Geriatricians Testing House Calls with Independence at Home Project

By William Zafirau, MD

The house call virtually disappeared from U.S. medical care for decades, but Cleveland Clinic is one of the sites participating in a demonstration program with Medicare to bring it back. This program, Independence at Home, is already showing success in terms of better patient outcomes and lower expenses.

How it works

About 30 percent of the 1,100 patients in our practice are eligible to receive care through this program. They have limited mobility and multiple medical problems – typically stroke, dementia, heart failure, COPD, diabetes, Parkinson’s or multiple sclerosis. Most of them rely on some sort of caregiver and struggle to come into the office.

The Independence at Home project is examining the effectiveness of providing primary care and chronic illness management in the home. Patients receive Medicare-reimbursed visits from geriatricians or mid-level providers. Some also see a social worker or pharmacist. Nurses are involved in case management and patient education.

Many of our patients have life-ending illnesses, and we also work with them to transition them to our other programs, including Palliative Medicine at Home and Hospice at Home.

If a patient goes to an emergency department or is hospitalized, we are alerted through our electronic medical records so we can follow up with them in the hospital and again after they return home.

Success for patients and providers

While many outcome measures of this program are still being analyzed nationally and locally, I can tell you that Cleveland Clinic’s initiative saved approximately 7 percent in the first year and 3 percent in the second year.

More importantly, though, the program also has recorded significant improvements in many quality measures, notably reduced readmissions and emergency department visits. And our patients are very happy with the care they are receiving. Press Ganey surveys show us that more than 90 percent highly recommend our service. This is no doubt a reflection of the fact that physicians who do this work truly enjoy it. Being in a patient’s home allows you to get to know them and develop very personalized care plans. Both patients and providers find this deeply gratifying.

Congress is working on making the program into a permanent Medicare benefit. We are currently operating in a two-year extension of what began as a three-year demonstration project. As home visits also work well within the context of an accountable care organization, I think we will continue to see greater implementation of this concept across many settings.

Based on our experiences at Cleveland Clinic, I would advise any practice considering adding home care visits to move forward with the idea. It is easier to implement than you would expect, and you almost certainly have at least a few patients who would truly benefit.

Dr. Zafirau is director of Cleveland Clinic’s Center for Connected Care.