Bring Back the House CallOctober 16, 2009
By Christine Moffa, MS, RN, AJN clinical editor
What should be done about a person with a chronic medical condition who can’t make it to their primary care provider but isn’t sick enough to call 911?
Recently a case came to my attention of a woman in her 60s with a history of impaired mobility due to primary lymphedema of the legs, obesity, and some other chronic medical problems. One day while getting up out of bed she strained her back. The pain from the injury made it that much harder to tolerate any kind of physical activity. She was no longer able to climb up or down stairs. Since there was no way to leave her house without going down several steps, she couldn’t get the medical care she needed to treat the acute back pain or the wounds on her lower legs associated with the lymphedema. As the months passed, her leg wounds grew worse and her inactivity led to more inactivity. Although her husband and children were able to assist her in some capacity, they had no way to get her out of the home.
Prior to the her back injury, she’d routinely visited her primary care physician as well as a vascular surgeon—but neither felt comfortable ordering home care for her (nor did they offer any solutions). Without an order, a home care service couldn’t take her case. A trip to the emergency room wasn’t really what she needed, but aside from calling 911 there was no other way of getting her seen by someone with the privileges to prescribe either the medications or home care she needed.
Her family was finally able to find a house-call service that was reasonably priced and willing to travel to her town. Most of these services don’t take private insurance (some take Medicare and Medicaid) and can charge as high as $600 for a visit. A physician’s assistant went to the home and examined her, and she finally got the prescriptions for home health care and pain medicine she needed. It’s too bad it took four months to accomplish this.
In some parts of the country there are programs, such as the Mt. Sinai Visiting Doctors Program, available to provide primary care to the homebound. However, most of these are geared toward the elderly or to severely disabled, chronically ill veterans.
But what about those who are not quite frail but are homebound due to less serious health problems? If not for the home visit, the condition of the patient described above would have declined to the point of requiring an ER visit or hospitalization. As the blogger KevinMD points out, “In-home visits could take the place of unnecessary and costly hospital stays and help prevent equally expensive re-admissions to the hospital.” Maybe it’s time to bring back the house call.
(By way of comparison during this time of debate about health care reform: France still does have house calls, very reasonably priced under that nation’s health care system.)