providers who have long-established relationships with their patients are also more likely to utilize house calls. Rural practice setting, older patient age and need for terminal care correlate with an increased frequency of home visits.5
Rationale for Home Visits
Studies suggest that home visits can lead to improved medical care through the discovery of unmet health care needs.6–8 One study found that home assessment of elderly patients with relatively good health status and function resulted in the detection of an average of four new medical problems and up to eight new intervention recommendations per patient.8 Major problems detected included impotence, gait and balance problems, immunization deficits and hypertension. Significantly, these problems had not been expected based on information obtained from outpatient clinic encounters. Other investigators have demonstrated the effectiveness of home visits in assessing unexpected problems in patient compliance with therapeutic regimens.9 Finally, specific home-based interventions, such as adjusting the elderly patient's home environment to prevent falls, have also yielded health benefits.10
Beyond the potential benefit of improved patient care, family physicians who conduct home visits report a higher level of practice satisfaction than those who do not offer this service.5 Physicians with more positive attitudes about home visits are more likely to have conducted house calls during training.11 Faculty mentorship and longitudinal exposure in training appear to be important for the development of positive attitudes toward home visits.5 However, in 1994, only 66 of 123 medical schools offered specific instruction in the role and conduct of home visits.12 Although 83 percent of the medical schools offered students the opportunity to participate in home visits, only three of the 123 schools required students to make five or more such visits.12
Home Health Care Industry
Physician home visits have largely been supplanted by the extensive use of home health care services, a $22.3 billion industry that augments a medical system largely comprising facility-based health care providers.13 The mean annual frequency of home health referrals was 43 per provider in a study published in 1992.14
Family physicians have authorization and supervision responsibilities for a broad spectrum of skilled services that can be offered in the home. Such services include home health nursing, assistance from home health aides, and physical, occupational and speech therapy. Other health care support services are provided by medical supply companies, respiratory therapists, nutritionists, intravenous therapy services, hospice organizations, respite care services, Meals-on-Wheels volunteers and bereavement support staff. Family physicians also work extensively with social workers, who provide invaluable assistance in coordinating these services.
Thus, effective use of home care services has become a core competency for family physicians. In 1998, the AMA published the second edition of Medical Management of the Home Care Patient: Guidelines for Physicians.15 The basic physician home care responsibilities outlined in that document are listed in Table 1.15
Recent data suggest that many physicians do not have the necessary knowledge and skills to perform these tasks effectively. For example, a survey found that 64 percent of physicians who had signed claims for care plans that were later disallowed had relied on a home health agency to prepare the plan of care, and 60 percent were not aware of the homebound requirement for home services.16 Thus, increased physician education about home visits seems necessary if the responsibilities and obligations created by the expansion of home health care industry are to be fulfilled.
Types of Home Visits
The four major types of home visits are illness visits, visits to dying patients, home assessment visits and follow-up visits after hospitalization (Table 2).17,18 The illness home visit involves an assessment of the patient and the provision of care in the setting of acute or chronic illness, often in coordination with one or more home health agencies. Emergency illness visits are infrequent and impractical for the typical office-based physician.
|Illness home visits|
|Dying patient home visits|
|Pronouncement of death|
|Assessment home visits|
|Polypharmacy and/or multiple medical problems|
|Excessive use of health care services|
|Immobility, social isolation or suspected abuse or neglect|
|Recent catastrophic diagnoses or possible need for nursing home placement|
|Hospitalization follow-up home visits|
|Acute illness, injury or surgery|
|Parents with newborn infants|
The dying patient home visit is made to provide care to the home-bound patient who has a terminal disease, usually in coordination with a hospice agency. The family physician can provide valuable medical and emotional support to family members before, during and after the death of a patient in the home environment. Family assistance involves evaluating the coping behaviors of survivors and assessing the medical, psychosocial, environmental and financial resources of the remaining family members.
The assessment home visit can also be described as an investigational visit during which the physician evaluates the role of the home environment in the patient's health status. An assessment visit is often made when a patient is suspected of poor compliance or has been making excessive use of health care resources. Medication use can be evaluated in the patient who is taking many drugs (polypharmacy) because of multiple medical problems. Evaluation of the home environment of the “at-risk” patient can reveal evidence of abuse, neglect or social isolation. Patients and family members who are trying to cope with chronic problems such as cognitive impairment or incontinence may particularly benefit from this evaluation. A joint assessment home visit facilitates coordination of the efforts of home health agencies and the physician. Finally, an assessment home visit is invaluable in assessing the need for nursing home placement of a frail elderly patient with uncertain social support.
