Factors associated with the frequency of house calls by primary care physicians

Barriers to Making House Calls by Primary Care Physicians and Solutions: A Literature Review

BACKGROUND

The number of house calls made by physicians has been declining over the years, while the number of people requiring house calls, especially the elderly, is growing.

AIM

To consolidate the literature regarding the barriers faced by primary care physicians in making house calls.

DESIGN OF THE STUDY

Literature review.

METHOD

Studies were sourced from PubMed and Embase.

RESULTS

7 studies were selected to be in the literature review. Barriers to making house calls by primary care physicians include inadequate remuneration, lack of time and training, unconducive home environment, concerns with professional liability and safety, and perceived low value-added in the patient's quality of care.

CONCLUSION

While primary care physicians do recognize the value of house calls in patient care, the perceived limited standard of care that can be achieved in the home setting, busy clinic practice (large patient loads), coupled with inadequate remuneration make house calls unrealistic for many doctors. These barriers must be addressed to ensure accessibility to primary health care services for the immobile, frail, and sick is not being compromised. One of the solutions may be to expose medical students and residents to house calls early through mentorship.

Attitudes, perceptions and practice patterns of primary care practitioners towards house calls

ABSTRACT INTRODUCTION Historically, doctors routinely delivered medical care to sick patients in their homes, with house calls accounting for 40% of all doctor–patient encounters in the 1940s. This proportion has dwindled to less than 1% today. Advantages of house calls include decreased mortality rates, admissions to long-term care in the general elderly population and increased patient appreciation. Therefore, we asked ‘Why do some primary care practitioners do house calls and what are the reasons that others do not?’. AIM This review aims to understand the attitudes, perceptions of Primary Care Practitioners (PCPs) towards house calls and their practice patterns. METHODS A search of PubMed and Embase was conducted for articles published before 31 December 2017. A total of 531 articles with 44 duplicates was generated. Of these, 13 were shortlisted along with three hand-searched articles for a total of 16 articles included in this review. RESULTS Primary care providers were aware of the role of house calls and their advantages in enabling comprehensive care for a patient. They saw making house calls as a responsibility with rewards that enhanced the doctor–patient relationship. However, opportunity cost, time, medical liability and miscellaneous reasons such as the lack of training precluded some PCPs from making more house calls. DISCUSSION Primary care practitioners recognise the importance of house calls, especially in the care of elderly patients, but there are many unaddressed issues such as opportunity cost and clinical inadequacy in the home setting that have caused a decline in house calls over the years.

A Curriculum to Teach Internal Medicine Residents to Perform House Calls for Older Adults

Physician house calls are an important but underused mode of delivering health care to a growing population of homebound elderly patients. One major barrier to internal medicine physicians making house calls is a lack of training in this setting. This article describes a needs assessment survey of residents from nine internal medicine residency programs for a house call curriculum that combines a longitudinal clinical experience with Internet-based learning. Implementation of the curriculum was begun in July 2006, and data will be collected and results evaluated for at least 2 years. Several educational outcomes from the intervention are anticipated, including increased learner knowledge of house call medicine, improved learner confidence in making house calls, and program director satisfaction with the curriculum. This early work lays the foundation for determining the effect of a carefully designed curriculum on the number of practicing internists with the skills, knowledge, and attitudes necessary to meet the growing need for physician house calls.

House calls to the elderly--a vanishing practice among physicians

BACKGROUND

Despite the growth in other home health care services, the number of house calls by physicians has declined dramatically during this century. We determined the frequency of house calls made by physicians to elderly U.S. patients in 1993 and analyzed the characteristics of the physicians and patients involved.

METHODS

We analyzed a 5 percent random sample of the 1993 Medicare Part B claims data for beneficiaries over the age of 65 who were not enrolled in health maintenance organizations (HMOs). With supplemental information from the Area Resource File and the American Medical Association's Physician Masterfile, we determined how many house calls were made, their cost, and a number of specific characteristics of the physicians and the patients.

