House calls becoming important part of hospice
House calls becoming important part of hospice
Home visits best for evaluations, recertifications
The trip to the doctor's office is too much for the 82-year-old patient with Parkinson's to make. His elderly wife knows that she'd have to call an ambulance to take him because of a knee injury that makes it impossible for him to walk.
He stills sees a doctor on a regular basis. The doctor checks his heart and lungs, talks about his medications, and examines his knee. All of this takes place in the patient's living room.
"We've always done home visits but not in the formal, organized manner that we established about three years ago," says Bruce Agneberg, MD, chief medical officer for HospiceCare in Madison, WI. A group of physicians who are employed by the hospice are available to visit the 600 patients served by the hospice. Referrals are made to the physician group in three ways:
Patient and family members request a house call from the hospice physician.
Primary care physician requests a visit from the hospice physician for pain management or other specialty evaluation.
Interdisciplinary team of hospice caregivers requests the visit for recertification or an additional clinical opinion.
No matter which way the referral comes to the hospice physicians, it is important to maintain communication with the primary care physician, points out Agneberg. "We are a community-based organization, and we depend upon relationships with other health care providers. We don't actively recruit patients for our practice, and we want community physicians to know that we are here to enhance their patient's care, not steal their patients," he adds.
The physician house call program at Cleveland Clinic Home Health and Hospice has been in place only since July 2008, but the benefits to patient care are immediate, says Steven Landers, MD, medical director for the agency. "Right now, it is just me visiting patients, but I also consult with home health nurses," he reports. Another benefit to a staff physician who can make house calls is the improvement in communication between physician and home health staff, Landers adds. "A nurse may have trouble reaching a physician for a change in medication or an order for a blood test, but I can review the case and call the physician with my recommendation, and we get a faster response," he explains.
Sometimes it is not necessary for Landers to call, just a statement from the nurse that "Dr. Landers recommends" something, is enough for the physician to approve the change, he says.
There are several different models for a physician house call program that can be implemented by a hospice, says Landers. "Some agencies will use physicians who are full-time employees of the hospice, while others will contract with local physicians for part of their practice to include hospice home visits," he explains. "You can start a program with one physician and also use physician assistants or nurse practitioners working under the supervision of the physician."
The model that works best for any agency will differ according to the community, the agency's needs, and relationships with local physicians.
Choose doctors who can work on their own
The key to success is the individual chosen to make the house calls, says Agneberg.
"The right physician is comfortable in the home setting, is highly skilled at diagnosing patients, can work on his or her own and, has a good bedside manner," he says.
Being able to work on his or her own might be the toughest challenge because the doctor can't call the lab to draw blood, Agneberg points out. While on a house call, the physician not only determines what blood work might be necessary, but also draws the blood to send to the lab, he points out. "Most importantly, the physician must be excited and passionate about hospice care and the ability to let patients stay where they want to stay," he adds.
Most physicians that he has found to enter hospice care are in their 50s and 60s and ready to return to a simpler way of practicing, says Agneberg. "We are at the point in our life where we've accomplished many or most of our career goals, but we're asking ourselves why we went into medicine," he says. The pressures of maintaining an office practice and losing touch with patients often spurs physicians to volunteer with hospices, so it is a natural progression to work in hospice, he points out.
House call physicians should have a strong background in internal or family medicine, preferably with some training in geriatrics, says Landers. "Most of our patients are elderly, so familiarity with the risk of falls and medications, late life depression, and functional challenges is an important part of all evaluations," he says.
Physicians can be certified by the American Board of Hospice and Palliative Medicine (www. abhpm.org) to demonstrate a specific knowledge of hospice and palliative care, Agneberg says. While this certification is not essential for a hospice house call physician, it does provide the extra level of knowledge that is beneficial to a program, he says.
One step that any hospice or home health agency needs to take before implementing a physician house call program is to carefully review reimbursement requirements, suggests Landers. Agencies must be prepared to bill for physician reimbursement, outpatient procedure reimbursement, and home health or hospice reimbursement, he points out. "Be aware that if you are in a market with a high penetration of Medicare Advantage, read the payment policies closely," he says. "They are not as straightforward as traditional Medicare."
Overall, physician house calls improve the quality of care provided by the hospice, says Landers. "You get to see people in their own homes," he says. Seeing their environment gives you a chance to see how they manage their medications, what food they eat, or how safe their physical environment is for their condition, he says. "You learn things you normally wouldn't learn in an office setting," Landers says.
Need More Information?
For more information about physician house calls, contact:
Bruce Agneberg, MD, Chief Medical Officer, HospiceCare, 5395 E. Cheryl Parkway, Madison, WI 53711. Telephone: (608) 327-7119. E-mail: [email protected].
Sten Landers, MD, Medical Director for Home Health Care, Cleveland Clinic, Mail Code RK30, 9500 Euclid Ave., Cleveland, OH 44195. Telephone: (216) 636-7870. E-mail: [email protected].
The American Academy of Home Care Physicians offers a variety of publications, articles, and presentations on issues related to house calls, including reimbursement issues. Go to www.aahcp.org and select "educational materials" and "info for home care professional/health care providers."The trip to the doctor's office is too much for the 82-year-old patient with Parkinson's to make. His elderly wife knows that she'd have to call an ambulance to take him because of a knee injury that makes it impossible for him to walk
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