Yes, doctors still make house calls, and studies indicate their effectiveness in controlling costs for older patients. The School of Medicine offers students and residents a chance to practice the art.
Aron Burke, M.D. ’98, goes where most physicians don’t—into patients’ homes.
For Burke, who practices in Rock Port and Tarkio in northwest Missouri, house calls are just part of being a good small-town doctor.
“I have many patients with limited mobility,” Burke said. “If one of them really needs attention, I think it’s my obligation to be there for them.”
And house calls, though still rare, appear to be making a comeback. More health care professionals are seeing them as cost-control efforts that reduce hospital visits for an aging population.
On the other end of the age spectrum, Burke welcomed a new patient into the world on a recent house call.
“It was a home delivery for a highly educated mother who wanted that,” said Burke, the 2013 Missouri Family Physician of the Year. “It was her eighth baby, and I’ve attended three of her deliveries, one in the hospital and the last two at home.”
Burke says he averages just a couple of house calls a month. And in a recent survey by the American Academy of Family Physicians, only 2.4 percent of family doctors said they made at least two house calls a week.
House calls once were common, accounting for 40 percent of doctor visits in 1940. But the post-World War II growth of specialized medicine and large hospitals equipped with expensive technology drove their decline, along with changes in insurance. By 1950, house calls were just 10 percent of doctor visits, a proportion that kept shrinking until it hit just 1 percent in 1980.
Now, as the over-65 population grows and the portability of high-tech medical devices increases, some physicians have been able to build entire practices around making house calls.
One of those is Dimitri Golfinopoulos, D.O., who graduated from the Kansas City University of Medicine and Biosciences in 1992 and completed his residency in internal medicine at the UMKC School of Medicine in 1995.
Golfinopoulos—Dr. Golf to his now hundreds of patients—said his practice mainly served geriatric patients, and “I rarely have to send a patient to the hospital.”
Someone who lives alone and doesn’t have a trusted physician “will call 9-1-1 when there’s a crisis and end up in the emergency room,” said Golfinopoulos. “I keep that from happening.”
“You get to know their children’s names, their dogs’ names.”
For example, a timely examination—with a chest X-ray if needed—and antibiotic or other treatment could head off pneumonia for a patient with breathing difficulties.
And technology, whose cost and concentration at hospitals in the past worked against house calls, now is more mobile and available.
“Outside companies can provide whatever’s needed—X-rays, ultrasound, EKG, lab testing,” Golfinopoulos said. “You can bring an entire doctor’s office to a patient’s home.”
One of his patients, Sharon Thomason, said Golfinopoulos’ care and attention had been “amazing” as she recovered from a stroke. On a recent visit, his tests included checking her grip, which indicated she was adding strength on her weaker side. He also checked her medications, made sure she could continue physical therapy, and checked for carpet or furniture that could pose a hazard.
Seeing where and how patients live can be a key to preventive care, house call advocates say. Especially for new patients, Golfinopoulos said, he checks for hazards, as falls are a severe problem for older patients. He can ensure that obstacles and unsafe features are removed and recommend safety features to be added.
He also said home visits can create trust and give patients a psychological lift.
“You get to know whether anyone visits them or looks in on them, and know their children, their children’s names, their dog’s names,” Golfinopoulos said.
Familiarity and trust can help, too, when cajoling patients to take better care of themselves. One patient, for example, hasn’t been able to quit smoking, but with Golfinopoulos’ encouragement she cut down by half.
On another recent house call, Golfinopoulos had less success in persuading Myrtle Jenkins to use her walker. “I’ll be 94 in September, and I’m getting around fine,” said Jenkins, who riveted B-25 bombers in World War II in the Fairfax district of Kansas City, Kansas. She said she felt recovered from a recent bout of bronchitis, though sometimes her legs swelled a bit.
That house call is a two-fer for Golfinopoulos, since Jenkins’ daughter, Nancy Delgado, has come to live with her mother. Delgado has multiple health problems, and Golfinopoulos spends substantial time checking on her conditions and deciding to change one of her medicines.
“I still drive,” Delgado said, “but it’s great being able to have the doctor come to us.”
Recent research supports Golfinopoulos’ belief that house calls cut costs, especially for patients with more than one chronic illness or disability. The federal Centers for Medicaid and Medicare Services last summer found that a demonstration project delivering comprehensive primary care in homes helped keep Medicare recipients “with multiple chronic illnesses or disabilities” out of nursing homes, hospitals and emergency rooms.
According to the centers, people with more than three chronic conditions make up 37 percent of the elderly and disabled who are on Medicare, and they account for almost three-quarters of the program’s spending. One study found that hospitalizations for that population cost $12,000 on average, supporting Golfinopoulos’ belief that the opportunities for cost savings are substantial.
In one Medicare demonstration project, providing home doctor visits saved an average of $1,010 per beneficiary. In another study, the savings reached $4,200 per person.
And 2014 research for the U.S. Department of Veterans Affairs found that home care for such multiple-illness Medicare recipients could save nearly $4.8 billion a year.
