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VNA service well-received by all involved
The Visiting Nurse Association (VNA) HouseCalls, which was founded by the VNA of Greater Philadelphia, provides a needed medical service to homebound patients by sending physicians and advanced practice nurses (APNs) to patients’ homes.
Although the service is fairly new, it has quickly become popular among patients and has had no difficulty recruiting staff, says Lynn T. Rinke, RN, MS, executive vice president and chief operating officer.
Here’s how the physician home care service works:
1. Recruit physicians and physician-extenders.
The home care agency has had little difficulty finding physicians who are willing to be employees and visit patients in their homes.
"Doctors don’t want to be involved with all the billing garbage, and they don’t want the hassle of running a small business," Rinke says. "They just want to see patients."
One of HouseCalls’ physicians said that she wanted to be 100% clinical with no administrative work, Rinke says. "She had a medical assistant she brought with her from her previous practice, and he was the office manager."
Depending on a state’s prescribing and referral regulations, a home care physician practice could save some expenses by having physician-extenders, such as nurse practitioners and physician assistants, also make home care visits. The VNA now has two full-time physicians and four full-time nurse practitioners.
2. Establish services.
The physician home care services include having physicians and nurse practitioners visit homebound patients, typically patients with chronic conditions who are covered by Medicare B insurance. It’s a patient-driven, comprehensive, and collaborative primary care model.
A nurse practitioner will visit each new patient for two to three hours. The visit includes a thorough history and physical and evaluation of the patient’s home environment, and psychosocial and medical history.
Other services include:
• assessing the patient’s ability to perform activities of daily living;
• minor skin surgery;
• writing prescriptions;
• diagnostic tests and medication management;
• Pap smears;
• symptom evaluation and treatment;
• osteopathic manual medicine;
• routine lab services;
• home safety advice;
• caregiver support and advice;
• referral to other medical or community services;
• home care coordination.
The physicians or nurse practitioners typically visit patients once every four to six weeks. They assess patients’ medications and make changes when appropriate. They also assess the patient for comorbidities that were previously not diagnosed, including depression which is common among such patients.
Depressed patients can be seen by HouseCalls’ psychiatric nurse, who may also provide behavioral therapy intervention. The staff also are available to patients on a 24-hour basis through an on-call service.
HouseCalls’ patients may include the physicians’ own patients or patients who are referred by community physicians who do not desire to make home care visits.
"The community doctor usually asks the nurse practitioner," Rinke says. "Usually, the visit targets some specific issue the doctor wants addressed, and then if the patient gets better and goes back to the community doctor’s office, that’s fine."
Often what happens is the HouseCalls service will see the patient for six months or longer, and at some point the community physician will suggest transferring the patient into HouseCalls’ practice, Rinke adds.
HouseCalls potentially could provide a variety of health care services, including foot care, ear lavage, cognitive exams, hospice care, dietary consultation, and others.
Podiatry visits can increase revenue
"One of the services we want to add is podiatry where we hire a podiatrist to make 10-15 home visits per day," Rinke says, adding that this could increase revenues substantially.
The key to making the service successful financially, as well as clinically, is for the physicians and nurse practitioners to learn how to provide every needed health care service during their home visits.
For example, the psychiatric nurse could conduct a mini-mental exam on every patient who has suspected psychological or cognitive difficulties. This exam is reimbursed by Medicare at a rate of $80 to $100. (See following story on how to maximize reimbursement for physician home care services, right.)
3. Organize office to manage reimbursement issues.
One of the main reasons physicians are interested in becoming employees is to eliminate the office management and reimbursement hassles.
HouseCalls has a medical practice director whose job is to run the office like a business while looking closely at the bottom line.
Before hiring the new director, HouseCalls staff have not been collecting all of the reimbursement they were entitled to collect. For instance, no one had time to bother collecting the copay and deductible dollars, which are similar to what patients would pay if they were to visit a doctor at the doctor’s office. "But we hadn’t invested anything into the infrastructure to collect these," Rinke says.
HouseCalls improved its billing process by purchasing an inexpensive software package to generate bills. Physicians generate the bill after a visit by identifying the level of home visit, and any procedures performed in the home. Then the physician ranks the patient’s diagnoses. The electronic bill is then handled by the finance staff, who submit it to Medicare.