November 2001

Grant Results

SUMMARY

Researchers at George Washington University School of Medicine and Health Sciences studied the current status of home medical care, conducted an assessment of the need for home medical care, and identified models of and barriers to providing this care.

Home medical care provides medical assessment, diagnosis, and treatment services and is performed by medical professionals such as physicians and nurse practitioners.

As part of the study, the principal investigators conducted interviews with experts in the home medical care field, focus groups with nurses and physicians, and a review of the medical literature to assess the current need for home medical care.

Key Findings
Findings of the study included:

  • Most home medical care models use interdisciplinary teams of physicians, nurse practitioners, and social workers.
  • Limited payment, lack of training, and physician "territorialism" are key barriers to the expansion of home medical care.
  • It is unclear whether recent changes in federal funding will affect the willingness of medical practices to expand into home medical care.

Recommendations
The research team identified 15 models of home medical care currently in use, and they developed their own model program, which they estimated would cost $3,000 per patient per year.

The researchers recommended that the Robert Wood Johnson Foundation (RWJF) and others:

  • Support the development of home medical care.
  • Examine the most cost-effective mix of providers.
  • Consider the possible impact of technology.
  • Study financing issues.

Funding
RWJF supported the project with a $35,383 grant from August 1998 to to January 2000.

 See Grant Detail & Contact Information
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THE PROBLEM

The family physician making a home visit to the sick and disabled is one of the most cherished visions that Americans hold of health care. As the population continues to age, there will be a need to revisit the benefits of, and barriers to, bringing medical care into the home.

Visits to a physician's office can be time consuming, expensive, and uncomfortable for the disabled patients, both young and old.

A variety of providers, including physicians, nurse practitioners, and physician assistants have made great efforts to accommodate homebound individuals. However, relatively little is known about the variety of financial and service delivery models that currently exist.

Home medical care differs from the more familiar home health care. While home health practitioners, such as physical and occupational therapists, can assess a patient and provide care regarding specific health problems, they do not perform medical assessment, diagnosis, and treatment. Home medical care involves these latter medical services and is performed by medical professionals such as physicians and nurse practitioners.

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THE PROJECT

This grant from RWJF funded a study of the current status of home medical care, an assessment of the need for home medical care, and the identification of model programs and barriers to providing this care.

The principal investigators at George Washington University School of Medicine and Health Sciences:

  • Conducted 24 interviews with experts in the home medical care field.
  • Conducted two focus groups — with eight nurses and six physicians — to identify issues pertaining to home medical care.
  • Conducted a literature review to identify projections of disease burden and the aging of the population, and used these to assess the current need for home medical care (see the Appendix for a list of the literature reviewed).
  • Identified 15 existing models of home medical care that were selected for their geographic diversity, varied use of technology, differing patient groups, and applicability to rural and urban settings. Their analysis also examined program costs and the possible uses of technology to enhance home medical care.

Based on their research, the investigators developed a model home medical care program. The model:

  • Organizes services around patient needs.
  • A care manager functions as a patient advocate and coordinator of services and links communications among patient, family, and all levels of care.

Services to assist disabled individuals of any age to remain in their homes include assistance with activities of daily living, financial management and social services. While the investigators depict home medical care as one of many services patients need to stay in their homes, they conceive of home medical care as part of the medical system.

They noted homebound patients frequently move between hospital, subacute care and long-term care. Referrals to home medical care may emanate from community agencies, health care providers and institutions.

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FINDINGS

The principal investigators reported the following findings to RWJF:

  • Most home medical care models use interdisciplinary teams. These teams typically include physicians, nurse practitioners, and social workers. Some are part of the federal Program for All-inclusive Care for the Elderly (PACE), which includes home care in a full-service program designed to keep individuals out of nursing homes. Another model, Senior Friendship Center, based in Florida, uses retired physicians, nurses, dentists, and mental health counselors who practice on a limited license to make home visits.
  • Limited payment, lack of training, and physician "territorialism" are key barriers to the expansion of home medical care. While most providers surveyed agreed that home medical care is needed, low reimbursement rates may discourage practitioners from providing it, especially given the travel time required to reach patients. Providers also felt that physicians and other health professionals had limited preparation for providing home medical services. Some physicians might be reluctant to recommend home medical care for fear of losing a patient by referring him or her to a home care provider.
  • It is unclear whether recent changes in federal funding will affect the willingness of medical practices to expand into home medical care. The federal Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration or HCFA), which administers the Medicare health program for seniors, increased its reimbursement rates for home medical services, but the impact of that change on the market remains unclear. The researchers say that the model program they developed could provide reasonable home medical services at a cost of $3,000 per patient per year.

