Researchers Make the Case for Home-based Medical Care

Frail Seniors Need Access to Care

December 12, 2018 03:07 pm Sheri Porter – Home-based medical care for frail older adults makes a lot of sense. Evidence demonstrating that physicians and other clinicians can deliver high-quality, cost-saving care to these patients is mounting, and use of these services is increasing nationwide.

In an interview with AAFP News, Cornwell said, "Since 1993, I've focused my medical career on house calls and have made more than 33,000 such visits to patients."

This family physician's passion is driven by what he has learned after 25 years of medical practice -- simply stated: "The sickest patients in society should get the most primary care, but because they cannot access it, they get the least."

Study Methods

Researchers analyzed 5 percent of Medicare claims from 2011 to 2014 for beneficiaries ages 65 and older who were continuously enrolled in traditional fee-for-service Medicare for at least one calendar year.

They identified medical visits to private residences and assisted-living facilities by primary care health professionals listed as family physicians, internists, general practitioners, nurse practitioners, physician assistants and geriatricians.

Beneficiaries who received at least two home visits were defined as home-based medical care users.

Researchers compared house call usage rates of beneficiaries with medium and high frailty-related comorbidity according to sex, race, ethnicity, rural versus urban setting and state of residence.

Key Findings

Researchers found that in their 5 percent Medicare population sample, primary care visits to private residences increased from 97,302 in 2011 to 102,853 in 2014.

For those patients residing in assisted living facilities, visits increased from 100,575 in 2011 to 129,805 in 2014.

Home-based care use increased significantly according to comorbidity status over time, with use among medium-comorbidity patients (those with summed comorbidity scores of four to six) increasing from 8.7 percent in 2011 to 10.1 percent in 2014; use among high-comorbidity patients (those with summed comorbidity scores of seven or higher) increased during the same timeframe from 14.2 percent to 15.7 percent.

Regarding disparities in use, Asian beneficiaries, men and rural residents had lower home-based medical care usage rates than other users. Specific findings show that

• Asians were 31 percent less likely to use such care than white patients,
  
• black beneficiaries were 21 percent more likely to do so than whites and
  
• Hispanics were 9 percent less likely to use home-based care than whites.

Furthermore, frail women used home-based medical care more than frail men, and women overall were 24 percent more likely to use home-based care than were men.

Rural residents had significantly lower home-based care usage rates than metropolitan residents. For instance, rates in the largest metropolitan countries increased from 13.4 percent in 2011 to 15.2 percent in 2014.

"In contrast, although HBMC (home-based medical care) usage rates in rural counties doubled (from 2 percent to 4 percent), they remained low," wrote the authors.

Authors also noted substantial geographic variations in usage. For instance, beneficiaries living in Michigan, Florida and Arizona had home-based medical care usage rates above 20 percent in the study sample.

However, beneficiaries in nine other states -- Vermont, Idaho, Wyoming, Iowa, Louisiana, Arkansas, South Dakota, Mississippi and North Dakota -- had rates lower than 5 percent.

In their discussion, authors noted an upward trend between 2011 and 2014 in the use of home-based medical care, particularly by frail, high-need and high-cost Medicare beneficiaries. However, "the vast majority of frail Medicare beneficiaries did not receive medical care at home," they wrote.

They concluded that the U.S. health care system needs more primary care clinicians to offer home-based medical care and called for continued work on the payment front to help ensure that home-based medical care is available to those who need it most.

Family Physician Perspective

Cornwell spent time with AAFP News further exploring the topic of home-based care; the results of that discussion are captured in the following Q&A.

Q. Why should this topic be of interest to family physicians?

A. The transition from fee-for-service to value-based payment, especially within Medicare, is a game changer. There is nothing I know of that has shown more value in terms of better outcomes at lower cost than home-based primary care. It targets the high-cost patients that have the greatest potential for cost savings.

Add to that our fragmented health system. These patients generally have not been getting the care they need, and when you bring that health care to them, you can make such a dramatic difference.

Q. Why is there such disparity between rural and urban communities in the availability of home-based care?

A. Density of population is the key; it's just easier to access patients in an urban area. In a senior high-rise setting, a physician could do 10 house calls in just one building; that means calculating elevator time, not travel time. In rural settings, I expect telehealth will help fill the health care gaps by providing clinicians the ability to check on people who have conditions like diabetes and heart failure between face-to-face visits.

Q. Any thoughts on why nurse practitioners provide a larger proportion of home-based care when compared to family physicians -- for instance, 43.4 percent vs. 31.1 percent, respectively, in rural communities with populations less than 2,500 that are adjacent to metropolitan areas?

A. Some of the discrepancy comes down to dollars in the fee-for-service payment system. House calls just pay a few dollars more than an office visit -- $10 to $30 more on average. That $10 barely pays for the gas, let alone the doctor's time. So, in some cases, it's not so much about what is ideal, but what's most practical in terms of use of physician time.

In addition, nurses have been very involved in home health for decades and they are taught in nursing school how to care for homebound patients. The concept is not as foreign to them.

Q. What's the most important finding you want readers to remember?

A. The unmet needs of the sickest patients are those who cannot leave the home; those patients are at the heart of this work. Previous research shows that there are approximately 3 million homebound patients who need these services, but only about 1,000 primary care clinicians who include home-based care as a significant part of their practices. However, 1.5 million nursing home residents have access to some 7,000 primary care professionals who regularly visit individuals in that setting to provide health care.

Q. How can these numbers be improved?

A. We need a payment model to incentivize caring for the sickest patients, and that is changing as the country moves into value-based payment.

Q. What are the next steps in terms of increasing the number of physicians who provide home-based medical care?

A. Once we improve payment issues, the bottleneck will be workforce. We need to explore the value of teaching home-based primary care in residency programs, and I'm already working with a program in my area to create a curriculum for residents.

When family physicians include residents on house call visits, they learn firsthand about team-based care, chronic disease management, transitions of care, complex care, how to support caregivers and so much more.