The Utility of House Calls in Pulmonary Disease

With the increasing population of adults living into advanced age, there is a growing prevalence of patients who are homebound due to functional impairment. In the United States, an estimated 5.6% of community-dwelling Medicare beneficiaries older than 65 years (approximately 2 million people) were mostly or completely homebound in 2011, exceeding the number of older adults residing in nursing homes.²

Compared with non-homebound patients, this group has been shown to have a greater disease burden, higher mortality rates, and more frequent hospitalizations and utilization of inpatient services.² Lung disease was one of the most common chronic conditions reported by patients in this sample, affecting 29.6% of completely homebound patients.¹

“Given this growing population, pulmonologists will see patients in their practice who become homebound due to disease progression, and will receive new homebound patients who struggle to come in for appointments, but have critical needs for assessment, diagnosis and treatment,” according to a review by McCormick et al, published in CHEST.² With health systems shifting toward payment models focused on value-based care, there has been an increase in the provision of house calls in the United States, although access to subspecialty consultation remains limited.² 

Home Visits in Pulmonology Care

“As the number of house calls grows around the United States, we believe pulmonologists should consider incorporating house calls into their practice,” wrote the investigators.² To that end, they discussed the benefits of house calls for patients with chronic pulmonary disease, as well as logistical considerations for physicians interested in offering this service.

Along with facilitating needed evaluation and treatment that may be inaccessible otherwise, consulting with patients in the home “also provides the ideal environment for assessing function, symptom burden, medication management, need for durable medical equipment and caregiver support,” as stated in the paper.²

Home visits offer a firsthand view of the patient’s current status, available resources, and remaining needs in these areas, as well potential exacerbation triggers including dust, pets, and secondhand smoke. House calls also present the “opportunity to meet family members and caregivers and provide education about disease management [and] prognosis and [to] discuss treatment preferences and goals of care.”

Among logistical issues covered, the researchers summarized preparatory steps for home visits, including common supplies such a stethoscope and blood pressure cuff, portable electrocardiogram, supplies needed for drawing cultures, and patient instructions and additional forms. Other practical considerations are highlighted below. 

Patient Selection

When determining which patients would be most appropriate for house calls, pulmonologists might offer a post-discharge visit to patients with repeated hospitalizations to assess their current medical and psychosocial needs. Other patients who may benefit from home visits include patients who are nonresponsive or nonadherent to medication, patients at the end of life, and patients for whom social determinants of health may be contributing factors in their disease or treatment response.²

“[Patients] who would benefit most from a house call include those with functional decline causing access issues, patients with recurrent [emergency department] visits or hospitalizations postdischarge, and patients who would benefit from a comprehensive medical reconciliation and/or home assessment for triggers of pulmonary disease,” explained coauthor Ania Wajnberg, MD, medical director of Mount Sinai Hospital Ambulatory Care, clinical director of the Division of General Internal Medicine, and associate professor in the Department of Medicine and the Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai in New York, New York.

Meanwhile, telemedicine may be a more suitable “option for more stable patients or patients who can receive some counseling or follow-up without a physical exam or in-person physical assessment,” she told Pulmonology Advisor. 

Frequency and Billing

Depending on the specific practice and patient population, pulmonologists may decide to provide a one-time house call for patients following hospitalization, which has been shown to improve outcomes and reduce readmissions in patients with a range of conditions including chronic obstructive pulmonary disease.³ If resources permit, clinicians may also conduct ongoing home visits for patients with substantial frailty and symptom burden.

In the past decade, clinician reimbursement for house calls has increased, and at the time of the publication by McCormick et al, there were 5 billing codes for house calls with new patients and 4 codes for visits with established patients. There may be further billing opportunities for non-in-person services such as care plan oversight and advance care planning.⁴ These billing considerations are covered in detail in the review.²

Challenges

There are various potential challenges involved in providing house calls, including travel time for the physician. “This can be mitigated by limiting visits to a manageable area and/or grouping visits by location,” said Dr Wajnberg. She and her coinvestigators noted that mapping programs can help optimize this planning, and that some practices use a driver to enable the clinician to complete documentation, care coordination, and other productive tasks while traveling.²

“Other challenges can include home safety, which can be assessed to ensure that patients receiving house calls do not actively use drugs, have weapons, dangerous pets, or other potential risks to providers or staff,” she added. “We recommend calling ahead to confirm visits, visiting patients during daylight hours, and if possible, arranging joint visits with team members, community nurses, trainees or others, as well as having a charged phone.”

Future Directions

While the provision of medical care in the home has been linked to improved patient outcomes, treatment quality, and cost, further “research is needed into the effects of house calls on clinical, satisfaction, and cost outcomes for patients with pulmonary disease,” according to Dr Wajnberg.^2,5

Note: In addition to the information described here, clinicians interested in offering this service can find a range of resources at the American Academy of Home Care Medicine website. 

References

1.      Ornstein KA, Leff B, Covinsky KE, et al. Epidemiology of the homebound population in the United States. JAMA Intern Med. 2015;175(7):1180-1186.

2.      McCormick ET, Escobar C, Wajnberg A. Role of house calls in the care of patients with pulmonary disease [published online November 27, 2019]. CHEST. doi:10.1016/j.chest.2019.10.050

3.      Coleman EA, Parry C, Chalmers S, Min S. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166(17):1822-1828.

4.      Rivera V, DeCherrie LV, Chun A. Review of transitional care management and chronic care management codes for pulmonologists. CHEST. 2018;154(4):972-977.

5.      De Jonge KE, Jamshed N, Gilden D, Kubisiak J, Bruce SR, Taler G. Effects of home based primary care of Medicare costs in high risk elders.J Am Geriatr Soc. 2014; 62(10):1825-1831.