From: Subject: House Calls: Taking the Practice to the Patient - June 2000 - Family Practice Management Date: Fri, 9 Mar 2007 09:42:11 -0800 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_0016_01C7622F.35FE1F20" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.3028 This is a multi-part message in MIME format. ------=_NextPart_000_0016_01C7622F.35FE1F20 Content-Type: text/html; charset="utf-8" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.aafp.org/fpm/20000600/49hous.html =EF=BB=BF House Calls: Taking the Practice to the Patient - = June 2000 - Family Practice Management
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<= /DIV>AAFP Home Page = > News=20 & Publications > Jo= urnals=20 > FPM=20 > June=20 2000
FPM=20 HOME | LATEST=20 ISSUE | PAST=20 ISSUES | CME=20 QUIZ | CONTACT=20 FPM | TOOLBOX=20 | FAQ=20 | SEARCH=20 FPM
June 2000 = (table = of=20 contents)
Vol. 7, = No. 6

House Calls: Taking the Practice to the = Patient

Visiting patients where they = live is not=20 only good medicine and good marketing. It's also = good=20 for the soul.

James M. Giovino, MD

3DCME Covered in = FPM=20 Quiz

3Dtool=20Tool=20 inside

SPEEDBAR=C2=AE =

=C2=BB=20 House=20 calls can help family physicians provide=20 high-quality, continuous, comprehensive=20 care.

=C2=BB=20 Visiting=20 patients where they live can also be = personally=20 rewarding.

=C2=BB=20 House=20 calls do not necessarily increase a = practice's=20 geriatric population, but they often bring = in the=20 children and grandchildren of elderly=20 patients.

=C2=BB=20 To=20 best manage a nursing home population, = family=20 physicians should limit the number of = nursing=20 homes they visit.

=C2=BB=20 A=20 practice of four physicians would want=20 approximately 40 to 50 nursing home = patients to=20 make their visits fiscally=20 worthwhile.

=C2=BB=20 Phone=20 calls can be the hardest part of nursing = home=20 medicine unless you train the staff to = call only=20 with urgent medical problems or=20 emergencies.

=C2=BB=20 For=20 homebound or home-hospice patients, cut = down on=20 travel time by making house calls on your = way home=20 or to another location.

=C2=BB=20 When=20 an unexpected house call arises, be = willing to=20 work it into your schedule.

=C2=BB=20 To=20 save time, use progress note forms and = finish your=20 documentation before you leave the = patient's=20 residence.

=C2=BB=20 The=20 key reason physicians shy away from house = calls=20 isn't inadequate reimbursement; it's=20 = unfamiliarity.

More = and more, we=20 are rediscovering what our predecessors = practiced=20 without a second thought: going to see our = patients=20 where they live. The modern twist is that they = live not=20 just in the family home but in the nursing home, = assisted living center and hospice house. As the = population ages, family physicians will = increasingly=20 have to make the choice between seeing patients = where=20 they live or transferring their patients' care = to other=20 doctors who will.

For me, the choice has been an easy one = because I've=20 seen that house calls lead to better patient = care, a=20 stronger practice and a more rewarding career in = medicine. In addition, I've found a way to = incorporate=20 house calls into my work day without losing my = shirt.=20 Here's how and why you should too.

The risks and = rewards

You might be thinking, "I don't have time to = see all=20 the patients in my office! Why would I want to = make=20 house calls?" While it's true that family = physicians are=20 under increasing time pressures, there are = compelling=20 reasons for making house calls a regular part of = your=20 practice.

Patient care. Very = simply, house=20 calls are good medicine. As family physicians, = we often=20 talk about our ability to provide high-quality,=20 continuous, comprehensive care. House calls can = help us=20 fulfill that mission by keeping us in touch with = our=20 patients, even those who cannot come to the = office. In=20 addition, by visiting patients where they live, = we can=20 learn more about them and connect with them on a = more=20 personal level.

