Physician Home Visits Research Articles

House Calls for Seniors: Building and Sustaining a Model of Care for Homebound Seniors

Homebound seniors suffer from high levels of functional impairment and are high-cost users of acute medical services. This article describes a 7-year experience in building and sustaining a physician home visit program. The House Calls for Seniors program was established in 1999. The team includes a geriatrician, geriatrics nurse practitioner, and social worker. The program hosts trainees from multiple disciplines. The team provides care to 245 patients annually. In 2006, the healthcare system (62%), provider billing (36%), and philanthropy (2%) financed the annual program budget of $355,390. Over 7 years, the team has enrolled 468 older adults; the mean age was 80, 78% were women, and 64% were African American. One-third lived alone, and 39% were receiving Medicaid. Reflecting the disability of this cohort, 98% had impairment in at least one instrumental activity of daily living (mean 5.2), 71% had impairment in at least one activity of daily living (mean 2.6), 53% had a Mini-Mental State Examination score of 23 or less, 43% were receiving services from a home care agency, and 69% had at least one new geriatric syndrome diagnosed by the program. In the year after intake into the program, patients had an average of nine home visits; 21% were hospitalized, and 59% were seen in the emergency department. Consistent with the program goals, primary care, specialty care, and emergency department visits declined in the year after enrollment, whereas access and quality-of-care targets improved. An academic physician house calls program in partnership with a healthcare system can improve access to care for homebound frail older adults, improve quality of care and patient satisfaction, and provide a positive learning experience for trainees.

What can family physicians contribute in palliative home care in Taiwan?

Family physicians in Taiwan have expressed low willingness to provide palliative home care. To explore the medical needs of terminal cancer patients in home care and thus clarify the role and tasks of family physicians in providing palliative home care. Seventy-seven terminal cancer patients discharged from a palliative care unit from July 2003 to July 2004 who had received family physician home visits were enrolled. A structured assessment form was applied to each visit. Under the collaboration by the palliative home care team and family physicians, the average interval from discharge to the first physician visit was 20.3 days and the average interval between physician visits was 37.9 days. The patients had an average of 5.9 active medical problems: the most frequent problem was pain (58.4%), followed by anorexia (42.9%) and constipation (42.9%). Forty-four patients (58.7%) died at home, while 31 patients (41.3%) eventually died in the hospital. Through multiple logistic regression analysis, patients who had never been rehospitalized [odds ratio (OR) = 12.95, 95% confidence interval (CI) = 3.41-49.19], who preferred to die at home (OR = 4.68, 95% CI = 1.21-18.09) and who were most functionally dependent with an Eastern Cooperative Oncology Group scale = 4 (OR = 4.36, 95% CI = 1.02-18.64) were found to be most likely to die at home under this care model. Through palliative home care with the participation of family physicians, patients' preference could be a significant determinant of home death. Our finding can be helpful to the establishment of an ethical care model for terminal cancer patients.

Home visits by family physicians during the end-of-life: Does patient income or residence play a role?

BackgroundWith a growing trend for those with advanced cancer to die at home, there is a corresponding increase in need for primary medical care in that setting. Yet those with lower incomes and in rural regions are often challenged to have their health care needs met. This study examined the association between patient income and residence and the receipt of Family Physician (FP) home visits during the end-of-life among patients with cancer.MethodsData Sources/Study Setting. Secondary analysis of linked population-based data. Information pertaining to all patients who died due to lung, colorectal, breast or prostate cancer between 1992 and 1997 (N = 7,212) in the Canadian province of Nova Scotia (NS) was extracted from three administrative health databases and from Statistics Canada census records. Study Design. An ecological measure of income ('neighbourhood' median household income) was developed using census information. Multivariate logistic regression was then used to assess the association of income with the receipt of at least one home visit from a FP among all subjects and by region of residency during the end-of-life. Covariates in the initial multivariate model included patient demographics and alternative health services information such as total days spent as a hospital inpatient. Data Extraction Methods. Encrypted patient health card numbers were used to link all administrative health databases whereas the postal code was the link to Statistics Canada census information.ResultsOver 45% of all subjects received at least one home visit (n = 3265). Compared to those from low income areas, the log odds of receiving at least one home visit was significantly greater among subjects who reside in middle to high income neighbourhoods (for the highest income quintile, adjusted odds ratio [OR] = 1.37, 95% confidence interval [CI] = 1.15, 1.64; for upper-middle income, adjusted OR = 1.19, 95%CI = 1.02, 1.39; for middle income, adjusted OR = 1.33, 95%CI = 1.15, 1.54). This association was found to be primarily associated with residency outside of the largest metropolitan region of the province.ConclusionThe likelihood of receiving a FP home visit during the end-of-life is associated with neighbourhood income particularly among patients living outside of a major metropolitan region.

