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

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

This clinical content conforms to AAFP criteria for CME.

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

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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.

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 BLarge-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 BLimited 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 CClinical 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 CClinical review and expert opinion

The increasing popularity of and call for home-based care have led to an increased need to study the outcomes and design of home-based primary care models in the United States. The two largest home-based primary care studies are the Centers for Medicare and Medicaid Services Independence at Home Demonstration and the U.S. Department of Veterans Affairs home-based primary care program.6,7 The Independence at Home program demonstrated a 23% reduction in hospitalizations, a 27% decrease in 30-day readmissions, and a cost savings of $111 per beneficiary per month, which is a $70 million savings over three years.710 Similarly, a large systematic review (N = 46,154; nine studies) 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 of care.11 The U.S. Department of Veterans Affairs home-based primary care study of chronically ill, frail adults (N = 179) in urban populations also found fewer hospital admissions and bed days of care, but no change in emergency department use.12

House calls benefit patients post-hospitalization by reducing readmission rates, associated health care costs, and errors related to transitions of care.13,14 There is an increased need for home-based care for the most vulnerable populations because of the recent shift in the United States toward value-based health care.1,3 In 2011, there were 2 million homebound people in the United States, of which only 12% reported receiving home-based primary care.15 This number is expected to increase to 4 million by 2030.1

House calls also benefit patients with socioeconomic barriers to care, including pregnant patients and children who are at high risk of abuse.16 Nurse- or social worker–led home visiting programs have reduced child maltreatment, decreased child health care overutilization, and improved cognitive skills of children born to a low income household with limited psychological resources.1618 Outcome data for physician-led house calls are limited for younger populations because most data are from studies on older adults. A meta-analysis of 51 studies of home-based family care reported small, statistically significant improvements in child cognitive outcomes, maternal life outcomes, and parental behaviors and skills.19 Additionally, a Cochrane review of 11,000 newly postpartum patients receiving frequent in-home visits from interdisciplinary teams showed a decrease in infant health service utilization and an increase in maternal interest in exclusive breastfeeding.20

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