MedStar Health is joining seven medical institutions in a nationwide effort to bolster the number of doctors trained to make house calls — an outdated practice now making a comeback because it has been shown to reduce health care costs and provide better outcomes for patients.
The new training program is spearheaded by the nonprofit Home Centered Care Institute, whose mission is to increase high-quality primary care for patients too sick to leave their homes. MedStar Total Elder Care's Medical House Call Program is being accredited as one of eight "Centers of Excellence" in major cities across the United States that will offer comprehensive training for new doctors to provide home-based primary care.
Eric DeJonge, executive director of MedStar Total Elder Care, said its house call program in Baltimore administered through Good Samaritan Hospital, has enrolled 105 patients since the program was established last year. It was started at the Washington Hospital Center in D.C. in 1999 before expanding to the Baltimore region.
DeJonge, who was on the board that developed the institute's new training program, said the initiative will help address a "huge, unmet need" for home-based care in every community in the United States. Homebound people often struggle to get the treatment they need, he said. Home-based care, or house calls, reduces health care costs while providing more comfort for elderly and medically complex patients.
"You can do just about anything in the home that an urgent care center can do," DeJonge said. "At a lower cost and in a setting that the patient and family prefer."
The U.S. Census Bureau projects that 98.2 million people will be 65 and older in 2060, comprising nearly one in four U.S. residents. In Maryland, the number of people age 60 or older is expected to grow from 1.2 million to 1.7 million between 2015 and 2030 — a 40 percent increase, according to the state Department of Aging.
The effort to increase house calls is a trend increasingly being embraced and promoted by doctors and others in health care, not only because of the cost benefits to the health care system but also because of the more personalized care it provides to patients and the helpful information doctors and other caregivers can glean about patients' home life. House calls can reveal whether patients' physical environments are safe and conducive to improving health, if there is enough food available and whether it's healthy, if there is a family support system in place or whether outside help is needed. Such measures can reduce costly rehospitalizations — at an annual cost of $17 billion, according to a 2014 report on hospital readmissions — and the emotional and physical stress on already frail, usually elderly patients.
Gene Ransom, CEO of the Maryland State Medical Society, praised the innovativeness of the training program and the savings it will bring to the entire health care system.
"We hope to see other hospitals and institutions do things like this," he said, adding that home-based care is also "an incredible benefit to the patient, because they're getting that specialized service they need in their home."
Other health systems participating in the initiative include the Cleveland Clinic, University of Arizona Center on Aging, University of California, San Francisco, and the Perelman School of Medicine at the University of Pennsylvania.
Dr. Thomas Cornwell, founder and CEO of the Home Centered Care Institute, said there are now more than twice as many sick people at home as in a nursing home. But while there are 7,000 primary care providers serving the majority of nursing home residents in the country, there are just 1,000 primary care providers doing the majority of house calls, he said, citing data from a 2016 study by Health Affairs, a leading health policy journal.
"We know there's about 3 million people that could use this now, but only about 400,000 are getting served," Cornwell said. The Centers of Excellence will train 5,000 clinicians as well as medical practice administrators over the next five years in an effort to address this unmet need. Would-be participants do not need to be affiliated with the Centers of Excellence to enroll in the training, which will begin this fall. The curriculum will include skills-based training, small group work and practice management skills, Cornwell said.
"There is a large skill set you need to learn how to take care of the sickest patients, but by doing that, you keep them out of hospitals and nursing homes," Cornwell said.
In 1930, 40 percent of all medical care took place in the home, Cornwell said. But as medical technology developed and quickly became centralized in hospitals, house calls dipped to 10 percent of all medical care in 1960, and less than 0.5 percent in 1996. The proportion remains at less than 1 percent, according to some estimates.
Technology is no longer a barrier, however. Doctors and caregivers can now administer lab tests, electrocardiograms, X-rays, ultrasounds and other medical procedures in a patient's home.
"It's kind of going back to the future," Cornwell said. "It's an old-fashioned idea with a very modern twist of teamwork and technology."
Interacting with patients in a setting they're familiar with is also beneficial for them and their families. Dr. Jennifer Hayashi, a geriatrician at Good Samaritan Hospital and medical director of Baltimore's MedStar Total Elder Care program, said house calls give practitioners flexibility and familiarity with their patients that wouldn't normally be available in an office setting.
"When I go to a patient's house, they're going about their business — they're not waiting for me," Hayashi said. "It's all on their terms."
Hayashi said treating people in their homes, and keeping them out of the expensive "revolving door" of hospitals, intensive care units and emergency rooms, allows her to build close relationships with patients in a way that also makes sense financially.
"For this particular population, the sick, old people who have trouble getting out of the house and might not otherwise access medical care, this is the best way to take care of them," she said.
DeJonge said homebound people are some of the highest-cost patients on Medicare, the federal health insurance program for people who are 65 or older and certain younger people with disabilities, averaging $30,000 to $60,000 in medical cost per year per patient. A 2014 study published by the Journal of the American Geriatrics Society found home-based primary care saved an average of $4,200 per patient per year in the Medicare system.
Hayashi said the training program will teach new doctors to think differently about patients and even challenge some of the traditional training they may have learned in medical school.
"It's an amazing way to make connections with people and understand who they are, and I think that's the best part of medicine, knowing your patients as people," she said. "It's really a privilege to be a part of their life in a way that might make it better."