QUALITY: House Calls Make a Comeback For Frail Elderly

In a standard office visit,  Dr. William Zafirau might not have discovered that "Mrs. S" had trouble handling the metered dose inhaler she needed for her chronic obstructive pulmonary disease.

On an old-fashioned house call, Dr. Zafirau had more time with his elderly patient. Time to talk. Time to observe. He learned that the arthritis in her hands made it hard for her to manipulate the inhaler.  He switched her to a nebulizer, and arranged pain relief and physical therapy for her arthritis. She's breathing better now despite her COPD. She is in less pain. She gets out more.

"You learn by being in a patient's home," Dr. Zafirau, a geriatrician at Summa Health System in Akron, OH,   explained in a telephone conversation this week. "You have a whole new level of honesty. There isn't the power differential that exists in the office. Plus it's a lot harder for patients to hide things from you. They want to be polite and not bother you. They don't lie, but it's not full disclosure."

At a patient's home, Dr. Zafirau gets a picture that is both fuller and more nuanced.  He can see when a patient is having trouble managing multiple medications, when medical equipment hasn't been delivered, when a patient cannot navigate safely around his or her own home. "I don't even have to ask. I can see with my own eyes," he said.

The house call program is one of several innovations that Summa has undertaken in the past 15 to 20 years to improve care of patients who are frail, elderly and/or chronically ill.  Well-coordinated care is also often less expensive care. More communication. Less duplication.  Fewer crisis. Shorter and less frequent hospitalizations.

But in our fragmented fee-for-service system,  where various health providers' and payers' interests are often at odds, this kind of model doesn't always work. Home visits and other time-intensive ways of managing and treating the chronically ill -- more face time, fewer tests and procedures -- doesn't make financial sense for physicians working in a fee-for-service environment. (It often doesn't work for the hospitals either.) In our current system, efficiency isn't always compatible with the bottom line.

But Summa has been moving toward becoming an integrated system -- a health system that includes a health plan (for profit), hospitals (nonprofit), a hospital-physician organization, and related resources in the community. It isn't totally integrated yet. But it's on its way, both because Summa has figured out how to make it work economically and because its leaders have a mission. To get where they really want to be, though, they need the incentives changed in the system, new tools to let them become fully integrated, to be an "Accountable Care Organization."

In other words, they need health reform.

"We've been working on all these pieces and parts to bring about integration," including research, teaching and community partnerships, said Dr. Kyle Allen, chief of the division of geriatric medicine and Summa Health's medical director of post-acute and senior services.

"We've built the infrastructure," Dr. Allen added. " Now we're waiting for health reform to give us the right incentives." 

The Summa home visit program began about three years ago. It joined a list of  Summa programs -- including geriatric rehab units,  geriatric intensive care units, a stroke unit, and a transition program developed with area nursing homes -- aimed at the frail elderly. Interdisciplinary teams, trained in geriatrics, focus not only on keeping a heart pumping or the lungs breathing but on minimizing a patient's functional decline. Not all the data has been collected, and not all of it's public (though some has been reported on the AHRQ website here and here.) They haven't reached all their goals, like reducing hospital readmissions across the board as much as they would like. But "the trend lines are in the right direction," Dr. Allen said. Overall, Summa reports that its costs are lower than the national average, outcomes are better, and the health quality cognoscenti are beginning to take note.

Dr. Zafirau's home visits serve about 150 patients with one (usually more) of four conditions -- congestive heart failure, COPD, recurrent aspiration pneumonia, and diabetes. Many also have dementia, depression or both. All have limited mobility and need help taking care of themselves. About half are dual eligibles -- old and/or disabled enough to quality for Medicare, poor enough to quality for Medicaid -- and part of an Ohio Medicaid waiver program aimed at providing home and community based care instead of nursing homes.

 "We are trying to help some of the people that were high utilizers [of health care] but underutilizers of ambulatory care," Dr. Zafirau said. In other words, they wanted to better serve patients who frequently saw the doctor -- but only in the hospital. A geriatrician or nurse practitioner sees each patient at home about once a month -- more if needed, sometimes less if the patient is very stable. They can provide services that are often not available outside a hospital or clinic --  immunization, x-rays, ultrasounds, IV fluids, what Dr. Zafirau calls "one-stop shopping for most of their medical needs." Social workers and nurse care managers are also closely involved; the medical and social services are entwined, which is not always the case in other systems. Mrs. S, for instance, not only has her breathing and arthritis better managed; she's visited by home health aides, and attends an adult day program once a week, alleviating her isolation.

Dr. Zafirau says surveys show a very high patient satisfaction, with almost all rating the home care program as excellent or very good. The patients aren't the only happy campers. 

"I am happier, " said Dr. Zafirau. "I spend more time with my patients, I get to know them more as people. For me that's a positive."