The House Call Redux
Morning rounds took place on a recent Friday with my professor Daniel Pound, a family physician, but it was not the usual series of case presentations. Instead of discussing elderly patients' diagnoses and then visiting them in their hospital rooms, we got into his Honda Civic, drove through the streets of San Francisco's Sunset district, and rang the doorbells at each of our patients' homes. Dr. Pound entered with his black briefcase--a portable primary-care office packed with a stethoscope, prescription pad, and blood pressure cuff--and greeted each of his patients like an old relative.
These visits are not just the resurrection of a quaint, old-fashioned practice but an increasingly essential extension of healthcare these days. There are 2 million chronically homebound patients now, and that number will most likely rise as the population of elderly doubles in the next 20 years. The government has recognized this need: Medicare's reimbursement rates for home-care visits nearly doubled in 1998. Since 1999, the number of such visits has risen by more than 25 percent to more than 1.8 million in 2003.
Medical educators have taken note, as well. At the University of California-San Francisco, where I am a fourth-year medical student, the home visit is a requirement in two clinical rotations, family medicine and pediatrics. Residency programs, too, are starting to view the home visit as a necessary skill. The American Academy of Home Care Physicians developed a curriculum for faculty in 2000 to teach residents how to execute a proper home visit.
Finances. But don't expect your doctor to be knocking at your door soon. Home visits are financially straining. Pound, for example, follows about 20 patients at any given time--the median age is 91--who are homebound because of dementia, fatigue, inability to walk, or poor vision. He does his visits every Friday morning, scheduling one patient per hour.
Even though reimbursement per visit has substantially increased, the money does not match the revenue Pound makes from seeing three patients per hour in the office. He is able to stay afloat because of subsidy from his own geriatric practice and the beneficence of the university.
Constance Row, executive director of the American Academy of Home Care Physicians, notes that the impetus for doing home visits is ultimately rooted in the desire to do what's best for the patient. "People do it because they really do care about homebound patients," she says. "They want a style of practice where they can meet the needs of patients with chronic illness."
The home visit is a Luddite's dream. It calls upon the old stalwarts, history taking and physical exam skills. Instead of sending patients for an echocardiogram or pulmonary function test, just go ahead and treat, Pound advises. But if further diagnosis is necessary, home X-rays are an option or, alternatively, calling an ambulance.
The home-visit requirement for my courses initially felt like a big headache, with logistics to coordinate and patients who kept canceling. But to my surprise, when I actually made the visits, they taught me volumes about my patients. Seeing patients in their natural habitat, rather than the sterile clinic room, gave me a much better understanding of their illnesses.
On my pediatrics rotation, for example, I saw a 3-year-old girl who had iron-deficiency anemia. After several months of the doctor's counseling the mother about dietary changes, her condition had not improved. When I did the home visit, I learned that she lived in the back of her parents' convenience store, sleeping six across in a 10-by-10-foot room, with no shower and no kitchen. She spent most days playing in the store--with access to lots of junk food--because the neighborhood was not safe enough to play outside. Only by visiting her home could I have figured out why she had stayed iron deficient: There was nowhere for her mother to cook meat and spinach and other iron-rich foods, and candy bars tasted better anyway, right?
Home visits are also just plain fun. I got a glimpse of old San Francisco as we chatted with a patient in her parlor in a home where she had lived for the previous 72 years. A classmate got to meet a 106-year-old patient, a living wonder on no medications. Pound says that he does home visits because they help him take better care of all his elderly patients. But there's another key reason, he adds: "It's harder for my office staff to interrupt me."
This story appears in the May 30, 2005 print edition of U.S. News & World Report.
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