A relic from the medical past — the house call — is returning to favor as part of some hospitals’ palliative care programs, which are sending teams of physicians, nurses, social workers, chaplains and other workers to patients’ homes after they are discharged.
The goal is twofold: to provide better treatment and to cut costs.
Walter Park, 68, of San Francisco says house calls prevented an expensive return visit to the hospital, where he initially stayed for seven weeks after a heart attack in 2012.
After his discharge, palliative care specialists from the University of California, San Francisco, were among those who visited his home to monitor his physical and emotional health. He got help with tasks as varied as household chores and organizing the 20 pills he takes daily for his heart and other conditions.
Confusion continues to exist over what palliative care is and whom it is for. Broadly, it is meant to ease symptoms and pain, and focus on quality of life for severely ill patients, who can choose between continuing or halting traditional medical treatment.
Palliative care also occurs in hospitals, but an added emphasis on home care has been a selling point. A vast majority of patients would rather be at home than in a hospital anyway, said R. Sean Morrison, co-director of the new Patty and Jay Baker National Palliative Care Center at Mount Sinai Hospital in New York and director of the National Palliative Care Research Center.
Home care is generally cheaper than hospital care, and for more than a decade, government programs such as Medicare and Medicaid have worked to create incentives for hospitals to switch to less-expensive treatment. Recently, under the Affordable Care Act, Medicare has begun to penalize hospitals when, under certain conditions, patients are readmitted within 30 days after discharge.
Some insurers, including Medicare, pay for house calls by doctors and nurses specializing in advanced care. In cases where insurance does not cover this type of palliative care, hospitals are financing it themselves, sometimes with grants.
Steven Pantilat, an internal medicine physician who leads the palliative care program at the University of California, San Francisco, says his hospital subsidizes some home care because “there is sufficient improvement in quality and costs to make the investment a good idea all around.”
A 2007 study by Richard Brumley and colleagues found that palliative care patients who received in-home, interdisciplinary care were less likely to visit the emergency room or be admitted to the hospital than those receiving more-standard home care, resulting in lower costs. The study, financed by the Kaiser Permanente Garfield Memorial Fund, covered terminally ill patents.
In Boston, palliative care doctors at Massachusetts General Hospital and at Brigham and Women’s Hospital make house calls. Nurse care managers, social workers and others also visit discharged patients in their homes or keep in touch by telephone as needed, said Timothy Ferris, who runs the Partners HealthCare accountable care organization.
Nurses from Partners HealthCare at Home, an affiliate with 900 employees, may also visit discharged patients. “The home care nurse is the eyes and ears and stethoscope in the patient’s house,” Ferris said.
Accountable care organizations, created under the Affordable Care Act, have the flexibility to pay for in-home palliative care services, he added, and his organization has done so.
Palliative care teams work with a patient’s regular doctors and specialists “to provide an added layer of support for people living with serious illness,” said Diane Meier, professor of geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai Hospital in New York and co-director of the Patty and Jay Baker National Palliative Care Center. They can address issues that someone who focuses intensively on a particular disease or organ system often cannot, she said — things like expert help with pain management, depression, fatigue and support for “exhausted and overwhelmed family caregivers.” They also offer practical help so patients can remain in their homes, she said.
While patients nearing the end of life can choose palliative care in a hospice setting rather than undergo expensive and risky treatment — many doctors say it is valuable for that very reason — it can also exist alongside efforts to treat and cure patients.
Park, the heart attack survivor in San Francisco, said his plans had changed. In 2012, his palliative care team urged him to identify his short- and long-term goals. He said he wanted to attend President Barack Obama’s second inauguration and return to his volunteer work at a nonprofit agency that helps older Americans. He was present at the January 2013 swearing-in, and later he resumed his volunteer work.
He is now looking forward to spending time with his two grandchildren, ages 8 and 11. “I used to plan only three years ahead,” Park said. “Now I really want to see my grandkids grow up and graduate.”