House calls ready to go national

A new Medicare project hopes to expand on the success of community healthcare groups that use home visits for the frail and elderly to improve lives and save money too.

By Michelle Andrews, Special to the Los Angeles Times September 13, 2010From the back window of his row house, Karl Schwengel can see the U.S. Capitol. But the 11 blocks might as well be so many miles, because he can barely walk across his bedroom, let alone go for a stroll.

Schwengel, 79, has congestive heart failure and arthritis. And though he lost 60 pounds during a recent hospital stay, he still weighs 260 pounds.

Last year he was retaining so much fluid that his calves were "almost the size of basketballs," he says, and walking became nearly impossible. When he traveled to a clinic or the hospital for medical treatment — an ordeal in and of itself — he relied on neighbors and an unofficial godson to take him.

All that began to change about six months ago, when a community group put him in contact with the Medical House Call Program at Washington Hospital Center. Now a doctor or nurse practitioner visits him every month to check his vital signs and medications and work with him to improve his health. A physical therapist recently joined the Schwengel team, and now he's practicing using a walker at home.

"The doctor says we're going to work on one problem at a time," he says.

In this era of assembly-line appointments, when you're lucky to get 10 minutes of face time with a physician, the idea of doctors making house calls seems old-fashioned. But for frail, elderly people with multiple health problems, bringing the medical establishment to the patient makes sense.

Because it's hard for these patients to get to the doctor, small problems languish and turn into larger ones. Eventually these patients land in the emergency room or hospital. If they recover, all too often the cycle starts again.

Home visits make financial sense as well, notes Jim Pyles, a Washington lawyer and member of the board of directors of the American Academy of Home Care Physicians. "We found that you could afford to treat a patient for a whole year at home by avoiding just one hospitalization," he says.

Washington Hospital Center's program, which started 11 years ago and serves roughly 600 patients, has reduced expected hospitalizations among participating patients by almost two-thirds, says Dr. George Taler, a gerontologist and co-director of the program.

Now that program and similar ones may get their turn on a national stage.

The healthcare overhaul signed into law this year creates a three-year Medicare demonstration project to test the home visit concept on 10,000 Medicare enrollees who were the sickest and most expensive to treat. To be eligible for the project, called Independence at Home, patients must have multiple chronic conditions and be unable to perform normal daily activities such as bathing and dressing. They must also have been hospitalized or in need of other high-cost care in the last year.

Healthcare organizations that participate in the project won't receive any money up front. If they succeed in cutting treatment costs by 5%, improving health outcomes and getting positive patient reviews, the groups share in any further savings. The program is slated to begin by January 2012, but some are pushing for a faster start.

Supporters say the project is a recognition of the increasing importance placed on growing old at home rather than in institutions. "It will help expand these programs and acknowledge Medicare's role in them," says Elinor Ginzler, a senior vice president at AARP.

But making a success of these program is not simple. Although Medicare pays practitioners more for home visits than for clinic visits, it doesn't pay for time spent traveling or for coordinating patients' care.

Clinicians working for Chicago-based Home Physicians see just 10 or 11 patients a day, far fewer than the 30 or more patients an office-based doctor would typically see, says Chief Executive Craig Reiff. His 15-year-old private company has 60 clinicians — including primary care doctors, podiatrists, nurse practitioners and physician assistants — who serve 12,000 patients in Chicago and Baltimore.

To make the visits pay, Reiff says he has to schedule his clinicians' visits carefully. And he notes that they make calls in tight geographic areas. "It could be very difficult to make it work in rural areas."

Practitioners have had no trouble reaching Karl Schwengel's home in Washington.

"They've done everything in the world for me," he says. With their help, he hopes to keep losing weight and to be able to walk again. "There are so many things I want to do. I want to take my dog for a walk across the park."

Or maybe to the Capitol.

Bonnie - what a great idea. This is the forward-type thinking we need to correct the great disparity in health care quality in this country.