Physician House Calls: An Old Model With a Modern-Day Twist

A physician who makes house calls often evokes a quaint stereotype of a kindly, experienced doctor, carrying a black bag when knocking on the doors of the infirm. In the 1930s, physician house calls represented 40% of physician-patient encounters.¹ By the late 20th century, this model largely became obsolete, pushed aside by office-centered medicine and mega health systems. In 1972, only about 5% of care provided by general practitioners took place in patients’ homes, and by 1980, house calls had decreased even further, to less than 1%.²

Today, physician house calls are staging a comeback, driven by the need to address barriers in healthcare access, including cost and availability of timely care.² Long wait times for appointments with a primary care physician and increasing use of costly emergency department (ED) visits have led to the reemergence of house calls as an alternative care delivery model.²

Evolving habits of consumers who use smartphone apps and on-demand services have led to the growth of on-demand, app-based physician house calls as a viable alternative to office- or ED-based visits or more traditional models of home-based services.²

To shed light on this emerging phenomenon, MPR interviewed three experts: Shannon Fortin Ensign, MD, PhD, Chief Resident, Internal Medicine, Scripps Clinic/Scripps Green Hospital and KL2 Clinician Researcher, The Scripps Research Institute, La Jolla, CA, who is the coauthor of a recent review of on-demand app-based physician house calls;² Justin Zaghi, MD, MBA, Medical Director of Heal; and Janet O’Brien, MD, MSPH, an internist on staff at Heal.

Dr Fortin Ensign

Can you please describe your study?

It consisted of a retrospective observational analysis of data collected from Heal, a practice that is based on physician house calls, regarding home visits to 13,849 patients over a 1-year period (from August 2016 to July 2017). We assessed wait times, visit time, diagnoses, outcomes, and patient satisfaction.

What motivated your study?

The Scripps Translational Science Institute has a strong interest in learning how new technologies can be applied within the field of individualized digital medicine, and their role to impact overall healthcare. We became aware of this mobile-based platform as a way of possibly meeting the increasing demand for primary care in the community and we wanted to see how well it was working, whether individuals were actually taking advantage of the platform, and what the initial data are about how it’s being used and received.

What were some of your salient findings?

We found a bimodal age distribution in the patient population utilizing this service, peaking at 1 year and at 39 years – meaning that the app was being used most in pediatrics and among young adults. Of these, close to 94% of pediatric and 67% of adult requests were for fever and/or acute upper respiratory infection.  The mean wait time for as-soon-as-possible house calls was approximately an hour and a half, and the mean duration of each visit was close to half an hour – 27.1 minutes, to be exact.

These represent very important improvements over the time involved in a typical ambulatory care medical visit, which includes time for travel to the clinic and wait time to see the doctor.

Why did patients choose a house call over other forms of delivery, such as Urgent Care or a doctor’s office?

Most (about 70%) reported doing so for the sake of convenience or – in the case of another approximately 34% – the ability to more rapidly receive services.

What do you think accounts for the age distribution? 

The young adult population is very tech-savvy. They are accustomed to using apps and quickly scheduling appointments with a few clicks. They are also very busy working and caring for young children, so a model that doesn’t require them to leave their homes when they have a sick child is very appealing.

Were patients happy with the house call model?

There were high levels of patient satisfaction, with almost all respondents (94.2%) reporting that they would schedule house calls again. People were happy with “ASAP” visits that were not based in Urgent Care.

What advice to you have for physicians, based on your findings?

I definitely
advise physicians to consider this type of model. PCPs in particular should consider
all their options. There is much that they can do other than office-based work,
which some report as being draining or contributing to burnout. House calls
should be one job option that’s worth looking at.

Dr Zaghi

What is Heal?

Heal is a medical practice that provides house calls. We also visit patients at work, or even in their hotel rooms if they are traveling. We use innovative technology and regard ourselves as re-humanizing the practice of medicine by making healthcare more personal and convenient.

How
did the company get started?

Dr Renee Dua and her husband, Nick Desai, co-founded the company in 2014 after their child got ill and required a 7 hour wait in the ED. The child got better, but Dr Dua and Nick were frustrated that they had to wait so long. While going home, they thought “there has to be a better solution” and came up with the idea of having the doctor visit the patient.

