Another aspect of the program focuses on meaningful conversations about the end of life and living wills. "When we look at patients terminating from the program, a common cause is death," Ruby said. "But when the patients die, it's often in their own homes instead of the hospital."
To make the house call business model work requires several factors. First, it needs enough patients and good scheduling to reduce what Zafirau refers to as "windshield time." This means scheduling patients so you're "delivering more care than you are driving to deliver care," Ruby says.
Sometimes house calls are performed as a supplement to primary care, as with the Just for Us program operated by the Duke Community Health in Durham, NC, under contract with Lincoln Community Health Center. Patients are enrolled as patients in Lincoln, which bills Medicare, Medicaid, or other insurers. Currently, 50% of the cost is reimbursed by Duke, but the goal of the program is to eventually make it self-sufficient.
The 24/7 responsibilities of providing healthcare falls on the primary care providers. However, enrollees in Just for Us—who are low-income seniors—receive care where they live that helps them, for instance, manage their diabetes, hypertension, or COPD, or receive assistance with diet and medication issues, says Fred Johnson, director of clinical and care management services with Duke's Division of Community Health.
The program's team—consisting of a supervising physician, a midlevel assistant, a social worker, a nutritionist, an occupational therapist, and a community health worker—visits 350 patients at least once every five weeks.
Many of the patients, who live in nearby high-rise buildings, will receive one-on-one visits in their apartments. (These are fully clothed visits that involve care above the navel, except for toenail trimming, Johnson says.) Some patients meet for group visits in their buildings' community rooms. All of the participants are home-bound, with little family support, and show high rates of low literacy.
And is the program working? In one survey, the program found that ambulance service costs (which the county pays for) dropped by 49%, emergency room costs went down 41%, and inpatient costs declined by 69% from when the program started among the patient group studied; meanwhile prescription costs went up 25%, Johnson says.
And then there are the small victories such as a smoking-cessation group. After two years, "We're down to no one smoking," Johnson says.