There's No Place Like Home: Evaluating Family Medicine Residents' Training in Home Care

ABSTRACT This study examined residents' experiences in a physician home visit program and their attitudes toward working with older patients in a home setting. In-depth personal interviews were conducted with all second and third year residents in a family medicine residency program (n = 17). Most residents expressed positive attitudes about caring for patients in their homes. Residents said home visits allowed them to provide better care, and enhanced their assessment skills and understanding of community services. We identified a lack of coordination and consistency in several areas, including home visit assessments and the role of physician preceptors. The need for formal training to identify and treat elder abuse was also identified. Participation in a home visit program appears to be an effective learning experience for residents, and helps residents to understand the needs of older people living in the community.

The Doctor on the Patient's Turf: Assessing Patient Satisfaction with Physician Home Visit Programs

ABSTRACT We evaluated a physician home visit program (n = 23 patients) focusing on program implementation and quality. Quality was measured by evaluating patient satisfaction with services using a patient satisfaction scale and interviews with patients, caregivers, and providers. Scale results showed patients expressed the highest satisfaction with access to routine care and physician consideration. Patients expressed less satisfaction with access to emergency care and continuity of care. Physician communication and integration with home- and community-based service providers were other areas of concern. Recommendations include enhancing physician communication skills in the home, providing care for urgent medical conditions, improving chart documentation, and incorporating community-based chronic care experts into the program.

Physician Home Visit Program for Patients with Human Immunodeficiency Virus: A Three-Year Experience

A Physician Home Visit Program for patients with human immunodeficiency virus infection was established to test its impact on patient care. A total of 113 patients with human immunodeficiency virus infection were seen for a total of 2170 visits over a three-year period. Visits were categorized as post-hospital discharge monitoring, acute home care, debilitated patient support, terminal care, and outreach. Outcomes were assessed for care that would have otherwise required an outpatient hospital visit, emergency room (ER) visit, or hospitalization. Also, frequency of ER visits and hospitalizations were measured for the six months before and after entry into the program. The program prevented an estimated 54 hospitalizations over three years, saving approximately $1,400,000. Program patients experienced a 17% reduction in ER visits and 24% in hospitalizations. The Home Visit Program reduced the frequency of hospital visits, while still allowing patients with complicated advanced medical conditions to receive quality care.

Patterns of predeath service use by dementia patients with a family caregiver.

To describe site of death and patterns of predeath service use (hospital, nursing home, and in-home services) among persons with dementia who have a family caregiver. Family caregivers who experienced the death of their relative while participating in a 5-year longitudinal study were surveyed retrospectively about service use patterns in the 90 days before the death of their relative. Community. Eighty-two family caregivers of a person with dementia who experienced the death of their relative while participating in a longitudinal study (n = 326) were included in this analysis. All participants were providing care to a relative with dementia in the home at entry into the study. Survey items were used to identify site of death and measure use of the following services in the 90 days before death: hospital, nursing home, skilled nursing services, home health aides, and physician home visits. Sixty-nine percent of the caregivers were spouses, and 28% were adult children. Family caregivers had been providing care for an average of 6 years (SD = 3.9) before the death of their relative. The most frequent setting for patient death was home (42%), followed by nursing home (32%) and hospital (26%). The average number of days spent at home in the 90 days before death by the sample was more than 60 days. Thirty-four percent of the dementia patients were cared for exclusively in the home in the 90 days before death, and 34% spent more than half of the 90 days before death at home. Hospital stays were brief, and less than one-fourth of the sample spent all of the 90 days before death in an institutional setting. Twenty-one percent of the sample used no in-home services in the 90 days before death, 48% of the sample did not use skilled nursing services, and only 27% received a physician home visit. The results of this study suggest that dementia patients who have a family caregiver receive a significant proportion of their care at home in the 90 days before death. A hospice approach may help address the needs for assistance of families who provide terminal care in the home for a relative with dementia.

Community Service Issues before Nursing Home Placement of Persons with Dementia

Family caregivers of persons with dementia (N = 98) [corrected] who placed their relative in a nursing home while participating in a longitudinal study were surveyed about their experiences with community services (adult day care, in-home services, and physician home visits). One third (34%) of the sample reported that at least one service issue (affordability, eligibility, access, or service quality) had a strong influence on the nursing home placement, whereas 40% reported that the availability of at least one additional service would have delayed the nursing home placement of their relative. Caregivers who were employed reported higher levels of unmet service needs. The results of this study support the existence of a group of dementia caregivers with a high need for and willingness to use community service interventions in the preinstitutional period.

