House Calls: Visiting certain patients at home is logical, doctor says

The doctor doesn't look like much of a crusader, bent over the frail frame of 90-year-old Alberta Scott.

He has a lavender stethoscope strung round his neck and some serious bedside manner at work on this stubborn nonagenarian who wants to be anywhere but where she is: in a nursing-home bed, hoping to heal and get back home.

"Squeeze my hand," Dr. Peter Boling prods. "Squeeze my hand. Come on. Hard!"

This is Boling's day job, providing medical care to some of Richmond's oldest and sickest patients. A geriatrician and head of general medicine at Virginia Commonwealth University Medical Center, he visits nursing-home patients with a smile, and he leads a team of specialists who take to the road, medical bags in hand, to see patients where and when they need it most -- in their own homes, before a crisis lands them in the emergency room or a nursing facility.

Boling and his team make house calls.

And now he is on a mission: To convince Congress that the old-fashioned house call could be a fresh answer to the modern-day health-care reform problem.

There are house-calls programs here and there. San Diego. Boston. The Veterans Health Administration cares for thousands in their own homes, saving money by reducing unnecessary hospitalizations and emergency-room visits.

But Boling wants to bring house calls to the masses -- up to 3 million of the most high-risk, high-cost Medicare patients in the country. The idea is not just cost-savings, but to provide a financial incentive to persuade more doctors to return to this kind of work. Mostly, it's about people such as Alberta Scott and the questions that first came to Boling's mind when he heard she had been admitted to an institution for treatment of a blood infection.

In a few weeks, if all goes well, can she go home? If so, who will take care of her?

At 55, Boling has a vague memory of his own pediatrician standing in the kitchen of his childhood home. It's not an image many of us can conjure in an era of overcrowded ERs and specialty clinics.

The visiting doctor went out not long after the horse and buggy, as technology advanced and institutionalized health care became the norm. In 1930, house calls accounted for 40 percent of doctor-patient encounters. Today, about 4,000 of the nation's 800,000-plus doctors make house calls a substantial part of their practices, the American Academy of Home Care Physicians estimates.

Boling was just a young doctor himself in 1984 when a mentor persuaded him to spend half his time doing clinic work, and the other half developing a house-calls program. He hung a giant map of Richmond on his office wall and began identifying patients who lived within a 15-mile radius of the downtown VCU medical center.

Each home was marked on the map with colored pins, and visits were scheduled by geography to maximize Boling's time. It took only a few stops, and some memorable patients, for Boling to recognize that home care made sense.

Take the stroke victim restricted to a second-floor bedroom in his home. Time and again his wife had to call an ambulance, whose crew carried him by stretcher down rickety stairs to an emergency room -- for a bloated gastrointestinal tract, high fevers and vomiting. Turns out, the patient had low blood potassium levels.

Boling began drawing blood at the house and prescribed a medication that stabilized his potassium, and staved off ER visits.

"It was so stark," Boling said, "the contrast between what he needed and what (the health care system was) giving him."

It's that type of patient that Boling envisions being cared for under the proposal pending in Congress. The so-called "Independence at Home" provision is but one small piece of the larger health-care reform measures.

Where other proposals have divided legislators, the house-calls idea is winning support from Republicans and Democrats alike as a "more cost-effective way for these patients to get the coordinated care they need," Sen. Richard Burr, R-N.C., said.

The provision calls for the Medicare program to partner with home-based primary-care teams to test whether house calls would reduce preventable hospitalizations, ER visits and duplicative diagnostic tests for high-cost, chronically ill patients.

That means patients with at least two chronic conditions -- congestive heart failure, diabetes, dementia, stroke and so on -- who have been hospitalized in the past year and require assistance for at least two daily-living activities, such as bathing, dressing, walking or eating.