House calls for better care, lower cost

Peter Boling, M.D., learned 32 years ago that the doctor’s office or hospital isn’t always the best place to treat elderly patients – not when they suffer from chronic illnesses or infirmities that make it a struggle getting out.

In 1984, Boling started doing house calls as part of Virginia Commonwealth University (VCU) Medical Center’s then brand new VCU House Calls program. For many home-bound elderly, as Boling soon realized, a slight ailment could fester into a crisis, an ambulance and a costly visit to the emergency department (ED).

“I saw people who just did not have any access to care except by ambulance through the ED and then were treated by someone who did not know them,” he says. “They come to the hospital in worse shape, stay longer and spend more time in intensive care.” It’s a care process that Boling calls “fraught with failure and not even remotely patient centered.”

Led by Boling, VCU House Calls changed the way care is provided for many in Richmond’s aging community. Its clinical teams make home visits – to private residences, senior apartments, adult homes, and the like – every weekday to provide both ongoing primary care, as well as urgent care, for patients whose multiple illnesses make them too sick or disabled to come to a clinic or physician’s office.

The team includes physicians, nurse practitioners, social workers, geriatric care managers and a pharmacist. They can arrange home-based blood tests, X-rays, EKG and ultrasound tests. They perform minor procedures, adjust medications and prevent medical crisis. Once a week, the team assembles to discuss their patients and various aspects of their lives.

To participate in the program, patients must live within 15 miles of the hospital. VCU House Calls cares for about 250 patients.

“It’s very rewarding work and we take it very seriously,” says Jay Holdren, director of the hospital’s Center for Advanced Health Management. “It’s truly a team-based approach to care.”

Holdren notes that physicians spend more time with a patient visited at home than is typical in other care settings. “We talk a lot about the patient experience, but the provider experience is an important part of this,” he says. “It’s a great teaching lesson.”

Through the years, VCU House Calls has earned high marks for patient satisfaction and quality care, along with reducing hospital costs for high-cost Medicare beneficiaries by 60%. The program’s success set Boling and other advocates on a campaign to convince federal policymakers that the home-based primary care model has an important role to play in modern medicine.

Their efforts culminated in enactment of a three-year Independence at Home demonstration program as part of the 2010 Affordable Care Act. Congress in July extended the demonstration program for another two years.

“We kept banging at the door often enough that people began to listen,” says Boling, who chairs the medical center’s geriatrics division. “We made sure we provided the hard data … the evidence to go along with our passionate arguments and common-sensical arguments about how this was a way of providing better care at lower cost.”   

VCU Medical Center is one of 17 house-call practices participating in the Medicare demonstration across the country. The hospital is part of the Mid-Atlantic Consortia, along with MedStar Washington (D.C.) Hospital Center and Philadelphia’s University of Pennsylvania Health System. The consortia has about 500 patients in the demonstration.

Through the demonstration program, up to 10,000 high-cost Medicare beneficiaries nationwide can receive primary care services in their homes and care coordination across all treatment settings. Physicians have incentives to reduce the usual costs of caring for chronically ill patients and are held accountable for maintaining quality of care standards and improving patient satisfaction. The first 5% of the savings goes to Medicare, with any remaining savings split between Medicare and the participants.

The Centers for Medicare & Medicaid Services (CMS) last June announced that in Mid-Atlantic Consortia’s first year – September 2012 to September 2013 – it met all six quality measures, including reducing 30-day hospital readmissions, admission rates for patients with the most serious chronic illnesses and ED visits. CMS said the consortia reduced per capita Medicare costs by 20%, and the agency awarded the practice a shared savings payment of $1.8 million.

Overall, the demonstration nationally saved more than $25 million, an average of $3,070 per participating beneficiary, in its first year. CMS later this spring is expected to announce results from the second and third year of the demonstration.

Boling wants the program to become a permanent part of Medicare, saying it has already proven its worth. Savings and performance improvement aside, he says the initiative’s most profound impact is making sure frail elders get quality and dignified care in the comfort of their home, and family caregivers get the support they need.

“The trust that comes with that is a big factor,” he says. “Ít’s part of the special bond that you have with your patients.”

Patients like Dorothy Pope, who died in early January from heart disease at the age of 88. She was Boling’s patient for 30 years. He visited her on Christmas Eve to say goodbye.

Interviewed in August 2014 for a VCU publication on House Calls, Pope expressed her appreciation for her longtime doctor.  “I love him and I wouldn’t have anybody else but him,” she said. “He knows how to talk to me and tells me things that no one else can explain to me. He is a natural and sweet guy.”

Those personal connections to patients are what makes House Calls so rewarding, says Boling. And he’s quick to add: “You will hear patients say the same things about all the members of our team. They have tremendous faith in the individuals who come to their home to provide health care.”