House Calls?

December 29, 2005

Just curious ...... are any PA's out there making "House Calls" to see patients like the doc's did when I was a kid? Had a family member call last night because they were sick (FLU symptoms) and wanted me to stop by and see them. It got me to thinking ..... "Hmmmmmm ....... I remember when Doc Campbell would come to our house when I was a kid and do his exam and fill a script right there in the living room"

Obviously this would probably be more practical in rural settings ...... just curious though. If you are making "House calls" to see patients ...... is there a billable charge for that or is it "Cash on the Barrell head"? Thanks in advance!

HAPPY NEW YEAR!!!!!!:D

kittryn · December 29, 2005

this interests me, too.

about a year ago I googled around for house call docs here in nyc, and there are quite a few. there are some organizations, too. I think there's even a specialty of this now, but I can't find that link. try a google search and see what you get!!

also, here is an NPR story on housecalls from dec. 19:

http://www.npr.org/templates/story/story.php?storyId=5059072&ft=1&f=1007

December 29, 2005

AWESOME Article! Thank you ..... can't wait to see what some of the others here have to say! Happy New Year!

kittryn · December 29, 2005

AWESOME Article! Thank you ..... can't wait to see what some of the others here have to say! Happy New Year!

oh -- it was right in the article I gave you! the Visiting Physicians Association -- that was the organization I was trying to think of.

I think it sounds awesome, don't you? slow the pace down a bit... ;)

December 29, 2005

AWESOME Bob! I also live and hope to someday soon practice in this "Mayberry" like community and would love to offer an occasional house call as needed! And your chaperone advice will be logged! Unfortunately cannot be too careful!

Curious though .... are you able to bill for the house call? In the above referenced article, it sounds as though Medicare is really pushing this sort of thing ..... Thanks for the reply!

themadmedic · December 30, 2005

Pridemark was doing something similar with this for 'acute' things with PAs I think...and I have heard of others doing it-but don't myself...

December 30, 2005

then you document that you reviewed the history and you only have one more out of the three to meet for billing a 99214 and maximizing your allowable charges!

caldje · December 30, 2005

The system I purchased has a feature that if your office has a web site you can develop a log in program for computer literate patients to actually make their own appointments on the weekend or after office hours by logging in and answering a few screening questions and then seeing which appointment slots are available on the day they want to come in and slip themselves into the open slot. On Monday you come in and they are already in the slot for an appointment without goint through yor office staff. They can even do the preliminary "history" for you by answering tiered questions. Slick, eh?

that sounds AWESOME... as a patient i would love that! not to mention as a provider also..

chris

Contrarian · December 30, 2005

From the resume'...

I serve as a Primary care provider (PCP) for 800 adult “homebound” patients. According to CMS (Medicare)... A patient is home-bound if an office visit requires ambulance transport or an office visit requires excessive physical/psychological effort or pain.

Many of these patients have dementia and an office visit would/could/usually significantly disrupts their fragile “orientation.” My entire practice consists of modern day house calls, which means going to see patients where they live, whether it is the family home, nursing home, assisted living center, adult family homes, group homes or dementia care centers. 200 mile days are routine.

This is an acticle I wrote and sent to Advance PA... and other journals...

Stop looking for a Job…

Create A Career...

House-Calls…offering A Heathcare Access Solution.

I was a Airborne Army Medic, a ER nurse, a Critical Care Nurse, and now PA/NP. Like many PAs, I continually educated myself to broaden my scope of practice. While in the military, I accepted the fact that I didn’t have any control of my quality of life or pay, but did enjoy the job security. After 8 years in the Army, it was time to get out and the thought of “looking for a job” in the civilian sector was a stress/nausea provoking event. After several EMT and nursing jobs, I realized that I still had no control of my quality of life, pay, and had lost the job security. I decided to go back to school.

While attending PA school, I noticed that entrepreneurial minded providers (MDs, PAs, NPs) were rare and most expected to “look for a job,”and “go to work for somebody” when they completed school. I had heard the horror stories of PAs “looking for a job” for 8-14 months after graduation. My immeadiate response would be, “why are they looking for a job, they should be creating a career.” At the time I was naiv’e and preached practice buy-in contracts, profit earnings, and true PA/MD financial partnerships to my PA school classmates. I assumed that if my billing was equivalent to the MD’s, then I would be considered an asset to the practice and treated accordingly.

