Only a fraction of older adults eligible for home-based primary care are being served
September 13, 2019
By Beth Baker
Part of the AGE-FRIENDLY HEALTH CARE SPECIAL REPORT
(Editor’s note: This story is part of a series for The John A. Hartford Foundation.)
Margaret Birt, then 62, had routine surgery in 2006. But in the recovery room, she had complete cardiac arrest. Initially in a vegetative state, Birt regained much of her cognition. Her life, however, was never the same. She was left with no physical capabilities, needing constant care.
Rather than ending up in a nursing home, though, Birt lives at home in Wheaton, Ill. with her husband, Maurice. She receives primary medical care there, covered by Medicare, from Dr. Thomas Cornwell and his team at Northwestern HomeCare Physicians. They perform exams, chest x-rays and blood draws — all in the comfort of Birt’s home. “We’re very fortunate,” says her husband. Cornwell is also CEO of the Home Centered Care Institute, dedicated to mentoring and training home-based providers.
“When you are in someone’s home, you [as the doctor] are not the center, it is the person. It is on their territory. You have to be comfortable with a change in the dynamic.”
In addition to her Medicare-covered primary care, Margaret Birt requires 24-hour help from caregivers that the couple must pay for out-of-pocket. Without the generous long-term care policy purchased years ago, Maurice Birt says, he would be bankrupt.
House Calls: A Cost-Saving Measure
Margaret Birt is among the 100,000 older adults in the United States with complex medical conditions who receive their primary care at home. In 2015 (the most current data available) some 2.5 million house calls were made in the U.S., according to Health Affairs.
“Home-based primary care focuses first on a vulnerable and disenfranchised population, often older adults with multiple chronic conditions who also experience problems with basic activities of daily living [such as walking or dressing],” says Dr. Bruce Leff, director of The Center for Transformative Geriatric Research at Johns Hopkins University School of Medicine. “They are what payers refer to as ‘high need, high cost.’”
Prior to January 1, 2019, health providers had to document the medical necessity for why a house call was needed instead of an office visit. Medicare has since eliminated this requirement. Now it is at the provider’s discretion where a patient is seen, explains Cornwell.
“The main difference is house calls could not be done prior to this year for the convenience of patients who could easily get to the office. Now they can. Having said this, most house call programs have as their mission to serve patients who otherwise cannot get to a provider’s office,” notes Cornwell.
It may seem counter-intuitive, but giving these vulnerable patients individualized primary care at home saves money for the nation’s healthcare system, according to studies by Department of Veterans Affairs and the Centers for Medicare and Medicaid Services (CMS), among others.
“Now there is strong evidence that home-based care results in better care outcomes and better experience of care by patients and by caregivers, who often have a lot put upon them,” says Leff, who is working with colleagues to develop quality standards for home-based primary care. “It also has a pretty robust effect on reducing healthcare costs.”
The John A. Hartford Foundation (a Next Avenue funder) awarded Leff and colleague Dr. Christine Ritchie, in partnership with the Home Centered Care Institute and the American Academy of Home Care Medicine, a $1.5 million grant to foster and expand home-based primary care.
“What we’re focusing on is a population who is really in need,” says Brent Feorene, executive director of the American Academy of Home Care Medicine. “Even if the adult son could get mom to the doctor’s office, the average primary care practice is not equipped to handle the patients. The doctors don’t have time, and often [the patients] have psychosocial issues.”
Patients with dementia may experience fear and anxiety at a doctor’s office, for example, and be disruptive to others in the waiting room.
At least 2 million older adults would benefit from home-based primary care, according to Health Affairs. Because these patients have difficulty getting to an office visit, they frequently end up in emergency rooms or hospitals. Per-patient savings range from $1,000 to $4,000 annually through reduced hospital and nursing home stays, emergency room trips and specialist visits, according to research cited by the American Academy of Home Care Medicine.
The CMS Independence at Home Demonstration, part of the Affordable Care Act, estimated that Medicare would save $10 to $15 billion total over a 10-year period if home-based primary care were extended nationally to those on Medicare who are homebound.
Benefits to Patients and Families
For patients with chronic conditions, in addition to the convenience of home-based primary care, “The biggest benefit is that the care is very well coordinated,” says Dr. Zia Agha, chief medical officer of West Health, a research and policy center focused on improving care delivery to older adults.