RESULTS

In our 1993 sample, 36,350 house calls were made to 11,917 of the 1,357,262 patients. When extrapolated to all Medicare beneficiaries over age 65 and not enrolled in HMOs, these figures correspond to 727,000 house calls to 238,340 patients nationwide. We estimated the cost of these house calls to be $63 million. The patients who received house calls from physicians were older than those who did not, were more likely to die within the calendar year, had higher rates of hospitalization, and were more likely to receive care from other home health providers, hospice programs, and skilled-nursing facilities. Patients residing in rural areas and those in areas with high physician-to-population ratios had an increased likelihood of receiving a house call. The physicians who made house calls were more likely than others to be generalists, osteopaths, older, male, board-certified, practicing in the Northeast, and in solo practice.

CONCLUSIONS

A very small percentage (0.88 percent) of elderly Medicare patients, mainly those who are very sick and near the end of life, receive house calls from physicians.

Home visits in a rural office practice: clinical spectrum and effect on utilization of health care services

OBJECTIVE

To describe the clinical features of home visits and their role in continuity of care, costs, and benefits in a rural office practice.

DESIGN

Prospective study of all home visits performed during a 26-month period.

SETTING

A general medicine teaching office practice located in rural Virginia.

PATIENTS

All persons to whom home visits were made during the study period.

MAIN RESULTS

138 home visits were made to 47 patients who had a mean age of 73.2 years. Home visits accounted for 1.4% of patient encounters in the practice, required a mean of 7.1 miles of one-way travel and a mean of 48 minutes, including travel time, to complete, and generated $36 in income per visit. Most patients (27 of 47) were not permanently homebound. Reasons for patients' being homebound were grouped into six categories (acute illness, frail elderly, terminal illness, advanced chronic disease, neurologic problem, and miscellaneous reasons). The reasons for visits were grouped into four categories (acute self-limited illness, exacerbation of chronic disease, routine follow-up of chronic disease, and psychosocial problem). Physicians judged that 80% of home visits represented appropriate use of their services. In addition, 46% of home visits made an emergency room visit unnecessary, and 9% made a hospital admission unnecessary. At the time of 75% of home visits, physicians reported personal benefits of making the visit.

CONCLUSIONS

Home visits have an important role in the care of ambulatory as well as permanently homebound patients. While physicians judged most home visits to be appropriate and personally beneficial, these visits required more time and generated less revenue than did office visits for comparable problems. Because home visits generated as well as prevented the use of medical services, their impact on the overall cost of medical care in this setting is unclear.

The home care practice and attitudes of Minnesota family physicians

OBJECTIVE

Assess home care practice and attitudes of Minnesota family physicians (FPs).

DESIGN

Mailed survey.

SETTING

State of Minnesota.

PARTICIPANTS

Members of the Minnesota Academy of Family Physicians, 80% of the FPs practicing in the state.

INTERVENTION

A 55-item mailed, self-complete questionnaire regarding general practice and personal physician characteristics (18 questions), specific questions regarding geriatric and home care practice and related attitudes (37 questions); up to four reminder or follow-up surveys were sent.

MAIN OUTCOME MEASURES

Descriptive summary of FP home care practice and attitudes.

RESULTS

Eighty percent of surveys were completed, 76% of responding physicians made at least one home visit in the previous year, and 92% of home visits were to geriatric patients. Discriminant function analysis identified six significant (P less than 0.001) variables that explained 52% of the variance (r2 = 0.52, Wilks Lambda = 0.48) in home visiting behavior between frequent home visiting FPs (greater than 24 visits/year) and non-visiting FPs. FPs most likely to do home visiting were older and tended to have small group or solo practices in rural settings.

CONCLUSION

The survey documented continued decline (from previously published surveys) of physician home visiting behavior and widespread dissatisfaction with reimbursement. However, attitudes regarding home care provided by other professionals were highly positive.