During clinical rotations, I noticed that complex internal medicine patients with altered mentation, and mobility challenges required enhanced practice resources to manage (usually 2-3 personnel just to room the patient). Due to complex medical issues… (physical- pain:mobility, or cognition- cva:coma:dementia) this population of patients must often endure gross physical/mental insults to receive adequate acute/routine healthcare. It is not uncommon when, “Psychotropic and Pain Medication Adjustments” become a necessity simply to provide safe, basic care for some dementia and chronic pain patients attempting to “re-orientate” to their “residences” after a simple office visit. The typical patient was a 80 year old accompanied by the spouse and inlaw (whom had to take a day off work to get their loved one seen for a simple 15 min office visit) for needed care.

Many seniors simply can't get out of their homes, nursing homes or hospice or dementia centers to receive medical care. Quite often, the initial indication that something is seriously wrong with this underserved patient population is discovered in the ambulance on the way to the emergency department.

I immeadiatly thought, “There’s got to be a better way”!

So while in school, I wrote a business plan to start a clinical practice that featured housecalls as the foundation. I shared this plan with anyone (MDs, PA-Cs, NPs, MBAs) who would listen. Most responses were positive but skeptical.

After school I accepted a position practicing Cardiology for several years, enjoyed it, but soon learned that the real world financial arrangements and job security are far different than I envisioned. I was treated as an “ancillary staff” employee whom just happens to bill greater than $400,000 a year for the practice. I agitated for production bonuses and even offered a $100,000 cash- percentage buy-in when the practice was cash strapped and expanding. Each attempt at justice resulted in a pat on the head and then being sent home with my $70,000 salary. I also felt that my hard earned “generalist” knowledge was slowly eroding.

I decided that I needed to practice Adult Primary Care Medicine, follow my own advice and Create a Career. As a transitory step in Creating a Career in Primary care, and to re-immerse myself in the medical care of the eldery, I took a nursing job as a resident care manager in a large skilled nursing care facility. I directed the standard of patient care, and served as the intermediary between nursing staff, family, and the providers of medical/nursing care. After about a year, I formed a Professional Limited Liability Corporation, retained an accountant service and attorney, bought tablet computers, an EMR, and searched for an open-minded physician to serve as medical director of the company.

The company is owned by PAs/Nps and we contract with MDs for “supervision/collaboration.” It’s a win-win arrangement when you consider the fact that MD’s earnings are limited by the number of patients he/she can see during a normal work day and the only way for them to make more money is to see more patients and anything over 27 patients a day severly affects quality of life.

By contracting with us, a physician can increase their practice panel and revenue by just answering their mobile phone… without seeing any additional patients or allocating expensive office resources (overhead).

Now…Five days a week, I leave my 10’x8’office (which is in my home), drive approx. 180-200 miles roundtrip...(400-600 miles a week...12-22 patients a day) to serve as a primary care provider for “homebound” patients. A patient is classified as home-bound if an office visit requires ambulance transport or an office visit requires excessive

physical/psychological effort or pain. Many of these patients have dementia and an office visit would/could/usually significantly disrupts their fragile “orientation.”

My entire practice consists of modern day house calls, which means going to see patients where they live, whether it is the family home, nursing home, assisted living center, adult family homes, group homes or hospice/dementia centers. When I go into my patients' homes, I see them in their most personal and vulnerable state.

I speak to the medical director and the other SPs daily (mostly cellular), and see them weekly to exchange the on call pager(s). According to my attorney, there is a limitation on the number of PAs a MD can supervise, but not on the number of SPs a PA can have which equates to job security. I pay the SPs a percentage of billing for “supervision,” and to take over when the patient’s care needs exceed my level of knowledge. We use Tablet PCs, a EMR, and secure VPN connection for clinical documentation and messaging. I “sync” my encounter documentation to my SP’s desktop nightly for review and billing.

TOOLS:

2005 Subaru Baja (decent gas mileage, and all wheel drive for snowy days on the hills of the Pacific Northwest). Satellite radio (commercial free comedy, jazz, caribbean, news, talk, sports). BlueTooth GPS (to find patient’s place of residence).

I had been using a Acer Tablet since Sep.04... (I found the 4.5lbs to be a limiting factor in convertible Tablet PCs. While in facilities...I find myself looking for a place to put it down...because the arm starts to cramp after about 3.5 patients... so I purchased a Motion LS800 slate tablet. It actually fits in a labcoat pocket!) I have installed a EMR & Billing, Quickbooks Premier, MS Office 2003 Pro Suite, Infopath 2003, 5MCC 2005, Epocrates desktop, Current Clinical Concepts 2005, Dragon Naturally Speaking 8, Harrison's IM 2005, and Tops Icd9 on the LS800 Tablet PC.

Mobile stand w/ port replicator and power inverter for Tablet PC installed in the vehicle.

