House Calls Are Making a Comeback
A relic from the medical past — the house call — is returning to favor as part of some hospitals’ palliative care programs, which are sending teams of physicians, nurses, social workers, chaplains and other workers to patients’ homes after they are discharged. The goal is twofold: to provide better treatment and to cut costs.
Walter Park, 68, of San Francisco says house calls prevented an expensive return visit to the hospital, where he initially stayed for seven weeks after a heart attack in 2012.
After his discharge, palliative care specialists from the University of California, San Francisco, were among those who visited his home to monitor his physical and emotional health. He got help with tasks as varied as household chores and organizing the 20 pills he takes daily for his heart and other conditions.
Confusion continues to exist over what palliative care is and whom it is for. Broadly, it is meant to ease symptoms and pain, and focus on quality of life for severely ill patients, who can choose between continuing or halting traditional medical treatment.
Dr. R. Sean Morrison and Dr. Diane E. Meier of the Patty and Jay Baker National Palliative Care Center at Mount Sinai Hospital.
YANA PASKOVA FOR THE NEW YORK TIMES
Palliative care also occurs in hospitals, but an added emphasis on home care has been a selling point. A vast majority of patients would rather be at home than in a hospital anyway, said Dr. R. Sean Morrison, co-director of the new Patty and Jay Baker National Palliative Care Center at Mount Sinai Hospital in New York and director of the National Palliative Care Research Center.
Home care is generally cheaper than hospital care, and for more than a decade, government programs such as Medicare and Medicaid have worked to create incentives for hospitals to switch to less-expensive treatment. Recently, under the Affordable Care Act, Medicare has begun to penalize hospitals when, under certain conditions, patients are readmitted within 30 days after discharge.
Some insurers, including Medicare, pay for house calls by doctors and nurses specializing in advanced care. In cases where insurance does not cover this type of palliative care, hospitals are financing it themselves, sometimes with grants.
Dr. Steven Pantilat, an internal medicine physician who leads the palliative care program at the University of California, San Francisco, says his hospital subsidizes some home care because “there is sufficient improvement in quality and costs to make the investment a good idea all around.”
Adrian King’s mother, Jacqueline Andersen, received palliative care at home.
JIM WILSON / THE NEW YORK TIMES
A 2007 study by Dr. Richard Brumley and colleagues, found that palliative care patients who received in-home, interdisciplinary care were less likely to visit the emergency room or be admitted to the hospital than those receiving more-standard home care, resulting in lower costs. The study, financed by the Kaiser Permanente Garfield Memorial Fund, covered terminally ill patents.
In Boston, palliative care doctors at Massachusetts General Hospital and at Brigham and Women’s Hospital make house calls. Nurse care managers, social workers and others also visit discharged patients in their homes or keep in touch by telephone as needed, said Dr. Timothy Ferris, who runs the Partners HealthCare accountable care organization.
Nurses from Partners HealthCare at Home, an affiliate with 900 employees, may also visit discharged patients. “The home care nurse is the eyes and ears and stethoscope in the patient’s house,” Dr. Ferris said.
Accountable care organizations, created under the Affordable Care Act, have the flexibility to pay for in-home palliative care services, he added, and his organization has done so.
Palliative care teams work with a patient’s regular doctors and specialists “to provide an added layer of support for people living with serious illness,” said Dr. Diane E. Meier, professor of geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai Hospital and co-director of the Patty and Jay Baker National Palliative Care Center. They can address issues that someone who focuses intensively on a particular disease or organ system often cannot, she said — things like expert help with pain management, depression, fatigue and support for “exhausted and overwhelmed family caregivers.” They also offer practical help so patients can remain in their homes, she said.
While patients nearing the end of life
can choose palliative care in a hospice setting rather than undergo expensive and risky treatment — many doctors say it is valuable for that very reason — it can also exist alongside efforts to treat and cure patients.
“There are a lot of people, including my mother, who don’t fit the criteria for hospice,” said Cameron Egan. In 2012, doctors told Ms. Egan’s mother, Jacqueline Andersen of San Francisco, that clearing her four clogged heart arteries would be unacceptably risky. Her health seemed fragile but fairly stable, and doctors could not estimate how long she would live.
Ms. Andersen, a retired high school English teacher, was clear that she did not want to spend more time in the hospital, said another daughter, Adrian King, who said, “She wanted to go home.” Ms. Egan moved in with her mother to care for her.
Dr. Pantilat helped oversee Ms. Andersen’s case, conferring with Ms. Egan, Ms. King and two other daughters on her care. He visited Ms. Andersen at home, and she received home visits from a spiritual counselor, who discussed her life, her fears and her attitudes about the end of her life, Ms. Egan said.
Ms. Andersen had an array of medical problems but “she was really with it,” Ms. King said. “There was no time that any of us thought she was diminished mentally.” Ms. Andersen died in February 2013, at 82, seven months after leaving the hospital. The day before, Ms. King said, she and her mother had “one of our classic Scrabble games.”
“She was in fine spirits when I left her, making sure I put the San Francisco 49ers flag in a vase in her window,” Ms. King said.
Dr. Pantilat said: “Without palliative care, it is likely Jackie would have been readmitted to the hospital, and the chances are 50-50 or more that she would have ended up having an operation. I also think her pain would not have been as well controlled.
“You can imagine what the cost of open-heart surgery would have been,” he said. “Tremendous. Avoiding even one hospitalization would have paid for all the palliative care she received.”
Proponents of palliative care say it can prompt people with terminal illnesses to face the future realistically. The focus is on making them comfortable, rather than exposing them to painful and expensive treatments.
But palliative care also seeks to extend life, Dr. Meier of Mount Sinai says. Several studies have shown that it “may be associated with a significant prolongation of life for some patient populations,” she noted in a 2011 article, adding that more research was needed to confirm whether these findings were applicable more generally.
Mr. Park, the heart attack survivor in San Francisco, said his plans had changed. In 2012, his palliative care team urged him to identify his short- and long-term goals. He said he wanted to attend the second Obama inauguration and return to his volunteer work at a nonprofit agency that helps older Americans. He was present at the January 2013 swearing-in, and later he resumed his volunteer work.
He is now looking forward to spending time with his two grandchildren, ages 8 and 11. “I used to plan only three years ahead,” Mr. Park said. “Now I really want to see my grandkids grow up and graduate.”