The hospitalization follow-up home visit is useful when significant life changes have occurred. For example, a home visit after the birth of a new baby provides an excellent opportunity to discuss wellness and prevention issues and to address parental concerns. A home visit after a major illness or surgery can be useful in evaluating the coping behaviors of the patient and family members, as well as the effectiveness of the home health care plan.
Many aspects of physician home care have not been evaluated in the literature. However, it seems likely that properly focused and conducted home visits can enhance home health care delivery, improve patient satisfaction and strengthen the doctor-patient relationship.
Conducting the Home Visit
EQUIPMENT AND PLANNING
Most equipment for a home visit can still be carried in the family physician's “black bag” (Table 3). Some additional items may be acquired from the patient's home.
|Otoscope and ophthalmoscope|
|Patient records and charting materials|
|Sphygmomanometer (various cuff sizes)|
|Sterile specimen cups|
|Stool guaiac cards|
|Patient education materials|
|Other supplies as dictated by patient need|
|Patient-supplied equipment (as needed)|
|Peak flow meter|
One of the keys to conducting a successful home visit is to clarify the reason for the visit and carefully plan the agenda. Preplanning allows the physician to gather the necessary equipment and patient education materials before departure. The physician should have a map, the patient's telephone number and directions to the patient's home. The physician, patient and home care team should set a formal appointment time for the visit. Coordinating the house call to allow for the presence of key family members or significant others can enhance communication and satisfaction with care. Finally, confirming the appointment time with all involved parties before departure from the office is a common courtesy to the family as well as a wise time-management strategy.
HOME VISIT CHECKLIST: “INHOMESSS”
The INHOME mnemonic was devised to help family physicians remember the items to be assessed during the home visit directed at a patient's functional status and living environment.19 This mnemonic can be expanded to “INHOMESSS,” which incorporates investigations of safety issues, spiritual health and home health agencies (Table 4).19
Immobility. Evaluation of the patient's functional activities includes assessment of the activities of daily living (bathing, transfer, dressing, toileting, feeding, continence) and the instrumental activities of daily living (using the telephone, administering medications, paying bills, shopping for food, preparing meals, doing housework). The physician can ask the patient to demonstrate elements of the daily routine, such as getting out of bed, performing personal hygiene and leisure activities, and getting in and out of a car. Corrective interventions can be directed at any deficiencies noted. For example, modified pill-bottle caps can be obtained for the patient who has trouble opening medication containers because of a condition such as arthritis.
Nutrition. The physician should assess the patient's current state of nutrition, eating behaviors and food preferences. Permission to look in the refrigerator or cupboard can be obtained by asking open-ended but directed questions. For example, the physician might say, “We have been working hard on your diet to control your diabetes. Would you mind if I look in your refrigerator to see the types of foods you eat?” Improvements in product labeling allow the physician to assess serving sizes and the nutritional value of foods with relative ease. Healthy food preparation techniques can also be reviewed with the patient.
Home Environment. The patient's home environment should allow for privacy, social interaction and both spiritual and emotional comfort and safety. A safe neighborhood with close proximity to services is important for many older patients. The home may reflect pride in the patient's family and past accomplishments and reveal the patient's interests and hobbies. The physician should not make assumptions about social class or material wealth based on the patient's physical environment.
Other People. Having the patient's social support system present at the home visit clarifies the roles and concerns of family members. During routine visits, the physician can assess the availability of emergency help for the patient from family members and friends and can clarify specific issues, such as who is to serve as surrogate for the patient in the event of incapacitation. Discussion of a durable power of attorney and a living will may be more comfortably performed during the home visit than in the usual clinic visit. Evaluation of the caregiver's needs and risk of burnout is critically important.
Medications. To remedy or avoid polypharmacy, the physician must evaluate the type, amount and frequency of medications, and the organization and methods of medication delivery. An inventory of the patient's medicine cabinet can provide clues to previously unidentified drug-drug or drug-food interactions. A home medication review can also allow a direct estimate of patient compliance, uncover evidence of “doctor shopping” and identify the use or abuse of over-the-counter medications and herbal remedies.
Examination. The home visit should include a directed physical examination based on the needs of the patient and the physician's agenda. Practical, function-related examination techniques may include having the patient demonstrate getting on and off the toilet or in and out of the bathtub. The physician can have the patient demonstrate proper technique for the self-monitoring of blood glucose levels. In addition, the physician can weigh the patient and obtain a blood pressure measurement. In-person correlation of home and office measures provides useful information for future telephone and clinic contacts.