Marketing. Few things build the = public's trust=20 and the desirability of a doctor more than = word-of-mouth=20 advertising that "he makes house calls!" As we = compete=20 with other practices and other specialties in = the=20 managed care world, better service will build a=20 practice. House calls are one of those rare = value-added=20 services that will make you outshine your=20 competition.

A feel-good approach to = medicine.=20 As we have less and less time to spend = with=20 patients during office visits, it can become = more=20 difficult to feel personally rewarded for = another ear=20 infection well treated. Compared with this, when = I go=20 into my patients' homes and see them in the most = personal and vulnerable state, I get a sense of = walking=20 on hallowed ground. Even visits for simple = problems take=20 on a meaningful hue.

Market share. The = demographics=20 are simple: America is aging. An estimated 13 = percent of=20 the U.S. population is over the age of 65, and = by 2025=20 that age group will grow to nearly 20 percent, = according=20 to the U.S. Census Bureau. Many seniors can't = get out of=20 their homes, nursing homes or hospice centers. = If you=20 want to capture market share, go get it. You may = even=20 find that grandma's entire family will choose = you as=20 their physician when you impress them with = grandma's=20 care.

KEY = POINTS:=20
  • The modern house call means going to = see=20 patients where they live, whether it is = the=20 family home, nursing home, assisted = living=20 center or hospice house.=20
  • House calls are good medicine, and = they can=20 increase a practice's market share and = enrich a=20 physician's career.=20
  • New efficiencies can be learned to = make=20 house calls a viable part of any family=20 practice. =

Of course there are risks involved with = expanding the=20 scope of your practice to include house calls. = Two of=20 the greatest concerns are its effects on patient = mix and=20 practice efficiency.

If you enjoy a broad mix of patients, you may = worry=20 that by expanding your services through house = calls you=20 will end up with a disproportionate share of = elderly=20 patients in your practice. In my experience, = house calls=20 have certainly added some geriatric patients to = my=20 practice, but they have added even more adults = and=20 adolescents as the children and grandchildren of = my=20 elderly patients join my practice.

You may also worry about the implications of = seeing=20 one homebound patient at the expense of a half = day of=20 office patients. New efficiencies must be = learned, but=20 if you consider the care of your homebound = patients an=20 essential part of your practice, you'll find a = way. The=20 following tips will get you started.

When I go=20 into my patients' homes, I get a sense of = walking=20 on hallowed ground. =

How to manage = a nursing=20 home population

If you are making house calls to patients in = a=20 nursing home, keep in mind these suggestions, = which will=20 improve your efficiency:

Limit the number of nursing = homes you=20 attend. Your patients (or families) who = are=20 looking for a nursing home will most likely = choose the=20 one you are willing to visit. If you already go = to more=20 than one nursing home, consolidate your patients = over=20 time (e.g., by seeing new patients at one = location=20 only).

The black bag

As you begin = doing house=20 calls, you will quickly customize your = black bag=20 to include those things that you find = necessary=20 and convenient. Here is a quick list of = things to=20 get you started:

  • Street map,=20
  • Stethoscope,=20
  • Blood pressure cuff (regular and = large),=20
  • Pen light,=20
  • Tongue depressors,=20
  • Otoscope,=20
  • Prescription pad,=20
  • Phone numbers (offices, pharmacies, = etc.),=20
  • Cell phone, palm-held computer, etc. =
  • Dictaphone/forms/progress notes,=20
  • Extra pens. =

Don't admit patients to a nursing home you = do not=20 plan to visit. It is better to lose that = patient to=20 another doctor than to give telephone medicine = when a=20 monthly exam is more appropriate. Also don't = rely on=20 patients being transported to your office for = monthly=20 visits. This quickly leads to unhappy patients = and=20 families. If you don't believe me, ask my many = patients=20 who have transferred to my care over this very = issue --=20 and who won't tell their former doctors why.

Make sure that you or a partner visits the = nursing=20 home once a week and sees every patient at least = once a=20 month. Block out the office schedule for the = nursing=20 home doc for that half day. Patients who become = ill=20 between visits with you can be seen by a partner = on his=20 or her turn at the nursing home.

