Insuring Your Health

Health-care overhaul includes pilot program of house calls for elderly patients

  Enlarge Photo    
By Michelle Andrews
Tuesday, July 13, 2010

From the back window of his rowhouse, Karl Schwengel can see the 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 although he lost 60 pounds during a recent hospital stay, he still weighs in at 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. Getting to a clinic or hospital for treatment was a nearly impossible ordeal.

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 to work with him to improve his health. A physical therapist recently joined the team, and now Schwengel is 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 some of these people land in the emergency room or hospital. They may recover, but often the cycle starts over 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 gerontologist George Taler, co-director of the program.

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

The health-care overhaul creates a three-year demonstration project to test the home-visit concept on 10,000 of the sickest, most-expensive-to-treat Medicare enrollees. 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 needed other high-cost care in the past year.

Participating health-care organizations won't receive any money upfront. If they succeed in cutting treatment costs by 5 percent, 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 supporters are pushing for a faster start.

Making a success of these programs is no simple task. 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 visit just 10 or 11 patients a day, far fewer than the 30 or more an office-based doctor would typically see, says Craig Reiff, chief executive of Home Physicians, a 15-year-old company whose 60 clinicians -- including primary-care doctors, podiatrists, nurse practitioners and physician assistants -- serve 12,000 patients in Chicago and Baltimore.

To make the visits pay, Reiff says he has to schedule his clinicians' visits carefully, even though urban patients live relatively close to each other: "It could be very difficult to make it work in rural areas," he says.

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 lose weight and walk again.

"There are so many things I want to do," he says. "I want to take my dog for a walk across the park."

Or maybe to the Capitol.

This column is produced through a collaboration between The Post and Kaiser Health News, an editorially independent news service.

© 2010 The Washington Post Company