Resurrecting the House Call

It's been 50 years or so since doctors made house calls on a regular basis. In fact, a physician house call was virtually unheard of just a short time ago. But now a new physician model -- the "residentialists" -- are emerging to care for homebound and access-challenged patients.

It has been about 50 years since physicians made house calls on a regular basis. In fact, a physician house call was virtually unheard of just a short time ago. Times change, however, or as Norman Vinn, DO, MBA, founder and chief medical officer of Housecall Doctors Medical Group Inc., likes to say, “Something very old is becoming something very new.”

The healthcare overhaul signed into law earlier this year includes a three-year Medicare demonstration project, called Independence at Home, that will test the home visit concept on 10,000 Medicare enrollees. But Vinn knows the house call marketplace is primed right now. “It’s a growth market, and the Medicare population is growing as we speak.”

Collaborating With Physicians

Vinn founded the Orange County, Calif.-based company about eight years ago, and has seen the practice grow to 15 full- and part-time contracted physicians managing more than 1,000 homebound patients in Orange, Los Angeles, Riverside and San Bernardino counties. He explains that HDMG is a collaborative effort, and that partnering with primary care physicians running traditional medical practices is a strategy that makes sense on both sides of the fence.

“We absolutely applaud and encourage individual physicians who are willing to make periodic or even regular house calls on their homebound and access-challenged patients almost on a regular and routine basis, because these people are often sicker than your average office-based patient,” Vinn explains. “And there is no better way to understand the totality of the patient’s situation than by seeing them in their home environment.”

But there are challenges that make collaborating a more viable option. What HDMG’s clinicians do is referred to as “residentialist care,” which requires a set of competencies and clinical skills from a logistics and dispatch perspective -- not unlike the way hospitalists have replaced physicians dashing out from their office at noon to see three patients in two different hospitals, Vinn says. Just as the hospitalist model has evolved to a core competency in the continuum of care, the care of patients in the home is somewhat of a core competency.

“Now, that does not say that we would not encourage anybody in an office practice to get to know their patients better and embrace the idea of making some house calls,” Vinn says. “However, when you have the ongoing fixed expenses of an office practice and you leave and go make house calls, the fixed expenses of the office practice continue.” Which is why collaborating makes both financial and clinical sense, he says.

Providing More Efficient Care

Raymond Zakhari, EdM, MS, NP, is a primary care nurse practitioner at New York Presbyterian Hospital. He’s also the founder of Metro Medical Direct, bringing healthcare services to patients in New York City. His year-old practice is based on seeing patients who want the convenience of not having to visit a doctor’s office, and he might see anywhere from two to six patients a week.

“You’re hard pressed to find physicians who are willing to make a house call,” Zakhari says. His company serves physicians who don’t make house calls, but who have patients the doctors would like seen at home. These physicians have embraced the model of keeping patients out of the emergency room at all costs, so that healthcare resources are not misused, he says.

“They would ask me to see the patient on their behalf, and then I would fax them back or send them back a report on what’s been done, so that their patient’s not falling through the cracks,” Zakhari says.

In addition, Zakhari’s service enables physicians to discharge patients from the hospital confident that reliable follow-up will be conducted. “Physicians will let the patients know that it’s not an insurance-covered service, but the upside is that the patient doesn’t sit in the hospital for three days,” he says.

Zakhari says he is keeping his overhead contained and growing the practice slowly so that it’s manageable and desirable in 10 years, “when it comes to, hopefully, making it my full-time application.”

The Slow Process of InnovationVinn sees the house call market, and the role of the residentialist, as a disruptive innovation that must go through the very slow diffusion process in healthcare -- a process which he says could take more than a decade before it becomes mainstream.

“The challenge that’s a little less obvious is creating a broad understanding -- a sort of business-to-business understanding that this is a mainstream component of the continuum of care,” Vinn explains. “It took 10 to 12 years, maybe longer, for the hospitalist model to become almost the standard of care for in-patient care. But now it is. And so I look at the residentialist model as being in the midst of a diffusion process.”