Build a nursing home = population of=20 sufficient size so that your trips are fiscally=20 worthwhile. If you would see 12 patients = in half=20 a day in the office, try to see at least 12 = patients at=20 each visit to the nursing home. For a practice = of four=20 physicians, the optimal nursing home population = may be=20 40 to 50. (You can do just fine with half this = number=20 though.)

Manage phone calls = proactively.=20 This is perhaps the hardest part of = nursing home=20 medicine. There are several good strategies: =

  • Make sure that you or one of your partners = goes to=20 every nursing home you round on every week, as = discussed previously. You can deal with all = the=20 paperwork and order-signing at that time.=20
  • Use "care process models," "care plans" or = "nursing protocols" to deal with trivial = calls.=20
  • Direct the nursing home staff to call your = office=20 with urgent medical problems and emergencies = only, and=20 establish a dedicated fax line for all other = nursing=20 home related messages and requests.=20
  • Plan to spend at least six months training = the=20 nursing home staff on the difference between a = request=20 for a laxative and a medical emergency. =

Give good service to the patients and = treat the=20 staff well. At least 20 percent of my = nursing home=20 patients have transferred to my care because of=20 recommendations from nursing home staff and = family=20 members of nursing home patients. You can always = say=20 "no" to a new patient if your service is larger = than you=20 want.

Consider becoming the medical director of = the=20 nursing home. If you're going to be there = anyway,=20 why not make a little extra money and have a = hand in=20 controlling the quality of the services at the = facility?=20 As medical director, you can also institute = policies,=20 procedures and care plans that will improve = patient care=20 and minimize inefficiencies.

If you do become the medical director of the = nursing=20 home, do not fall into the trap of answering = questions=20 from staff about other doctors' patients, = rounding on=20 those patients when the other doctor won't, or = taking=20 nursing home call for doctors who won't take = their own.=20 In these cases, pick up the phone and do a = little=20 "teaching" with the other physician. If you = start=20 covering for doctors who won't practice = acceptable=20 medicine, you'll end up hating the nursing home. = Your=20 job is to improve the quality of the care at the = nursing=20 home, not to enable inappropriate behavior from = other=20 physicians.

Using forms to decrease = work

Physicians can = create a=20 variety of forms or templates to make = house calls=20 more efficient. Here is an example of a = progress=20 note form used for house calls to Medicare = patients. The form guides you through the=20 necessary home assessment, encourages = accurate=20 coding and will help you document the = necessity of=20 the home visit. This form can be = downloaded as a=20 Micr= osoft=20 Word file or a PDF = file. To access the PDF files, you = will need=20 Adobe Acrobat Reader, which you may download=20 free of charge.

HOUSE CALL -- = Medicare

Need = for House=20 Call: Pt = home-bound O/V requires = ambulance=20 transport O/V requires = excessive=20 = effort/pain

CC

HPI

Physical Exam

BP P R T

HEENT

Lungs

Cor

Abd

Ext

=

Skin

Home=20 Environment Patient = Activity Support
Smells: = urine rotting=20 musty OK Walks = in home:=20 no = assist=20 assist=20 no Family=20 visits: qwk
Temp:=20 x/s = cold=20 x/s = hot=20 OK Uses = prescribed=20 walker/cane: y = n Friend=20 visits: qwk
Clean:=20 clean messy dirty filthy Pt = falling:=20 y = n=20 freq:____________ Nurse visits:=20 qwk
Rugs:=20 Exposed rug=20 edges Pt = dresses self:=20 y = n HH Aid=20 visits: qwk
Furniture:=20 sturdy=20 flimsy=20 cluttered Pt = bathes self:=20 y = n Meals on wls:=20 qwk
Toilet: = accessible=20 =20 inaccessible Pt = cooks for self:=20 y = n  
toilet = rails=20 shower=20 rails    
Phone:=20 accessible=20 inaccessible    
Food:=20 healthy = balance=20 x/s = canned    
x/s junk = food=20 x/s=20 salt/sugar    
Food = quantity:=20 adequate=20 scant x/s    
Lighting:=20 bright=20 mod = dim    