Safety. Common home safety issues are listed in Table 5. The goal of the home safety assessment is to determine whether the patient's environment is comfortable and safe (no unreasonable risk of injury). To raise the subject, the physician should simply state the intention to identify and help modify potential safety hazards. For example, furniture placement or throw rugs may create problems for an elderly patient with gait instability, or the tap water may be so hot that the patient is at risk for scald injury.20
|Areas to be assessed||Questions to consider|
|Kitchen safety (especially use of gas stove)||Is it easy to tell when a burner or oven gas is turned on or off? Does the patient wear loose garments when cooking?|
|Bathroom safety||Are hand-holds in appropriate places? Can the toilet seat be raised, if needed? Does the shower or bathtub have a nonslip surface? Is the floor of the bathroom slick?|
|Stairs||Are stairs well lit? If carpeting is present, is it secure?|
|Gas or electric utilities||Which systems does the home have? Are systems checked and properly maintained?|
|Heating and air-conditioning||Are the controls accessible and easy to read?|
|Hot water heater||Is the temperature below 49°C (120°F)?20|
|Water source||Is water from a public service or a well?|
|Emergency actions and evacuation route||Are emergency numbers on or near the telephone? Is there a means of exit in case of emergency?|
|Electrical cords||Are cords frayed or lying across walking paths?|
|Lighting and night lights||Is the wattage sufficient?|
|Fire and smoke detectors and fire extinguishers||Are fire extinguishers present and accessible? Are fire and smoke detectors present? Are batteries charged or changed regularly?|
|Loose carpets and throw rugs||Can loose carpets and throw rugs be secured or removed?|
|Tables, chairs and other furniture||Is furniture sturdy and well-balanced?|
|Pets||Are the animals easy to care for and to feed?|
Spiritual Health. If the home contains religious objects or reading materials, the physician can ask about the influence of spiritual beliefs on the patient's sense of physical and emotional health. This information may provide the impetus, as desired by the patient, for a discussion of spirituality as a coping and healing strategy.
Services. Having members of cooperating home health agencies present for the house call can enhance communication and cooperation among the physician, patient and agencies. Existing orders can be clarified, priorities for future care can be established and other perspectives on the care plan can be solicited. The patient's relationship with home health agency providers can also be assessed.
Elements of the INHOMESSS mnemonic may be used independently, based on the needs of the patient and the physician's agenda. For example, the physician may wish to focus on polypharmacy and safety in a patient with a recent fall, or to assess mobility and the extent of social support in a patient with newly diagnosed Alzheimer's disease. Figure 1 presents the major elements of the home visit in a checklist format that facilitates comprehensive assessment.
INTEGRATING HOME VISITS INTO CLINICAL PRACTICE
Lack of reimbursement and the busy pace of office practice are the reasons commonly cited for not conducting house calls. Poorly organized, sporadic home visits may indeed interfere with clinical practice. Therefore, it is important to develop a systematic approach for planning home visits.21
Most practices will benefit from using home visits with patients who have difficulty accessing outpatient facilities because of sensory impairment, immobility or transportation problems. Removing such logistically difficult appointments from the clinic schedule and performing them in the home setting may actually enhance clinic functioning. Clustering home visits by geographic location and within defined blocks of time may also improve efficiency. Finally, nurse practitioners and physician assistants can conduct visits as part of a home health care delivery team.
|Code||Visit description||Medicare reimbursement*|
|99341||New patient, low severity||$ 52.85|
|99342||New patient, moderate severity||74.10|
|99343||New patient, moderate to high severity||107.51|
|99344||New patient, high severity||137.84|
|99345||New patient, unstable||165.63|
|99347||Established patient, minor||41.60|
|99348||Established patient, low to moderate severity||62.19|
|99349||Established patient, moderate to high severity||91.88|
|99350||Established patient, high severity||132.80|
Telephone Calls and Telemedicine
Proactive telephone calls are an underutilized method of conducting highly focused and time-efficient “virtual” home visits.23 Provider-initiated telephone calls can be used to reassure family members after a patient has had an acute illness or has been hospitalized.23 These calls can also be helpful in reinforcing patient compliance with new medications, following patients with chronic diseases and reducing inappropriate use of primary care clinic or office services.24
As fewer patients are admitted to hospitals and hospital stays become ever briefer, the medical complexity of home care will increase, as will the demand for both in-person and “virtual” physician home visits. Physicians interested in obtaining additional information about home care provision can contact the American Academy of Home Care Physicians (P.O. Box 1037, Edgewood, MD 21040; Web address: http://www.aahcp.org/).