Recommendations

The project directors made the following recommendations in a report to RWJF:

  • Support the development of home-based medical care for outpatient care similar to the ideal model proposed by the researchers. The development of this model should have the following three goals:
    1. To provide high quality care for patients and family members.
    2. To be cost-effective.
    3. To explore policy implications for Medicare and Medicaid funding.
  • Examine the most cost-effective mix of team members in providing home medical care. For any given group of patients, it is not known what mix of physician care, nurse practitioner or physician assistant care, or rehabilitative or social work services produce the best outcomes.
  • Examine how the use of technology to augment caregiving abilities in home medical care might improve patient care and provider satisfaction. Examples of useful technology include two-way video hook-ups between patient homes and providers, and simple e-mail contact between patients or caregivers and medical providers.
  • Examine cost/financing issues related to home medical care. These issues include the impact of HCFA reimbursement rates; the willingness of families to pay out-of-pocket for all or a percentage of home medical services; the possibility of a Medicare waiver program to allow more than a 20 percent co-pay to be charged to patients to support the model; and the possibility of combining Medicare and Medicaid funding streams to provide more comprehensive coverage, as is employed in the PACE model of care.

Communications

The project directors submitted a report to RWJF, titled Home Medical Care Project. (See the Bibliography.) There was no other dissemination activity during the term of the grant.

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AFTER THE GRANT

The researchers plan to disseminate the information collected regarding home medical care and, through George Washington University clinical practice, test the "ideal" model of home medical care developed through this project.

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GRANT DETAILS & CONTACT INFORMATION

Project

Review of the Current Status of Home Medical Care

Grantee

George Washington University School of Medicine and Health Sciences (Washington,  DC)

  • Amount: $ 35,383
    Dates: August 1998 to January 2000
    ID#:  034912

Contact

Jean E. Johnson, Ph.D.
Elizabeth Cobbs, M.D.
(202) 994-3725
hspjej@gwumc.edu

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APPENDICES


Appendix 1

(Current as of the time of the grant; provided by the grantee organization; not verified by RWJF.)

Literature Reviewed for the Study

Adams D. "Home Healthcare: A New Venue for Telemedicine." World Medical Technology Update, pp. 226–228. 1997/1998.

AHCPR. "Pneumonia: More Patients May Be Treated at Home." AHCPR Publication No. 97-R030, 1997.

Alexy BB and Elnitsky C. "Rural Mobil Health Unit: Outcomes." Public Health Nursing, 15(1): 3–11, 1998. Abstract available online.

American Academy of Home Care Physicians. Making House Calls a Part of Your Practice, booklet, 1996, 1997.

American Medical Association. Medical Management of the Home Care Patient: Guidelines for Physicians. 2nd edition, 1998.

Bayne G. Press Release. "High Tech Devices and Computers Provide Advances in Health Care." SAIC, 1996.

Boling PA, Retchin SM, Ellis J and Pancoast SA. "Factors Associated with the Frequency of House Calls by Primary Care Physicians." Journal of General Internal Medicine, 6(4): 335–40, 1991. Abstract available online.

Bula CJ, Berod AC, Andreas E, Stuck CA, Alessi CA, Aronow HD, Santos-Eggimann B, Rubenstein L and Beck JC. "Effectiveness of Preventive In Home Geriatric Assessment in Well-Functioning, Community-Dwelling Older People: Secondary Analysis of a Randomized Trial." Journal of the American Geriatrics Society, 47(4): 389–395, 1999. Abstract available online.

Campion EW. "Can House Calls Survive?" New England Journal of Medicine, 337(25): 1840–1841, 1997.

Cauthen DB. "The House Call in Current Medical Practice." Journal of Family Practice, 13(2): 209–213, 1981. Abstract available online.

Council on Scientific Affairs and Council on Medical Education. "Educating Physicians in Home Health Care." Journal of the American Medical Association, 265(6): 769–771, 1991. Abstract available online.