Assessment/Plan

 

 

New Patient: 99341 99342 99343 99344 99345

Est Patient: 99347 99348 99349 = 99350

Patient Name:

MR#:

=

DOB:

Date of Visit: = _________________=20 Signature: = ______________________________

Copyright =C2=A9 2000=20 American Academy of Family Physicians.=20 Physicians may photocopy or adapt for = use in=20 patients' charts. All other rights=20 = reserved.

<= /CENTER>

How to manage = a homebound=20 or home-hospice population

To best manage your time and resources during = visits=20 to homebound or home-hospice patients, consider = these=20 tips:

Use home health nurses to their potential. = They are free to you! Meet the home = health=20 nurse at the patient's home, and communicate = care plans=20 directly to the nurse, the patient and the = family at the=20 same time. Home health nurses will appreciate a = doctor=20 who is willing to work with them and talk to = them as=20 people. Add in a couple of house calls, and you = will be=20 forever in their hearts. Besides creating better = working=20 relationships, this will also bring you new=20 patients.

Use care process models, care plans and = nursing=20 protocols with the home health nurses as you do = with=20 nursing home staff. This will save time and = ensure=20 that you're working toward the same = objective.

Minimize travel time. = There are=20 several strategies for doing this:

  • See both members of a couple at the same = time;=20
  • Make house calls when you plan to be in = the car=20 anyway (such as on your nursing home half day = or on=20 your way to another location);=20
  • Make a group of house calls during the = same half=20 day;=20
  • Make a house call at the end of each day = (you=20 could work in five house calls per week and = make a bit=20 more in production since house calls pay more = than=20 office visits).

Dictate your notes in the car. Don't = wait=20 until you return to the office or your home. = Dictate=20 while the visit is fresh in your mind, and = you'll get=20 through it more quickly. In fact, you can = dictate on=20 your way to the next visit and waste no time at = all.

Be willing to make an = unexpected house=20 call now and then when the patient really needs = you.=20 You'll find a way to work it in if you = think of=20 it as an "admission," but skip the hospital. = Your=20 patients, their families and your community will = grow to=20 love you, and your practice will thrive.

Coding house = calls

The table below = compares=20 the CPT codes for house calls to similar=20 office-visit codes.

House = call=20 requirements House = call CPT=20 code Approx. time for=20 house calls Similar office-visit = code Office = visit=20 requirements
New=20 patient
Problem-focused=20 history and exam
Straightforward = medical=20 decision making		 99341 20 99201 Problem-focused=20 history and exam
Straightforward = medical=20 decision making
Expanded=20 problem-focused history and = exam
Medical=20 decision making of low complexity		 99342 30 99202 Expanded=20 problem-focused history and=20 exam
Straightforward medical decision = making
Detailed = history and=20 exam
Medical decision making of = moderate=20 complexity		 99343 45 99203 Detailed = history and=20 exam
Medical decision making of low=20 complexity
Comprehensive history=20 and exam
Medical decision making of = moderate=20 complexity		 99344 60 99204 Comprehensive history=20 and exam
Medical decision making of = moderate=20 complexity
Comprehensive history=20 and exam
Medical decision making of = high=20 complexity		 99345 75 99205 Comprehensive history=20 and exam
Medical decision making of = high=20 complexity
Established = patient
Problem-focused=20 interval history and = exam
Straightforward=20 medical decision making		 99347 15 99212 Problem-focused=20 history and exam
Straightforward = medical=20 decision making
Expanded=20 problem-focused interval history and=20 exam
Medical decision making of low=20 complexity		 99348 25 99213 Expanded=20 problem-focused history and = exam
Medical=20 decision making of low = complexity
Detailed = interval=20 history and exam
Medical decision = making of=20 moderate complexity		 99349 40 99214 Detailed = history and=20 exam
Medical decision making of = moderate=20 complexity
Comprehensive interval=20 history and exam
Medical decision = making of=20 moderate to high complexity		 99350 60 99215 Comprehensive history=20 and exam
Medical decision making of = high=20 = complexity