Treo 650 w/Bluetooth dial up networking for unlimited internet access (fax/email) anywhere in my service area and a Bluetooth hands free speaker phone.

In my home office, (I see no patients here, only for clinical administrative tasks) I have, three PCs. I use winfax for faxes, and have a wireless cable internet access network set up so when I pull into the driveway...Voila'...the pc in my labcoat pocket talks to the pc in the office via BT or WiFi...I guess I was fortunate in that the Medical School I attended required each student to report on the first day with a laptop & PDA in hand. (Go Cardinals!!)

Since then... I have always actively sought ways to incorporate technlogy to "work smarter..not harder."

Business is great. We are now looking for more SPs so we can add more PAs. I now have control of my quality of life, pay, and job security.

I had to Stop looking for a Job… and Create A Career

DocNusum, FNP, PA-C

PrimeCare, PLLC.

Doctors Home Visits.

December 30, 2005

DOC ...... YOU ARE MY HERO!!!! And there is Absolutely NO Sarcasm there!! That's what I envision for myself in about 3-4 years!!! AWESOME!!!!! I am sure that I will have a Ton of questions for you ..... but still digesting all of the above info! Thanks!

Contrarian · December 30, 2005

ACP-ASIM Observer, June 2001 - Medicare clarifies its definition of ‘homebound’Clinical

How to provide home care without losing your shirt

Q: How has Medicare changed its definition of homebound?

A: In 2000, Congress passed a law that further clarifies the Medicare

definition of homebound.

Medicare law requires that a physician certify a beneficiary as homebound

before the patient is eligible to receive home health benefits. The

revision to the law expands the list of circumstances in which patients

can leave their home and still be classified as homebound to include

participating in adult care and attending religious services.

The revised definition, which took effect in February 2001, appears below

(revised text is indicated in bold):

An individual does not have to be bedridden to be considered confined to

his home. However, the condition of these patients should be such that

there exists a normal inability to leave home and, consequently, leaving

the home would require a considerable and taxing effort.

Any absence of

the individual from the home attributable to the need to receive health

care treatment, including regular absences for the purpose of

participating in therapeutic, psychosocial or medical treatment in an

adult day-care program that is licensed or certified by the State should

not disqualify an individual from being considered confined to his home.

Any other absence of an individual from the home shall not so disqualify

an individual if the absence is infrequent or of relatively short

duration. For the purpose of the preceding sentence, any absence for the

purpose of attending a religious service shall be deemed to be an absence

of infrequent or short duration.

The revision states that occasional absences from the home for nonmedical

purposes (a trip to the barber, a walk around the block or a drive) will

not necessarily disqualify a beneficiary from being classified as

homebound. However, the absences must be infrequent or of a relatively

short duration.

Long, frequent absences indicate to HCFA that the patient

has the capacity to access health care outside the home.

Generally speaking, beneficiaries will be considered homebound if they

have an illness or injury that restricts their ability to leave their

residence except with the aid of supportive devices (canes, wheelchairs

and walkers), special transportation or another person. Beneficiaries with

conditions for which leaving home is medically contraindicated are also

considered homebound.

The following are examples of homebound patients:

Beneficiaries paralyzed from a stroke and confined to a wheelchair or requiring crutches to walk.

Blind or senile beneficiaries who require another person’s assistance to leave their residence.

Beneficiaries who have lost the use of their upper extremities and are unable to open doors, use stairway handrails, etc., and therefore

require another person’s assistance to leave their residence.

Beneficiaries recently released from the hospital following surgery, who may be suffering from resulting weakness and pain, and whose activity is

restricted by their physician to certain specified, limited activities

(such as getting out of bed only for a specified period or walking

stairs only once a day).

Beneficiaries with arteriosclerotic heart disease of such severity that they must avoid all stress and physical activity.

Beneficiaries with a psychiatric problem that is manifested in part by a refusal to leave their home environment or that makes it unsafe for them

to leave their home unattended, even if they have no physical limitations.

Elderly beneficiaries who do not often travel from their home because of

feebleness and insecurity brought on by advanced age would not meet

Medicare’s criteria for homebound unless their condition is analogous to

those above.

Keep in mind that you must be able to provide Medicare documentation

demonstrating that the patient is homebound if it is requested.

Contrarian · December 30, 2005

...........

kittryn · December 30, 2005

great article, doc -- it is inspiring. I dislike the confines of an office and enjoy my independence...I think I could seriously embrace a career like you describe, and I appreciate you sharing such details in how you set yourself up (electronically, administratively, etc). thanks again. ;)

December 30, 2005

To any and all moderators ...... is there a chance that we can make this a "sticky" so that it may be accessed easily for future reference? Thank you!