Get the Door, It’s the Doctor: House Calls for Older Patients in San Francisco

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Carol Jenkins Hill has been unable to walk since breaking her ankle two years ago. Her mobility was poor even before that, and despite physical therapy it’s almost impossible for the 73-year old to put weight on her legs. That keeps Hill, who lives in San Francisco, from doing many of the things she enjoys, like getting out to see friends. But, more significantly, it keeps her from doing the things she must do, like regular checkups at the doctor.

So, the doctor comes to her.

Hill used to get her care at St. Mary’s Medical Center in San Francisco before the accident, and when she contacted the hospital to say she could no longer make it in, a social worker referred her to the University of California/San Francisco Care at Home Housecalls Program which provides primary care to homebound seniors.

Now, a physician comes to see Hill at least every other month, nurses give flu shots in her living room and social workers from the program set up other at-home services like physical therapy and work on coordination with her home care aides.

“Without this I don’t know how I’d see a doctor,” says Hill, who would need an ambulance, which is not covered by Medicare, and not affordable on her fixed income, to get her to a doctor’s office.

UCSF’s House Calls program started in the early 1990s as a training module for medical students and residents. Need and demand have helped the program grow to a current 300 patients and another 100 on a waiting list, says Dr. Carla Perissinotto, an attending physician in the program and Carol Hill’s personal physician. New technology has expanded the program’s capabilities including portable x-ray and ultrasound equipment. Dr. Perissinotto recently used telehealth technology to check a patient’s skin infection, and gerontology residents at UCSF who are part of the visiting staff often use the telehealth technology during a patient visit to consult with attending physicians.

Patients’ families often struggle for enough superlatives to describe how much they appreciate the at-home program. “The heavens parted” is how one son in his sixties describes how he felt when his mother, a San Franciscan in her 90s, came off the waiting list. Having doctors and nurses come to the house for people who are homebound, means children, who may leave far from their parent, or other caregivers, don’t have to hire an ambulance at their own cost or risk the older person falling while out of the house or have to deal with the exhaustion and disorientation trips outside can cause for homebound seniors.

Just as important, the program has doctors on call 24/7 who have immediate access to every patient’s files. When the San Franciscan in her 90s, who didn’t want to be identified by name for this story, recently fell out of bed at her assisted living facility, staff there wanted to rush her to the emergency room to check for broken bones. Her son insisted they first contact the Housecalls physician on call. The doctor listened to a description of the fall and the patient’s symptoms and told the staff to take the patient back to bed, certain no bones were broken. A program doctor checked the patient in her room the next day and found a small bruise on her head, but no breaks. “That hospital visit could have set her back so badly,” says her son.

The on-call doctor, though, doesn’t always rule out a trip to the hospital. Elizabeth Prosek’s father, who died earlier this year at age 87, suffered from congestive heart failure and one night suddenly felt hot and then cold. His daughter called the Housecalls doctor on call for a treatment suggestion but instead got advice to head to the emergency room immediately where they quickly treated her dad for an infection.

If patients move from home to assisted living in the area, they often can remain in the Housecalls program—which keeps care from being disrupted.

Dr. Perissinotto says an earlier version of the Housecalls program got attention from UCSF hospital directors about ten years ago when it was a small demonstration program for older patients discharged from the hospital. Planned as a stop-gap until the patients could go back to making the trip to the doctor, the program showed that it in fact reduced hospital readmissions . Now, early findings from a much national trial show the concept can also save money.

When the Affordable Care Act was passed in 2010, it included funding for a three year senior house calls demonstration program called Independence at Home. The demonstration project, (which the UCSF program is not a part of) began in 2012 and is run out of the Center for Medicare and Medicaid Services (CMS) Innovation Center. The first three years (the program was recently extended for an additional two years) included 17 practices and close to 9,000 at-home patients. Results published last June on the program’s first year found that the demonstration had average savings of $3,070 per patient. As part of the demonstration program CMS will be paying incentive fees to nine of the 17 participating home care programs that both saved money and met quality of care goals such as:

–Fewer hospital readmissions within 30 days of discharge.

–Follow-up contact from their provider within 48 hours of a hospital admission, discharge, or visit to an emergency room.

–Reduced use of the hospital and ER for conditions such as diabetes, high blood pressure, asthma, pneumonia, or urinary tract infections.

“This is a great common sense way for Medicare beneficiaries to get better quality care with smarter spending from Medicare,” says CMS Acting Administrator Andy Slavitt.
Physician fellows in the program say they have gained so much they want to make home visits a part of their practice when they finish their training.

“I feel like I fulfill my role as a physician,” says Meera Sheffrin, 31, a geriatric fellow at UCSF. Sheffrin says “it would be almost impossible to imagine [these patients] coming into the clinic, and this way it’s me who has to take the stairs.”

Another benefit Sheffrin notes is that being homebound contributes to many patients feeling socially isolated “and they appreciate being visited and being cared for.”

Karen, Batchelder, whose mother in law Bea, 95, is seen in an assisted living facility by the UCSF Housecalls doctors, agrees. “She loves her docs,” says Katherine. “ She’s always insisted they stay and… have a cup of tea and [a] cookie.”

Update: This story has been changed to reflect the correct spelling of Meera Sheffrin’s last name. 

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