How to manage = an=20 inpatient hospice population

For "house calls" to an inpatient hospice = population,=20 here's what to expect:

Hospice patients need routine visits for = months,=20 which can be scheduled ahead of time. = Eventually, they=20 will require unscheduled visits as symptoms = worsen. You=20 can use all the above techniques to manage the = care of=20 these vulnerable, special patients. But here, = you have=20 one additional advantage: the hospice nurse = (another=20 free nurse for you). These well-trained = professionals=20 will do all they can to make your job easy. They = will=20 almost certainly already have standing orders = for you to=20 approve, and they are highly autonomous at = managing=20 patients' symptoms. You will almost never = receive a=20 trivial phone message or a needless request from = a=20 hospice nurse. Care of the hospice patient in = the home=20 or in the hospice house combines the best of = home care=20 and nursing home care. This is a good model to = apply to=20 all your homebound and nursing home = patients.

What about=20 coding and documentation?

For documentation, the short answer to what = works=20 best is whatever works for you. I recommend = doing the=20 documentation immediately after the visit, using = a=20 one-page progress note form specifically = designed for=20 house calls (see=20 page 51) or a dictating machine. Either way, = I=20 finish my documentation in my car before I leave = the=20 patient's residence.

Remember that house calls pay more than = office=20 visits. To be reimbursed at the higher rate by = Medicare,=20 you must document the reason a house call was = necessary.=20 Reasons include "the patient is home-bound," "an = office=20 visit requires ambulance transport" or "an = office visit=20 requires excessive physical effort or pain."

House call CPT codes are similar to office = visit=20 codes, but there are two major differences. = First, the=20 typical face-to-face time is longer with house = calls.=20 Second, for house calls to established patients, = the=20 lowest code is essentially equivalent to a = 99212. (See=20 the comparison on page 53.)

Bottom=20 line

I like house calls. If I hated them, I = wouldn't do=20 them even if they were profitable. I suspect you = wouldn't either. The biggest obstacle to = incorporating=20 house calls into regular practice isn't = inadequate=20 reimbursement; it's inadequate training. When we = don't=20 have a good, thorough experience with a = particular=20 aspect of medicine as residents, we tend not to=20 gravitate toward those things in our practices. = Comfort=20 comes from experience. Without comfort in making = house=20 calls, we don't do them even though we can and=20 should.

My advice is to do just six house calls. = You'll work=20 out the logistics after the first two or three = and, by=20 the end of the sixth, have a sense of their = value to you=20 as a physician and as a person. If you don't = like them,=20 no sweat. Do them when you have to, but = otherwise leave=20 them to your colleagues. If you like them, don't = look=20 back. It may be the most rewarding experience = you have=20 as a doctor.

Editor's = note:=20 Please keep in mind that CPT and ICD-9 codes = change=20 annually. For the most detailed and up-to-date=20 information, refer to the current CPT manual, = the=20 related "Documentation Guidelines for Evaluation = and=20 Management Services" and the ICD-9 manual.

Dr. Giovino is = director of=20 the Mercy Health System Family Practice = Residency=20 Program in Janesville, Wis., and is medical = director=20 of Mercy Hospice. He is also a contributing = editor to=20 Family Practice=20 Management.

Copyright =C2=A9 2000 by = the American=20 Academy of Family Physicians.
This content = is=20 owned by the AAFP. A person viewing it online = may make=20 one printout of the material and may use that = printout=20 only for his or her personal, non-commercial=20 reference. This material may not otherwise be=20 downloaded, copied, printed, stored, = transmitted or=20 reproduced in any medium, whether now known or = later=20 invented, except as authorized in writing by = the AAFP.=20 Contact fpmserv@aafp.org=20 for copyright questions and/or permission=20 requests.

3D""=20=20 =

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