The need for house calls is likely to grow. Today, one in 20 Americans age 65 and older are homebound. About 46 million Americans are in that age bracket now, and the number is expected to more than double by 2060, to 98 million people.
Medicare reimbursement has improved for home visits, and there’s evidence that house calls have increased. The Centers for Medicaid and Medicare Services say the number of Medicare Part B reimbursements for house calls increased from 1.5 million in 1995 to 2.1 million in 2005 and about 2.6 million each year from 2011 through 2015.
Such demand has helped Golfinopoulos build his practice.
‘He works long hours’
“We have worked with nursing homes, assisted living facilities, home health agencies; we get referrals,” Golfinopoulos said. “It took time, but we’ve recently added a nurse practitioner and an office assistant. We needed them to help us keep up.”
In Golfinopoulos’ practice, the “we” are the doctor and his wife, Dencia, who handles scheduling, finances and other business functions.
“He works long hours,” Mrs. Golfinopoulos said. “We always answer the phone. It has been very gratifying to see the practice grow.”
Golfinopoulos estimates his patient count around 800, nearly all of them on Medicare or Medicaid, and some living in subsidized housing. As a result, his practice also involves taking their finances into consideration.
“That’s another part of getting to know them, knowing their financial limits,” he said. With this knowledge, Golfinopoulos can prescribe less expensive generic medicines and, when possible, steer away from more expensive drugs that aren’t covered.
Golfinopoulos was a hospitalist for several years, but he got the idea to make a change on vacation in Arizona, where he noticed some house-call practices. Building family physician relationships again appealed to him, and he felt well grounded in the wide range of skills and procedures a home-care practice would need.
“My residency at UMKC was my fountain of knowledge and medical experience,” Golfinopoulos said. “It involved such great learning and tough, on-call challenges.”
At the School of Medicine, he split time between Truman Medical Center on Hospital Hill and Saint Luke’s Hospital and “was exposed to a wide variety of difficult cases.”
Though making house calls wasn’t part of the residency back then, Golfinopoulos said that didn’t prove to be a problem because the training gave him all the skills he would need, including interacting well with patients.
Skills for any situation
Current residents in community and family medicine are required to make at least two house calls, one to a geriatric patient and another to a mother the resident saw during her pregnancy. Internal medicine residents also have opportunities to make house calls, though not as often since a federal program ended that financed a variety of expanded residency experiences.
Stephen Griffith, M.D., professor of community and family medicine, said, “We try to equip our residents to treat any patient in any situation, whether that’s the Serengeti in Africa, the ER at Truman, or in their home.”
Year 5 students in the B.A./M.D. program or Year 3 students in the M.D. program also might make house calls depending on their rotations.
Jacob Rash, a Year 5 student who spent a month with Burke in a rural preceptorship, said he just missed out on attending the recent home birth.
“We were waiting and waiting, but I think her baby came the day after I left,” said Rash, who did get to see some patients where they live. “I accompanied Dr. Burke on several nursing home rounds. Thursday is his ‘day off,’ and he usually visits then.”
Noushin Ansari, M.D. ’15, and Jessica Richter, D.O., are both in the second year of their three-year community and family medicine residencies at UMKC, and both recently made their birth follow-up visits. That included assembling and delivering a glider rocker, provided free through the American Academy of Family Physicians’ national Rocking Chair Program.
Richter joked that she had a “proud moment” when the chair came together and seriously described the visit as a good experience for everyone.
“It could be kind of uncomfortable, going into someone’s house; that’s not typical in this era,” Richter said. “There was lots to do, observing how mother and baby are doing, how they interact.”
Ansari also was happy to get to visit with her patients: Breauna Williams and Easton, her thriving 2-month-old.
Ansari and Williams already had built a strong bond during the pregnancy and at Easton’s 6-week well-baby visit at Truman Medical Center at Lakewood. The house call gave them even more time to discuss issues.
“Dr. Ansari has been wonderful,” Williams said. “She answers all my questions and has helped me be more relaxed and confident.”
Easton was pretty relaxed during the home visit, too, rocking to sleep in Williams’ new chair.
For Ansari, the home visit and her other residency experiences “bring out the human side of medicine, the compassion and understanding.” She also was looking forward to her house call on one of her older patients.
“I think that’s the direction geriatric medicine may be going,” she said.
That’s certainly how it has gone for Golfinopoulos. He can fit anywhere from eight to 16 visits into a day, he said, and the practice can handle even more with the addition of its nurse practitioner.
Golfinopoulos said having more patients actually can reduce his driving time. He coordinates visits to see more than one patient in a particular neighborhood or apartment complex, or at an assisted living center.
But no matter the travel time, his patients make it more than worthwhile.
“My patients are very thankful,” Golfinopoulos said. “This practice is so rewarding, and seeing people in their homes lets me give very personal care.”
That’s something Burke also is able to do for his patients in rural northwest Missouri.
“It’s important to know your patients, and I try to know all of mine fairly well,” he said. “But you do learn even more when you get to see them where they live.”