A National Survey of the Home Visiting Practice and Attitudes of Family Physicians and Internists

Over the past decade, while physician home visiting has continued to decline, the home care industry has been experiencing dramatic growth. In response, several major physician organizations have been encouraging increased physician education and involvement in home care and urging related health policy changes. This study provides the first in-depth, nationally representative descriptive data on the current home visiting practice and related attitudes of physicians. Data were gathered through a structured 15-minute telephone survey, consisting of 141 items covering physician's general practice, personal home visiting practice, interaction with other home care providers, and attitudes regarding home care issues. Subjects were a nationally representative, randomly selected sample of 2200 family practice physicians (FPs) and internal medicine physicians (IMs) currently in active practice with at least 10 hours per week of professional time spent in ambulatory care. Sixty-five percent of eligible participants completed the survey. Of all physicians surveyed, 65% of FPs and 44% of IMs reported that they may make house calls (P less than .001). Mean number of visits per year was 21.2 (median, 10) for FPs, and it was 15.7 (median, 6) for IMs. Physicians in rural practice were more likely to make home visits (P less than .001). Physician attitudes related to home care reflect a strong dissatisfaction with reimbursement, but positive opinions about the use of other home care professionals and the importance of home visits for selected patients. Logistic regression analysis comparing home-visiting physicians with non-visiting physicians allowed for prediction of the correct classification 73% of the time, and it revealed six variables that were significant predictors of home visiting. The strongest of these predictors were the physician's positive attitude regarding the importance of home visits for selected patients and his or her perception of having time available for home visits. Other significant variables predictive of home visiting were family practice specialty, rural location of practice, greater numbers of referrals to home care agencies, and, interestingly, dissatisfaction with reimbursement. Although the great majority (over 75%) of FPs and IMs still regard the physician home visit as important for the care of selected patients, only about half report making one or more home visits within a 12-month period. Family physicians generally report a greater involvement in home care than do IMs. Physician reimbursement for home visits is perceived to be inadequate, and almost half (45%) indicate that they would do more home visits if reimbursement were increased. Most physicians (over 80%) have the opinion that home care agencies should be used more.

Physician home visits for persons with dementia: Is there a need?

This study explores the potential role ofphysician home visits in the care of persons with dementia. Family caregivers (n = 182) of relatives with irreversible dementia were surveyed about their use of physician home visits, perceptions of the availability of home visits and anticipatedfuture need for this service. Persons with dementia who had used home visits had higher functional and mobility deficits, were more likely to have used other types of in-home assistance and were more likely to require catheter or decubitus care. Over half of the sample intends to use physician home visits in the future, but mostfamilies have not investigated the availability of the service. Barriers to the use of physician home visits are presented and policy implications are discussed.

In-home physician visits and large medical groups.

In-home care has grown rapidly in the past decade and has become increasingly complex. Accompanying these changes has been a resurgence of what was once thought to be an endangered if not extinct species, the physician house call. This paper is concerned with the involvement in the provision of physician home visits by large medical groups, and with how this involvement is related to the characteristics of the medical group. In December 1989, telephone interviews were conducted with 174 large medical groups (those with more than 50 physician members), representing a response rate of 73 percent of the universe of (239) groups found to fit study criteria. Of responding groups, 52 percent indicated that they provided physician home visits. Groups in states with higher proportions of population aged 85 years and over and groups that report accepting physician house calls are more likely to provide house calls. It is concluded that the provision of house calls by large medical groups is likely to increase with the greater complexity of in-home care, the shift of acute care into the home, and the rapid growth of the very old population.

Physician Home Visits from the Viewpoint of the Disabled Elderly and Their Caregivers

In contrast to most studies about physician home visits which questioned physicians about their practices, we interviewed 307 caregivers regarding their elderly relative's experience with physician home visits. Twenty-one percent reported having received a home visit by the primary physician and an additional 24% believed the physician would come if needed. The length of time the physician had been caring for the patient was significantly higher than the group who had received home visits. The only health services utilization data that could be shown to correlate was the use of visiting nurse services. Three patient characteristics demonstrated significant positive correlations to the receipt of a home visit: the need to be lifted or turned, the use of urinary catheters, and the need to be cleaned of incontinent stool.

The Physician Home Visit

The Physician Home Visit