Davidson J and Doka K. Living With Grief. Hospice Foundation of America, Washington, D.C., 1998.

Department of Health and Human Services. Changes to Medicare Home Health. Health Care Financing Administration, Washington, D.C., 1998.

Di Pollina L, Gold G and Meier DE. "Health Care for the Homebound Older Adult: A Medical Model." Mount Sinai Journal of Medicine, 60(6): 488–91.

Diwan S, Berger C and Manns EK. "Composition of the Home Care Service Package: Predictors of Type, Volume, and Mix of Services Provided to Poor and Frail Older People." Gerontologist, 37(2): 169–81, 1997. Abstract available online.

Eng C, Eleazer P, Pedulla J, Fox N and McCann P. "Program of All-inclusive Care for the Elderly (PACE): An Innovative Model of Integrated Geriatric Care and Financing." Journal of the American Geriatrics Society, 45(2): 223–232, 1997. Abstract available online.

Fleishman JA. "Utilization of Home Care among People with HIV Infection." Health Services Research, 32(2): 155–175, 1997. Abstract available online.

Freedman VA and Kemper P. "Designing Home Care Benefits: The Range of Options and Experience." From Nursing Homes to Home Care, 7(3/4): 129–148, 1996.

Freedman VA and Reschovky JD. "Differences Across Payors in Charges for Agency-Based Home Health Services: Evidence from the National Home and Hospice Care Study." Health Services Research, 32(4): 433–452, 1997. Abstract available online.

Fried TR, Pollack DM, Drickamer MA and Tinetti ME. "Who Dies at Home? Determinants of Site of Death for Community-Based Long Term Care Patients." Journal of the American Geriatrics Society, 47(1): 25–29, 1999. Abstract available online.

Fried TR, Wachtel TJ and Tinetti ME. "When the Patient Cannot Come to the Doctor: a Medical Housecall Program." Journal of the American Geriatrics Society, 46(2): 226–231, 1998. Abstract available online.

Gratefully Yours. National Library of Medicine, National Institutes of Health Publication: HCFA, 1998 Part B Carrier Procedure Summary File.

Health Policy Group. The Home Health Care System, 1. Physician Guide to Home Health Care, Chicago, Ill.: American Medical Association, 1989.

Health and Public Policy Committee, American College of Physicians. "Home Health Care." Annals of Internal Medicine, 105: 1986.

Intramural Research. Highlights. National Medical Expenditure Survey, 45: 1–4, 1995.

Kane RL. "PACE: A Model of Integrated Acute and Long-Term Care." Hospital Practice, 32(4): 23–24, 27, 30, 1997.

Keenan JM, Bland CJ, Webster L and Myers S. "The Home Care Practice and Attitudes of Minnesota Family Physicians." Journal of the American Geriatrics Society, 39(11): 1100–1104, 1991. Abstract available online.

Keenan JM, Boling PE, Schwartzberg JG, Olson L, Schneiderman M, McCaffrey DJ and Ripsin CM. "A National Survey of the Home Visiting Practice and Attitudes of Family Physicians and Internists." Archives of Internal Medicine, 152(10): 2025–2032, 1992. Abstract available online.

Keenan JM, Fanale JE, Ripson C, et al. "A Review of Federal Home-Care Legislation." Journal of the American Geriatrics Society, 38(9): 1041–1048, 1990.

Kemper P, Applebaum R and Harrigan M. "Community Care Demonstrations: What Have We Learned?" Health Care Finances Review, 8(4): 87–100, 1987. Abstract available online.

Kenney GM and Dubay LC. "Explaining Area Variation in the Use of Medicare Home Health Services." Medical Care, 30(1): 43–57, 1992. Abstract available online.

Knight AL and Adelman AM. "The Family Physician and Home Care." American Family Physician, 44(5): 1733–1737, 1991. Abstract available online.

Koran JM. "Home Care — Who Cares?" New England Journal of Medicine, 1986; 314, 1998.

Lee W, Eng C, Fox N and Etienne M. "Pace: A Model for Integrated Care of Frail Older Patients. Program of All-inclusive Care for the Elderly." Geriatrics, 53(6): 62, 65–66, 69, 73, 1998. Abstract available online.

