One physician finds that home visits are good medicine
From the October ACP Observer, copyright © 2005 by the American College of Physicians.
By Janet Colwell
For his first five years in practice, general internist Nick Fitterman, FACP, tried to spend two days a month making housecalls on patients who found it hard to visit his office. Both he and his patients loved the home visits, but the increasing financial pressures of working in a multispecialty group practice and a managed care environment forced him to stop making them.
But two years ago, frustrated by rushing patients through 15-minute visits, Dr. Fitterman, 43, downsized and started a concierge practice. The Long-Island, N.Y.-based physician now charges patients a premium above typical insurance reimbursements plus an annual fee of $1,500 in exchange for longer visits and more personal service. With a patient load that has dropped from more than 3,000 to 600, Dr. Fitterman is back on the road.
Across the country, the number of housecalls—which are as old as the medical profession—is on the rise. (See "By the numbers: Medicare and housecalls.") Besides helping keep homebound patients out of hospitals and nursing homes, the visits foster closer ties between doctors and patients, a quality Dr. Fitterman said can be sorely lacking in modern practice.
On Wednesday mornings, Dr. Fitterman packs his black medical bag with a blood pressure cuff, stethoscope, an assortment of antibiotics and pain medications, prescription pads, pneumonia and flu vaccine in season, needles, syringes and alcohol swabs. He then spends the next five hours driving among patients' homes.
Most calls are to debilitated or elderly patients who have a tough time leaving their homes. In a typical morning, Dr. Fitterman will see three patients and spend about 45 minutes with each. Out of his patient panel, about 20 require home visits, a number that varies depending on the weather or the severity of patients' conditions. Dr. Fitterman decides to make housecalls on a case-by-case basis, depending on patients' post-operative recovery or degree of chronic illness.
'It's not so much that you can make a better diagnosis in the home but you get a better realization of what's going on in the patient's life.'
—Nick Fitterman, FACP
"A lot of it is social," Dr. Fitterman said. "It's not so much that you can make a better diagnosis in the home but you get a better realization of what's going on in the patient's life."
His visits often occasion family gatherings to discuss a patient's progress and care—an excellent way, he said, to see what kind of support network patients have.
"It's not uncommon for other family members to come over when I visit," he said. "Brothers, sisters, kids—we all have a family meeting over a cup of tea. When they hear I'm coming, some of them alter their schedules in order to meet me."
One of his regular stops is the home of a frail, 90-year-old woman who lives with her daughter and son-in-law. When he first started making housecalls, the woman had almost given up on trying to improve her health.
"She was huddled in the corner of a couch in a dark room every day. She didn't go out even to sit on the porch and had no social interaction," Dr. Fitterman recalled. "The daughter did the best she could but both she and her husband worked full time."
Instead of pulling out his prescription pad, as he might have done in his office, Dr. Fitterman was able to put the patient in touch with a local social program that provides bus service to and from a local senior day care program. Soon the woman was making friends—and taking care of some long-neglected health issues, such as getting her hearing aide replaced and her cataracts removed.
"With some pushing," Dr. Fitterman said, "she gradually went from being a shut-in to having a relatively social life."
Missing pieces to a puzzle
The details gleaned in a home visit can be the missing pieces to a puzzle, explaining why patients aren't making progress or coping well with their condition.
On one visit, for instance, Dr. Fitterman discovered after a quick tour of the house that his elderly male patient was an accomplished artist. The realization put the man's condition—age-related macular degeneration—in a new light.
"I realized how devastating it was for him to be diagnosed," he recalled. "It helped put things in perspective for me." He ended up prescribing antidepressants for the patient—and helped the patient connect with cognitive behavioral therapy.
Making home visits also allows Dr. Fitterman to make practical suggestions to help keep elderly patients at home. He recently walked around a house with the wife of one patient, suggesting ways to alter their downstairs-by expanding a bathroom door, putting in a handicap rail, installing a hospital bed-that could keep her husband out of a nursing home.
"They did it all and he's still at home," said Dr. Fitterman. He said he recently made three housecalls in one morning-all to patients who wouldn't be living at home if he didn't come out to see them.
It's an old-fashioned approach that Dr. Fitterman said is as healing to him as to his patients.
"The changes I made in my practice were bittersweet because I had to say goodbye to a lot of patients," he said. "But the ability to make housecalls again is one of the things that makes it worthwhile."
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