“What do you think of the coconut water?”
I took a sip before sitting down on my patient’s brown living room sofa. “It’s delicious,” I said, and I meant it.
“Yes, and it treats diabetes,” Mrs. Hamilton (not her real name) added triumphantly.
She had always shunned my medical recommendations, relying instead on home remedies to treat her high cholesterol, diabetes, and arthritis. After many exasperating in-clinic appointments with her, my only victory had been getting her to take medication for her blood pressure.
Sipping the cool glass of coconut water in her living room, I made a silent promise not to rehash our old battles during our first home visit. Her eyes glowed with excitement as she told me of her childhood in Jamaica and adult life in Boston. I was surprised to learn that her arthritis was so severe that she was essentially homebound, leaving home only to go to church or medical appointments.
An estimated 400,000 elderly Americans are completely homebound; another 1.6 million leave their homes at most once a week. Homebound individuals are more likely to be elderly, less educated, female, and non-white, groups that already have trouble accessing health care. They are also more likely to have multiple chronic medical conditions. Yet only 12 percent of completely homebound individuals report receiving medical care at home.
Home-based interventions such as primary care visits have consistently been linked to good health outcomes and significant cost savings. For example, the Department of Veterans Affairs Home Based Primary Care program provides, as the name implies, primary care to homebound veterans with complex chronic diseases. VA plus Medicare costs for those enrolled in the program were 11.7 percent lower than projected. The main driver of savings was a reduction in inpatient hospitalizations. Veterans and their family caregivers also reported greater access to care, stronger relationships with their health care providers, and better quality of care.
Even for individuals who aren’t completely homebound, home-based primary care visits build trust in their providers and allow them to unearth and address issues not readily apparent in a short clinic visit, such as unsafe housing, poor nutritional choices, and difficulty taking prescribed medications.
Despite the value of home visits, the number of physicians actually performing them is small. The Commonwealth Fund reported that in 2014 there were only 1,066 clinicians who made more than 1,000 house calls to Medicare beneficiaries.
Part of the problem is a lack of training in home-based care in residency programs. In one survey of internal medicine residency programs, only 25 percent required a home visit. While such visits are more common in family residency programs, one-third of those programs reported that their graduates didn’t perform enough visits to be competent.
There are several reasons why residency programs don’t focus on educating residents about performing home visits. First, home-visit programs need to take place within a multidisciplinary team with adequate support. Done without that, residents will encounter behavioral health and social concerns they aren’t well-equipped to treat. Second, residency is a busy time. Residents currently work 80 hours a week and spend much of their free time studying for licensing exams and completing paperwork. Adding more training requirements would only contribute to the feeling of burnout that many residents experience.
Finally, the current payment environment makes it unlikely that physicians will perform home visits. The current fee-for-service payment structure of health care remains a major barrier in the expansion of home-based primary care programs. Medicare reimburses doctors for home visits, but not enough to cover the extended length of these visits compared to in-office visits or for the time spent driving between homes.
The Independence at Home Demonstration authorized by the Affordable Care Act has become an important source of funding by offering some home-based primary care programs the opportunity to participate in risk contracts. This means the programs receive bonuses when they reduce total health care costs and meet quality metrics. The first-year data showed that the demonstration project saved an average of $3,070 per beneficiary.
Beyond the cost savings, patients enrolled in the demonstration had higher quality care. Medicare beneficiaries participating in the demonstration project were more likely to have had contact with their primary care physicians soon after a hospital admission and had fewer hospital readmissions. Due to its success, the demonstration was recently extended for two more years by the Bipartisan Budget Act of 2018, and there is a movement to make it permanent.
When I was told during the second year of my residency that I would have to visit one of my primary care patients at home, I jumped at an opportunity to improve my relationship with Mrs. Hamilton. Sitting and talking in her living room, I could see one of the values that home visits offered: I had grown closer to her over the past 60 minutes than I had during the previous two years.
“Thanks for visiting me,” she said as I stood to leave.
Breaking the promise I had made to myself, I made another plea for her to take pain medication for her arthritis. “You’ll feel less pain when you go to church,” I promised.
I was surprised when she responded, “OK.”
“And,” I added as she was shutting the door, “during our next visit, we can also talk about the right medication to treat your diabetes.”
She laughed. “I’ll think about it.”
Ifedayo Olufemi Kuye, M.D., is a third-year resident in internal medicine at Brigham and Women’s Hospital in Boston.