The Return of the House Call

As the population ages, the medical needs of the oldest and most infirm are projected to greatly weigh on America’s healthcare system.  In an attempt to meet these needs in an economical manner, Healthcare Partners Affiliates Medical Group initiated a house call program for recently discharged patients. Their goal was to provide adequate medical care and social support to obviate unnecessary hospital readmissions, a difficult task considering the majority of enrolled patients were over 85 years old and had over 7 co-morbidities.  The program is structured around geographical regions serviced by medical pods consisting of a physician, nurse practitioners, medical assistants, and social workers. Patients, often referred following a hospital admission, are examined by nurse practitioners then receive a care plan from collaboration with a physician. Contact with the PCP is maintained, although he or she is instructed not to schedule any more appointments with the patient. 24/7 support with triage nurses is offered to provide after-hours and weekend coverage.

Source: Raymond K. Martin (Flickr/CC)

Source: Raymond K. Martin (Flickr/CC)

The results of the program, although lacking robust statistical analysis, appear positive. Health care spending per person per month decreased by approximately half in the three months following enrollment compared to the three months prior to enrollment.  Similarly, emergency department visits per person per month decreased from 0.70 three months before enrollment to 0.29 three months after. Mortality and clinical outcomes were not assessed. Over time, the program saw greater relative reimbursement of nurse practitioners and less towards physicians, likely a move to save costs.

Considering the sublimely disheartening price of health care, our country must find systems that can alleviate this burden while maintaining quality. Initiatives like the House Calls program serve as case studies to guide further tinkering. Although promising, the published results should not spur change without further research.  A comparison of readmission rates and costs between similar groups of people included versus excluded from the House Calls program would make the case more convincing.  Secondly, mortality and clinical outcomes must be studied.  Before advocating for the expansion and insurance coverage of similar house call programs, more proof is necessary.

This Policy Prescriptions® review is written by Chris Frey, a medical student at Baylor College of Medicine, as part of our Health Policy Journal Club Series.

Abstract

In 2009 HealthCare Partners Affiliates Medical Group, based in Southern California, launched House Calls, an in-home program that provides, coordinates, and manages care primarily for recently discharged high-risk, frail, and psychosocially compromised patients. Its purpose is to reduce preventable emergency department visits and hospital readmissions. We present data over time from this well-established program to provide an example for other new programs that are being established across the United States to serve this population with complex needs. The findings show that the initial House Calls structure, staffing patterns, and processes differed across the geographic areas that it served, and that they also evolved over time in different ways. In the same time period, all areas experienced a reduction in operating costs per patient and showed substantial reductions in monthly per patient health care spending and hospital utilization after enrollment in the House Calls program, compared to the period before enrollment. Despite more than five years of experience, the program structure continues to evolve and adjust staffing and other features to accommodate the dynamic nature of this complex patient population.

PMID: 26733698 Melnick, GA et al. Health Affairs. 2016; 35 (1): 28-35.