Home Care: A Key to the Future of Family Medicine?

I believe we should make a careful distinction between home visit (house call) and home care. In Italy we do an average of 3-4 traditional house calls every day: the number has diminished, thanks to better communications and easier transport. On the contrary home care patients are increasing in number, because we have much more older patients, who have multiple morbidities, requiring the work of a home care team (physician, nurse, physiotherapist, social worker). This service will surely be a key to the future success of family medicine. A third kind of service could be "Assessment (evaluation) home visit" a periodic, preventive, visit to older patients to assess, with a standardized procedure, physical, mental, social well-being. According to a Swedish researcher such a programme postpones mortality. Similar research in other countries could be useful.

Lindholm L. et al. Preventive home visits postpone mortality- a controlled trial with time limited results. BMC Public Health 2006, 6:200

Competing interests:   None declared

During my training in a Family Medicine Residency Program in South West London and while working as a locum GP and moonlighting for a major private house call company (the Southern Relief Service) in London, I was fortunate to experience firsthand the many benefits that Dr. Landers points out.

In my third year of residency in the UK, I was required to make on average, 2-3 home visits a day, and up to 5-10 on a call day.This contrasts strongly with one or two visits a year in the US.

In England, although the daytime visits are included in the GP's salary, the night visits after 10pm are reimbursed substantially. In our Practice in London, we were reimbursed at a higher level if we visited our new postpartum moms and babies 3 or more times in the first week. In addition, to help meet our immunization targets we would immunize at home patients who were behind on their schedule and who were unable or unwilling to come to the office.

Some of the more rewarding aspects of house calls included providing end-of- life care in conjunction with the hospice nurses, postpartum care with the community midwives, seeing patients with chronic psychiatric and medical conditions in their home environment, and establishing deeper and closer bonds with all the family members.

As we are updating our Residency policy to meet and exceed the RRC's policy on house calls for 2006 onwards, we are compiling a list of resources to help and encourage our residents to incorporate house calls into their new Practices.

In addition to Dr. Lander's article, some of the resources are listed below. We would be happy to hear from any other Programs regarding useful tools or articles they have used in training their residents.

Giovino JM House Calls: Taking the Practice to the Patient Family Practice Management. Vol7 No 6, 2000 June. http://www.aafp.org/fpm/20000600/49hous.html

Brand AL. Cashing in on house calls. Family Practice Management. 13(2):67-8, 2006 Feb. http://www.aafp.org/fpm/20060200/67cash.html

Borgsteede SD. Graafland-Riedstra C. Deliens L. Francke AL. van Eijk JT. Willems DL. Good end-of-life care according to patients and their GPs. British Journal of General Practice. 56(522):20-6, 2006 Jan.

Scanameo, A M. Fillit, H. House calls: a practical guide to seeing the patient at home. Geriatrics. 50(3): 33-6, 39, 1995 Mar.

Oldenquist, G W. Scott, L. Finucane, T E. Home care: what a physician needs to know. Cleveland Clinic Journal of Medicine. 68(5): 433-40, 2001 May.

Unwin, B K. Jerant, A F.The home visit. American Family Physician. 60(5): 1481-8, 1999 Oct 1.

Home Care Chapter 11 pp108-114 from "The Clinical Encounter: A Guide to the Medical Interview and Case Presentation". J Andrew Billings, Fred Rubin

"Assessment of Older Adults in their Home" , Handbook of Geriatric Assessment. Joseph J. Gallo Jones & Bartlett Publishers; 4th edition 2005

And finally, an excellent book written by the role model and technical advisor to "Marcus Welby, MD." Stern, Thomas L House Calls: recollections of a family physician Published 2000 BookPartners, Inc.

Competing interests:   None declared

Congratulations on an excellent essay on home visits.

As one who enjoyed the many home visits I did during my practice days in Alaska, I missed them during my years in academic medicine in Seattle (although I still made a few). Returning to practice for another six years before retiring, renewing home visits was a reward. I am aware that both practice sites for me were in very small communities where travel among the homes and office was easy. It is good to know it can work in the city also. I hope your essay will encourage home care as a part of the new model of Family Medicine.

A practice dedicated entirely to home care may be the way to go. But, perhaps we can re-invent the traditional English style of general practice with the day divided into three parts; 2 or 3 hours in the office in the morning, another 3 hours or so of home visits, followed by a couple of hours back at the office.

Competing interests:   None declared

I'd like to believe that a home care could work as a family doctor's practice, but I can't see how it would add up to a viable business plan. Dr. Landers states that reimbursements can be close to $100/visit for a home call. I would assume that there is great downward variation on that number based on what is done and how long is spent at each visit.

But assuming that each house call were compensated $100, it would take an enormous amount of frantic driving every day, 5-6 days/week, to make the kind of money that will equal an office-based practice. Something else will need to be done to fill in the gaps. Otherwise, I just don't see how home visits can be anything but quaint throwbacks to an era of medical care standards that are nearly forgotten today.

Competing interests:   None declared