Home Visits:

A Primer
Hugh Silk, MD
with
Gerry Gleich, MD
and Alexa Connell, PhD

What is home
to you? To
others?

Goals of Workshop

Learn about the scope of home care

Gain an appreciation for effectiveness of
home care
Identify the physicians role
Identify the role of other team members
and community resources
Learn the evaluation and assessment of
a home care patient
Learn about financing and regulations of
home care
Define goals of your home visit
assignment

Why do Home
Visits?

Doctor Reasons

Feels good (1 study = 70% of the time

JAGS 48:677-681)
Comprehensive care
Learn a lot that cant be learned in the
office (e.g patients environment,
support systems)
Decrease excessive use of medical
services
Relationship building
Assess adherence issues
Cost containment - Less overhead
Good PR for you

Thoughts on Home
Visits
A description of William Carlos Williams
in Patterson, New Jersey in the 1950s:
his ever-alert watchful eyes; his
attentive-ears, eager for input; and not
least, his heart pounding away with
bodily duty, but also with the grateful
passion of a doc lucky enough to
learn so much in those homes, where
ill kids, or grownups suddenly off kilter
with sickness, become teachers
From Robert Coles, House Calls with
WCW, 2008

Patient Reasons

Patients living longer and live at

home longer

Discharged from hospitals sooner

Ease for patient (immobile, infirm)

13 % of the U.S. is > 65, and by 2025 it will

grow to 20 %
2030 >70 million US citizens will older than
65*

36% of 75-85 year olds cant walk 1

block*

Patients desire home care

Technologies and therapies are

System Reasons

System Reasons

Maryland cost analysis 2001

485 home visits; 57 patients;
($225/visit)
$109, 013 spent

$138,000 saved on ED visits; $1200 per

visit
132 hospitalizations avoided;
$1,188,000 saved; ($9000 per visit)

Importance of
Home Care

?Dying Art?

1930 40% of patient encounters

occurred in the home
1980 1% were house calls

Average number of family physician

visits per week in various setting, May
2005 = <1 home visit/week

Source: American Academy of Family Physicians, Practice Profile I Survey, May 2005

Yet, Fastest Growing

Service Industry in US

Since 1998 300% increase in home

care employment
Expenditures increased from $1
billion to $18 billion from 19801996
>7 million individuals receive home
care in the US
For every patient >65 in a nursing
home, 3 other similar patients are
cared for at home

Medicare Part B billings

1999 1.4 million visits

2009 2.3 million visits
Why?
Change in regulations
50% increase in reimbursement
rates

Effectiveness of
Home Care

Improvement in Care
Level B evidence

Home assessment of healthy elderly

patients found 4 new medical problems
and 8 new health related
recommendations
Ramsdell et al, J Am Geriatric Soc 1989

Home visits have been found to reduce

mortality, re-hospitalizations, and
nursing home admissions
Bouman A et al, BMC Health Serv Res 2008
Stuck AE et al, JAMA 2002
Elkan R et alBMJ2001
Levine SA, et al JAMA 2003
Beales JL et al. Clin Geriatr Med 2009

Prevention

home preventive visits:

delay the onset of disability
improve accuracy of medical
information

J Am Geriatr Soc 1999

J Gen Intern Med 2001

Where?

Home!
Nursing home
Group home
Independent living home
Assisted living home
Family members home
Visiting family member

When?

1 day or half day per week

Cluster by geography

Entire practice
Less Ideal:
Early in the morning
First patient appointment of a session
Lunch time
End of day

You really can have a home

visit only practice!

Medical Economics July 23,

2010; 8-17

Why not done more

often?

Time
Money
Limited technical support
Lack of training
Fewer primary care doctor
Fear

Who?

Urgent
Chronic care
Dying/hospice
Grief support
Death pronouncement
Elderly couples?
New patient
Postpartum mom
and baby
Hospital follow up

Health
promotion/disease
prevention e.g flu shot
Assessment

Polypharmacy
Excessive health
care use
Suspected
abuse/neglect
Change in health
Family meeting
Poor adherence

Who?

Homebound Status
Do not have to be bedridden
Need intermittent skilled nursing, PT,
OT
Inability to leave home or leaving home
requires a considerable effort

Wheelchair, walker
Blind
Demented
Post hospital stay still debilitated
Psych illness
Cant leave home without assistance
Medical contraindication to leave home

Who?

Requested by home health team,

patient, family member
Need to negotiate care plan
Need to assess home environment

Document reason in progress note

Homebound patients

Can leave home to:

Visit the doctor
Go to church
Attend adult day care
Go to family event
A haircut
Walk around the block

More on caregivers

Need a lot of MD support

Need team support
Need to be monitored for burn out,
depression, abusive behavior
Mobilize resources daycare, baby
sitter, friendly visitor (church,
student)

Roles of other
Team Members and
Support Services

Who else can help?

Family members
Office nurse
Visiting nurse
Social worker
OT/PT
PharmD
Geriatrician or FP interested in
Geriatrics
Psychologist/Behavioral Health
Chaplain
Hospice team member
Elder services

What to do
during the
visit?

