Contributors: Shayne Ladak, MD | P. Shaun Barbour, Ph.D.
Remember the old days when you were sick? You called your family doctor and he (yes, they were all men) would make a housecall. Of course you don’t remember this! This hasn’t been the prevailing model of medicine for over 50 years. However, perhaps it should be. We just might have medicine all backwards and should be going back to that model.
The Patient Perspective:
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Author Ami Claxton’s husband Chad has a high-level spinal cord injury – he can shrug his shoulders and turn his head but that is all. To visit a healthcare facility, he must have someone able to get him dressed and into his wheelchair, someone with enough time available to drive him to an appointment, and in a wheelchair accessible van. Now in their case, he has his wife (although time off of her full-time job can be tricky when frequent visits are required) and they own a converted minivan. But for many, perhaps even most, these can be the trifecta of woe – getting up, having a driver and having access to a vehicle.
Furthermore, there are a wide variety of conditions, not just spinal cord injuries, for which it is difficult for a patient to get to an office. The patient may have dementia and be too disoriented to successfully navigate to an office. A patient may have other mobility issues such as those with ALS or MS. Additionally, many patients may have personal transportation issues, such as lack of a reliable car, or may have a medical condition that itself actually contraindicates mobility to get to an office.
The latter issue is especially common in spinal cord injury; these individuals often get pressure sores (decubitus ulcers) on their “sit bones”. The treatment for these sores is to keep all pressure off of the sore until it is healed. This treatment for sores especially includes not getting into his or her wheelchair. This then makes going to a doctor’s office impossible – where treatment is often thwarted by inaccessible facilities for transferring to a table to turn and view a sore anyway.
The Doctor’s Perspective:
As a doctor, seeing a patient in his or her home environment brings a fuller picture of the patient to an exam. There is something in a home visit that cannot be replicated in a sterile 15 minute office visit. First, the patient is wearing his or her own clothes, not a skimpy paper gown that they are nervously holding around themselves. Second, patients are often not (as) nervous within the four walls of their own home. The term “white coat hypertension” exists for a reason! Patients in an office can also be reluctant to ask questions.
In their own home, patients are more comfortable, and with that feeling of comfort comes increased odds that they will be more willing to share their full medical history, articulate what their questions are, and will be more willing to ask questions when they do not understand the diagnosis or treatment you provide.
In addition, the physician gets a more complete picture of the home environment, family support, and even what’s in the patient’s refrigerator. This so-called “refrigerator biopsy” may inform the physician as to their eating habits and the consequent impact on health.
The Bottom Line:
In the area in which we live (Raleigh-Durham, NC), there is a practice, “Doctors Making Housecalls” (DMH), which does exactly what it says – authors of this article Doctors Ladak and Barbour are employees of this practice. Patients call for an appointment and a doctor will come to the patient, and in this case, author Ami Claxton’s husband Chad. While DMH bills insurance as a normal appointment, you must also pay a travel fee of approximately $95 per visit for the doctor to come see you. This may put the service out of the reach of many for financial reasons.
However, medical housecalls have the potential to greatly increase quality of care and ultimately reduce healthcare costs and hospital admissions through improved disease management. DMH is one of sixteen practices throughout the country selected to participate in the Independence at Home demonstration. The purpose of this inquiry is to demonstrate that the physician home visit practice model, officially known as Home-Based Primary Care, can reduce the total cost of care even while improving quality of care and patient satisfaction. Through this research we hope to show that patient home visits greatly reduce costs, increase patient satisfaction, and most importantly will improve patient outcomes.