Updating the House Call: Elderly and Disabled Most in Need, Funding Unclear
Researchers at George Washington University School of Medicine and Health Sciences studied the current status of home medical care, conducted an assessment of the need for home medical care, and identified models of and barriers to providing this care.
Home medical care provides medical assessment, diagnosis, and treatment services and is performed by medical professionals such as physicians and nurse practitioners.
As part of the study, the principal investigators conducted interviews with experts in the home medical care field, focus groups with nurses and physicians, and a review of the medical literature to assess the current need for home medical care.
Findings of the study included:
- Most home medical care models use interdisciplinary teams of physicians, nurse practitioners, and social workers.
- Limited payment, lack of training, and physician "territorialism" are key barriers to the expansion of home medical care.
- It is unclear whether recent changes in federal funding will affect the willingness of medical practices to expand into home medical care.
The research team identified 15 models of home medical care currently in use, and they developed their own model program, which they estimated would cost $3,000 per patient per year.
The researchers recommended that the Robert Wood Johnson Foundation (RWJF) and others:
- Support the development of home medical care.
- Examine the most cost-effective mix of providers.
- Consider the possible impact of technology.
- Study financing issues.
RWJF supported the project with a $35,383 grant from August 1998 to to January 2000.
The family physician making a home visit to the sick and disabled is one of the most cherished visions that Americans hold of health care. As the population continues to age, there will be a need to revisit the benefits of, and barriers to, bringing medical care into the home.
Visits to a physician's office can be time consuming, expensive, and uncomfortable for the disabled patients, both young and old.
A variety of providers, including physicians, nurse practitioners, and physician assistants have made great efforts to accommodate homebound individuals. However, relatively little is known about the variety of financial and service delivery models that currently exist.
Home medical care differs from the more familiar home health care. While home health practitioners, such as physical and occupational therapists, can assess a patient and provide care regarding specific health problems, they do not perform medical assessment, diagnosis, and treatment. Home medical care involves these latter medical services and is performed by medical professionals such as physicians and nurse practitioners.
This grant from RWJF funded a study of the current status of home medical care, an assessment of the need for home medical care, and the identification of model programs and barriers to providing this care.
The principal investigators at George Washington University School of Medicine and Health Sciences:
- Conducted 24 interviews with experts in the home medical care field.
- Conducted two focus groups with eight nurses and six physicians to identify issues pertaining to home medical care.
- Conducted a literature review to identify projections of disease burden and the aging of the population, and used these to assess the current need for home medical care (see the Appendix for a list of the literature reviewed).
- Identified 15 existing models of home medical care that were selected for their geographic diversity, varied use of technology, differing patient groups, and applicability to rural and urban settings. Their analysis also examined program costs and the possible uses of technology to enhance home medical care.
Based on their research, the investigators developed a model home medical care program. The model:
- Organizes services around patient needs.
- A care manager functions as a patient advocate and coordinator of services and links communications among patient, family, and all levels of care.
Services to assist disabled individuals of any age to remain in their homes include assistance with activities of daily living, financial management and social services. While the investigators depict home medical care as one of many services patients need to stay in their homes, they conceive of home medical care as part of the medical system.
They noted homebound patients frequently move between hospital, subacute care and long-term care. Referrals to home medical care may emanate from community agencies, health care providers and institutions.
The principal investigators reported the following findings to RWJF:
- Most home medical care models use interdisciplinary teams. These teams typically include physicians, nurse practitioners, and social workers. Some are part of the federal Program for All-inclusive Care for the Elderly (PACE), which includes home care in a full-service program designed to keep individuals out of nursing homes. Another model, Senior Friendship Center, based in Florida, uses retired physicians, nurses, dentists, and mental health counselors who practice on a limited license to make home visits.
- Limited payment, lack of training, and physician "territorialism" are key barriers to the expansion of home medical care. While most providers surveyed agreed that home medical care is needed, low reimbursement rates may discourage practitioners from providing it, especially given the travel time required to reach patients. Providers also felt that physicians and other health professionals had limited preparation for providing home medical services. Some physicians might be reluctant to recommend home medical care for fear of losing a patient by referring him or her to a home care provider.
- It is unclear whether recent changes in federal funding will affect the willingness of medical practices to expand into home medical care. The federal Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration or HCFA), which administers the Medicare health program for seniors, increased its reimbursement rates for home medical services, but the impact of that change on the market remains unclear. The researchers say that the model program they developed could provide reasonable home medical services at a cost of $3,000 per patient per year.
The project directors made the following recommendations in a report to RWJF:
- Support the development of home-based medical care for outpatient care similar to the ideal model proposed by the researchers. The development of this model should have the following three goals:
- To provide high quality care for patients and family members.
- To be cost-effective.
- To explore policy implications for Medicare and Medicaid funding.
- Examine the most cost-effective mix of team members in providing home medical care. For any given group of patients, it is not known what mix of physician care, nurse practitioner or physician assistant care, or rehabilitative or social work services produce the best outcomes.
- Examine how the use of technology to augment caregiving abilities in home medical care might improve patient care and provider satisfaction. Examples of useful technology include two-way video hook-ups between patient homes and providers, and simple e-mail contact between patients or caregivers and medical providers.
- Examine cost/financing issues related to home medical care. These issues include the impact of HCFA reimbursement rates; the willingness of families to pay out-of-pocket for all or a percentage of home medical services; the possibility of a Medicare waiver program to allow more than a 20 percent co-pay to be charged to patients to support the model; and the possibility of combining Medicare and Medicaid funding streams to provide more comprehensive coverage, as is employed in the PACE model of care.
The project directors submitted a report to RWJF, titled Home Medical Care Project. (See the Bibliography.) There was no other dissemination activity during the term of the grant.
AFTER THE GRANT
The researchers plan to disseminate the information collected regarding home medical care and, through George Washington University clinical practice, test the "ideal" model of home medical care developed through this project.
GRANT DETAILS & CONTACT INFORMATION
Review of the Current Status of Home Medical Care
George Washington University School of Medicine and Health Sciences (Washington, DC)
Dates: August 1998 to January 2000
Jean E. Johnson, Ph.D.
Elizabeth Cobbs, M.D.
Literature Reviewed for the Study
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(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Cobbs E and Johnson J. Home Medical Care Project. Washington, D.C.: George Washington University School of Medicine and Health Sciences, 2000. One copy submitted to RWJF.
Report prepared by: Jodi Miller
Reviewed by: Robert Narus
Reviewed by: Richard Camer
Program Officer: Susan Hassmiller