What to do

I Immobility
N Nutrition
H Housing
O Other people
M - Medications
E Examination
S Safety
S Spiritual Health
S - Services

**Function**

ADLs, IADLs
Fall prevention

Cognitive
Psychosocial
Nutrition

Anatomy of a
Contextual Home Visit

Before
During
After
Context
Context
Context
Context

of
of
of
of

who patient IS
function
community
support

Thoughts about Home

Visits

Often, before we began house

calls (as he called them), Dr
Williams was quick to tell his
young listener to look around,
let your eyes take in the
neighborhood the homes, the
stores, the people and places,
there waiting to tell you, show
you something. It was as if to
this traveling [ ] doc, there were
voices out there, in buildings as
well as individuals, having their

What to take Black

Bag
Scissors
Stethoscope

Oto/ophthalmoscope
BP cuff (many sizes)
Thermometer
Tongue depressor
Sterile cups
Dipsticks/guaiac cards
Lubricant
Latex gloves
Tape measure
Reflex hammer
Suture kit materials
Sharps container

Toe nail clippers

Scale
Med samples/vaccines
Peak flow
Glucometer
Blood drawing
equipment
Cellphone/PDA

Optional
Pulse oximeter
EKG machine
Nebulizer

What to take Paper

Street map or GPS

Prescription pad (for narcotics)/call
prescriptions in
Patient records/Access to EHR
Advanced directive forms
Release of information forms
Informed consent forms
Mini Mental status Card
Patient information Handouts
Billing slips

Teaching Opportunities

Direct Observation
Faculty to senior or junior resident
Senior resident to junior resident
Resident to medical student
Allied Health Professional to
learner/faculty
Patient and family to all of us

After the Visit

Make next
appointment
Chart/dictate
Bill
Follow up
referrals, phone
calls

Billing

Home:

Nursing Home:

New patient 99341-99345

Established patient 99347-50
New patient 99324-99328
Established patient 99334-37 $130-$275*

Document why visit is NECCESARY

Dont forget tests, vaccines

(* 2006 figures)

More on billing

Office
Established patient

99213 = $121
99214 = $181
Preventive Care
40-64 y/o = $266

Home
New Patient

Established patient

1 hour = $568

99342 $78
99343 $126
99344 $165

99348 = $79 (145)

99349 = $115 (229)
99350 = $160

1 hour = $374

Other billing
considerations

Overhead car vs office staff,

utilities
Satisfaction physician, patient
Improving adherence,
comprehensive care -> saves time,
the system, the patient; what is that
savings?????

Finances

For elderly average annual expense

= $3000 for Home Care
~60% Out of Pocket
~10-15% Medicare
~15-20% Medicaid

Finances - Eligibility

Need reason for skilled nursing

Fall risk
Uncontrolled HTN, diabetes
Acute change recent hospitalization

Certification/Recertificati
on

Every 60 days
Document:
Sign Home Health Certification and
Plan of Care
Agree that skilled services are needed
Attest patient is homebound
Must see patient within 60 days then q
6 months
Consider brief note in chart
G0180 (Certification) $51 G0179

Home Visit Doctor

Stories

Successes
Difficult situations

Sample Home Visit

70 year old male

Born in Puerto
Rico
15 siblings
Moved to US in
1957
Worked for 28
years making
handbags in New
York
Met his wife when

Came to Worcester in
1985
Visiting two friends
that were sick and in
the hospital
Has been here ever
since
He and his wife live
by themselves in an
apartment

Sample Home Visit

In 1985, when he
was visiting his
friends in
Worcester, in MVA
Car hit a pole
He has been
quadraplegic ever
since
Dependent on his
wife for all
ADLs/IADLs

He has not moved

from the same
position in bed for 3
years.
Drinks, but does not
like to eat because
the food stinks
Does some
exercises in bed

Issues?

Poor nutrition
Immobility
Infection
Contractures
Little to no supports
Anything else?

Home Visit Assignment

Select a patient
Set up visit
Perform visit
Dictate note including function, safety,
other aspects of contextual visit
Highlight goal setting with patient
Companion (short) essay:
What did you learn that you could not
learn in the office?
How will you now care differently for
your patient
Write about one (or more!) success you
had during the visit

Thoughts on Home
Visits

Dr. Williams would look at buildings, doors,

windows, long and hard before he actually
entered a place to meet people. Once I heard the
fast-waling, very busy doc say this: I like to stop
in my tracks sometimes, watch kids teasing and
touching and daring one another: Ill see grownups tired and worn, or tough and ready to take
on one more day, get through to the next one
and Ill think, theres me, taking it in during
house calls, coming up with my medical pictures
in m y mind, like those artists do with their head
and heart using their easel... So it goes for many
of us: doctors [trying] to figure things out, get
the right medical picture, as do artists, painting
and photographing, trying to get their kind of a
right picture.

References/
Acknowledgements

Unwin BK, Tatum PE. House Calls. AFP

2011;83(8):925-931.
Brand, AL Cashing in on House Calls,
FPM, Feb 2006.
http://www.aafp.org/fpm/20060200/67cash
.html

Giovino JM. House Calls: Taking the

Practice to the Patient, FPM June 2000.
http://www.aafp.org/fpm/20000600/49hous.html

Resources

Questions/Comments