Where does your company currently operate?

At the moment, we operate in Los Angeles, Orange County, San Diego, San Francisco, Washington DC, and most recently Atlanta. We are fortunate to be growing rapidly, driven by strong demand for our services.

What is the structure of your physicians’ schedules?

The majority of our physicians are full-time, although we also have part-time shifts available. Our shifts tend to be about 12 hours at a time – usually from 8:00 AM to 8:30 PM. Our physicians do around 16 shifts monthly (each consisting of 12.5 hours), which averages to around 48 hours per week.

What is the structure of the actual patient visit?

Physicians go to the patient’s home, accompanied by a
medical assistant, who does the driving. The medical assistants are also
certified phlebotomists and during the appointment they do blood draws, strep
tests, collect vital signs, and help with documentation.

The assistant carries a kit that contains almost everything you would have at a typical doctor’s office, including a stethoscope, otoscope, blood pressure cuff, thermometer, equipment to repair lacerations, etc.

Do you provide emergency services?

I’d like to make it clear that we don’t provide emergency services and there is a strict triage system in place to make sure that we are not being sent to emergency cases. Every now and then, we’ll arrive at a patient’s home and determine that the situation actually is an emergency, and we will send them to the emergency room. If we need imaging or a referral, we make those arrangements.

Are there differences in liability with this model?

There are no differences in liability.

Aren’t physicians vulnerable if they are going into people’s homes?

We make sure for safety reasons that a medical assistant, who plays an important role in preserving physician safety, always accompanies our physicians. Thankfully, there has never been any violence toward our staff. The medical assistant is always present for examinations.

What are other advantages of the house call model?

Most of the time when a person is ill, they don’t want to go out to see the doctor. It is a huge convenience if the doctor can come to them. I also think they get better care. People are being seen in their natural environment, so there is better medication reconciliation, and the doctor can assess for environmental hazards, such as a tobacco smell, or rugs, which can create a fall-risk for the elderly.

Most importantly, our physicians spend almost double the amount of time with each patient as they would in a typical office appointment. There is an unhurried atmosphere. Blood work is done in the convenience of one’s home.

People are so happy with Heal that we have received an unprecedented Net Promoter Score of +83.

Dr O’Brien

What made you decide to become a Heal provider?

One of the priorities of Heal is making physicians happy, and as a doctor, it’s hard to deliver good care if you’re stressed and burned out. There are so many challenges in delivering care in a traditional environment. In a traditional doctor’s office, the physician has only a few minutes with patients. We at Heal, on the other hand, can take 45 minutes with a patient, even if it’s something as simple as sinusitis. We can ask the patient to share whatever is medically most important to him or her, and we also set a high priority on ascertaining whether a patient has had recommended screening tests. For example, if a woman over age 40 has sinusitis, we will treat the sinusitis but also initiate a discussion about whether she has had a mammogram. We have the luxury, in terms of time, of bringing up and discussing lifestyle elements like diet and exercise.

And being in people’s home enables me to see their lifestyle first-hand. For example, I saw an asthmatic patient who said that the household was smoke free and everyone who smoked did so outside. But there were overflowing ashtrays everywhere, which suggested that smoking was taking place in the home. Because I saw this, I was able to bring it up with the patient.

This is the type of medical practice I like to do – to treat the whole patient, and do a comprehensive job.

How does this model fit in with your own lifestyle?

Each shift is 12 hours, which admittedly is a long shift. On the other hand, I do only 16 shifts in a month, so that I have 2 weeks off each month. I can organize my schedule so that I can dovetail my “off” time – for example, I didn’t work the last 2 weeks of April and the first 2 weeks of May, and I took 4 weeks off without using any vacation time.

Would you recommend that other physicians adopt this model?

I consider myself one of the happiest clams on the beach, doing exactly what I went to medical school to do. So I definitely encourage other physicians to try this.

References

1. Kao H, Conant R, Soriano T, McCormick W. The past, present, and future of house calls. Clin Geriatr Med. 2009 Feb;25(1):19-34.
2. Fortin Ensign S, Baca-Motes K, Steinhubl SR, Topol EJ. Characteristics of the modern-day physician house call. Medicine (Baltimore). 2019;98(8):e14671.

This article originally appeared on MPR