Health Care Of The Future: House Calls?

May 21, 2015

Patient-centered medical homes. Community health teams. Accountable care organizations. Integrated medical and behavioral health care practices. Case management.

Jargon?

Yes, it's health policy wonk speak, for sure. But what these concepts have in common is simple: they all refer to a kind of health care that's about reconnecting patients with a primary care doctor. The idea is to help people manage their overall health, avoid expensive hospital visits, and basically keep chronic conditions from becoming full-blown emergencies. The goal: healthier patients and lower costs for everyone. This is pretty much what every attempt to "reform" health care is trying to do. In some places, in some ways, it's working. In others, progress is slow.

There are lots of efforts underway in Rhode Island to encourage these primary care doctor (or nurse care manager) - patient relationships. At a press conference Thursday morning, a group called the Care Transformation Collaborative (CTC) announced its successes in enrolling thousands of Rhode Islanders in so-called "patient-centered medical homes," or PCMHs. These are basically primary care doctors' offices with nurses and other staff who can help coordinate a patient's care with multiple providers. You might even belong to one and not know it. PCMHs often offer more convenient office hours. And they're sometimes paid a set amount per patient per month to manage that patient's overall health care. That's a clear incentive to keep a patient healthy, so a PCMH might send a doctor on a house call, or bring in a behavioral health specialist. Now, the CTC is launching a PCMH for kids, too.

Neighborhood Health Plan of Rhode Island has been doing some hotspotting with its "Health@Home" program, sending teams of nurses and psychiatrists and pharmacists to the homes, sometimes many times a week, of patients who have a lot of health problems and have been using a lot of services but not necessarily getting better. Hotspotting is a tool for identifying what health policy wonks call "high utilizers," or people who use a lot of expensive health care services like visiting the emergency room. The hope is that if you can help these patients manage these health problems at home, and address some of the other barriers they might have to connecting with a regular, primary care provider (maybe an unaddressed mental illness, or unstable housing), you can reduce the number of emergency room visits and expensive hospital stays.

The Rhode Island Foundation has just made some grants to organizations that promote this kind of community-based health care (house calls included!). Note they're all about reducing ER visits, helping people manage chronic illnesses, and making it more convenient for patients to connect with a primary care provider.

  • From a statement RIF issued Thursday about the grants: "Comprehensive Community Action Program (CCAP) was awarded $37,233 to develop a home-based Nurse Care Manager program to provide in home evaluation, support, treatment and intervention for patients of its Wilcox Health Center in Warwick who are suffering with chronic and disabling diseases."
  • Planned Parenthood of Southern New England received funding to help its doctors provide primary care services, in addition to women's health services.
  • And Rhode Island Hospital shares in the round of grants with funding to help expand its primary care practice for kids (through Hasbro): “This will result in more timely care, more convenient access and a reduction in ER use.  In addition, our pediatric primary care residents will be able to see more patients and, in particular, see first-hand the importance of offering primary care on weekends,” said pediatrician Patrick Vivier, MD, leader of the hospital’s Primary Care Initiative, said in a statement.

There are other community health team projects underway, involving the state's community health centers, that aim to help people with multiple, chronic conditions manage those conditions better at home. Some of these projects are sending health care providers into the home as well. These projects help patients who aren't as sick as the ones Neighborhood Health Plan of Rhode Island is targeting with Health@Home. But for some reason they haven't been able to establish that all-important relationship with a primary care provider and might be at risk of hospitalizations or emergencies.  House calls can help remove any other barriers a patient might have to getting to a doctor - a lack of transportation, lack of child care, a work schedule that doesn't permit getting to a day-time appointment, or what have you.

House calls were once commonplace for doctors. How many times have you heard a character in a movie say, "Send for the doctor!" Since those days, decades ago, we've drawn strict silos around medical fields. We have hospitals and specialists here, primary care doctors here, mental health care providers over here, addiction treatment over here, and so on. It can be tough to navigate a fragmented system. But if this system continues to evolve along the lines I've described above, we may be looking at a future where even more doctors make house calls, primary care doctors and family physicians are your compass, your guide to the medical world, and more of them get paid to do what they think is necessary to keep you healthy, not for each discreet exam or test or procedure.

I wonder if that world will include an electronic medical record that follows you wherever you go, and doesn't just live within a particular hospital system or doctor's office.