Leveille SG, Wagner EH, Davis C, Grothaus L, Wallace J, LoGerfo M and Kent D. "Preventing Disability and Managing Chronic Illness in Frail Older Adults: A Randomized Trial of a Community-Based Partnership with Primary Care." Journal of the American Geriatrics Society, 46(10): 1191–1198, 1998. Abstract available online.

Maryland Medical Directors Association. "Newborn Twins at Risk — What Can Telemedicine Do?" MMDA News, 1(July/August): 1–4, 1998.

"Older Americans Report. A Look at Home Health Controversy." Silver Spring, Md.: Business Publishers, Inc., 1998.

Pawlson LG. "Financing, Coverage, and Costs of Health Care for Older Persons." Geriatrics Review Syllabus. 4th edition, 1999.

Pezzin L, Kemper P and Reschovsky J. "Does Publicly Provided Home Care Substitute for Family Care?" Journal of Human Resources, 650–676, 1996.

Philbrick JT, Connelly JE and Corbett ED Jr. "Home Visits in a Rural Office Practice: Clinical Spectrum and Effect on Utilization of Health Care Services." Journal of General Internal Medicine, 7(5): 522–527, 1996. Abstract available online.

Ramsdell JW, Swart JA, Jackson JE and Renvall M. "The Yield of a Home Visit in the Assessment of Geriatric Patients." Journal of the American Geriatrics Society, 37(1): 17–24, 1989. Abstract available online.

Rose MA. "Home Care Nursing Practice: The New Frontier." Holistic Nursing Practice, 3(2): 1–8, 1989. Abstract available online.

Rubenstein Z. "The Importance of Including the Home Environment in Assessment of Frail Older Persons." Journal of the American Geriatrics Society, 47: 111–112, 1999.

Scanameo AM and Fillit H. "House Calls: A Practical Guide to Seeing the Patient." Geriatrics, 50(3): 33–6, 39, 1995. Abstract available online.

Schwartzberg JG and Guttman R. "Effect of Training on Physician Attitudes and Practices In Home and Community Care of the Elderly." Archives of Family Medicine, 6(5): 439–44, 1997. Abstract available online.

Siwek J. "House Calls: Current Status and Rationale." American Family Physician, 31(4): 169–174, 1985. Abstract available online.

Steel RK and Vaitovas B. "The Expansion of Home Care Into Academic Medicine-Geriatric Medicine Requires It." American Academy of Home Care Physicians, 10(2): 11–14, 1998.

Steel RK, Musliner M and Boling PA. "Medical Schools and Home Care." New England Journal of Medicine, 331(16): 1098–1099, 1994. Abstract available online.

Stessman J, Ginsberg G, Hammerman-Rozenberg R, Friedman R, Ronen D, Israeli A and Cohen A. "Decreased Hospital Utilization by Older Adults Attributable to a Home Hospitalization Program." Journal of the American Geriatrics Society, 44(5): 591–598, 1996. Abstract available online.

Stessman J, Hammerman-Rozenberg R and Cohen A. "Home Hospitalization in the Spectrum of Community Geriatric Care." Disability Rehabilitation, 19(4): 134–141, 1997. Abstract available online.

Stone RI and Murtaugh CM. "The Elderly Population with Chronic Functional Disability: Implication for Home Care Eligibility." Gerontologist, 30(4): 490–497, 1990. Abstract available online.

Taler G. "Community-Based Care." Geriatrics Review Syllabus, 4: 57–63.

Twardon CA and Gartner M. "The Nursing Plan: Innovative Home Health Documentation." Nurse Manager, 24(11): 81, 84, 86, 1993. Abstract available online.

Von Sternberg T. "The Role of the Geriatrician in Managed Care: Opportunities and Responsibilities." Journal of the American Geriatrics Society, 47(5): 605–610, 1999. Abstract available online.

Warburton SW, Sadler GR and Eikenberry EF. "House Call Patterns of New Jersey Family Physicians." Journal of Family Practice, 29, 1989.

Windom R. "Limited License." SCMS, 20, 1997.

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Reports

Cobbs E and Johnson J. Home Medical Care Project. Washington, D.C.: George Washington University School of Medicine and Health Sciences, 2000. One copy submitted to RWJF.

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Report prepared by: Jodi Miller
Reviewed by: Robert Narus
Reviewed by: Richard Camer
Program Officer: Susan Hassmiller

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