Transcript House calls 101

HOUSE CALLS 101
Sandra Qaseem MD
Goals and objectives
At the end of the presentation knowledge gained will help to
• Identify patients that would likely benefit from house calls
•Select the equipment necessary for a basic house call
•Understand how to set up and perform a house call and bill for the
service
•Implement house calls as part of your regular practice
Background
• Number of homebound is increasing- 11 million adults living at home
are limited in their ability to perform ADL’s
• Number of house calls is increasing- in2010 (medicare data) The
total number was 2,517644 for house call codes and 2,204,351 for
domiciliary care. This represents a 6.5% increase for house call codes
and a 9.9% increase in domiciliary care codes from 2009.
• Concept of medical home
• Independence at Home
• Face to face requirement for skilled homecare services (RN, PT, OT
etc)
http://www.cdc.gov/prc/pdf/PRC_HA_fact_sheet_summer2006.pd
Changing Demographics of Elderly Population
http://www.agingstats.gov/agingstatsdotnet/Main_Site/Data/2006_
Documents/Population.pdf
Where Do Our Patients Live?
•At home with or without caregiver assistance
•At home with Adult Day Care Services
•Assisted Living Facilities
•Shelter Care or Residential Care Homes
•Total care community
•Nursing Homes
Why make house calls?
• Patients need them and are more satisfied with treatment in the
home
• Patients access more regular care
• Less hospitalization and use of Emergency Department translating
to reduced healthcare costs
• Better assessment of environmental contribution to medical
problems
• Evaluation of caregiver
• Families are happy and caregivers less stressed
• Personal satisfaction
• Schedule flexibility
Equipment- ‘The Black Bag’
• As you begin doing house calls, you will quickly customize your black bag to include
those things that you find necessary and convenient. Here is a quick list of things to
get you started:
• Street map or GPS,
• Netbook/ laptop
• Stethoscope,
• Blood pressure cuff (regular and large),
• Pulse Oximeter
• Pen light,
• Tongue depressors,
• Otoscope,
• Prescription pad,
• Phone numbers (offices, pharmacies, etc.),
• Cell phone, palm-held computer, etc.
• Dictaphone/forms/progress notes,
• additional pens.
House Calls: Taking the Practice to the Patient
James M. Giovino, MD ,Fam Pract Manag. 2000 Jun;7(6):49-54
Patient Eligibility for Home Care
• The visit must be “medically reasonable and necessary”
• Mobility impairments
• Disruptive behavior
• Terminal illness
• Multiple complex medical, psychiatric and social problems
• Compliance issues
• Not required to be as totally homebound as for skilled homecare
from agency such as RN/ PT/OT
Identify a patient (or 2)
• Try to find a patient on your panel with mobility issues having great
difficulty accessing care in the clinic
• Ask him/ her if they would like a house call and explain the potential
benefits (not everyone prefers them- for some it is a rare social
event to come to the clinic!)
• Set up a date and time for visit preferably at the end of the work
day, if possible have a family member or caregiver present
especially for the first visit
Making the visit
• If possible call the patient the day before to remind them of your
visit
• Print out a paper copy of the patient’s recent notes, or have
electronic access to the chart on the visit, include all demographic
information
• At the patient’s home introduce yourself and any others with you,
ask if other family members present are participating in the visit
• Identify a quiet place comfortable for the patient and yourself to
conduct the visit
• Proceed as you would for a clinic visit, identify the presenting
complaint etc.
In addition there is much to learn
• Perform a medication review, and determine whether or not
patient understands their medications
• Observe the patient walking and functioning in their own home
• Perform a home safety assessment, with permission look at the
bathroom for grab bars etc
• Observe interactions between the patient and the caregiver or
family
• Is the home clean?
• With permission look in the refrigerator- is fresh food available?
Wrap up
• Ask if there are any last questions
• Set up a follow up visit
• Leave written instructions for the plan of care
• Return all furniture to its rightful place
• Thank the patient for allowing you into their home
Back at the office
• Document the visit
• Follow up paperwork
• Order tests as necessary- X-ray, EKG, Laboratory tests, Cardiac Echo,
Doppler and overnight oximetry can all be done in the home
• Phone calls
• Billing
Billing Codes
• Patients own home versus assisted living/ group home facility
• New patient versus established patient
• Level of visit- as in clinic based on complexity, number of diagnoses,
medical decision making etc as in outpatient clinic
• For more in depth information the American Academy of Homecare
Physicians publishes a guide Making house calls a part of your
practice.
Codes and reimbursement 2011-patient’s own
home
•
•
•
•
•
•
New Patient Visit:
99341- $54.70
99342- $79-50
99343- $129.79
99344- $174-30
99345- $209.29
•
•
•
•
•
Established patient
99347- $54.36
99348- $82.22
99349- $121.64
99350- $185.22
http://www.cms.gov/apps/physician-fee-schedule/search/search-results.aspx
Codes and reimbursement 2011- Domiciliary visit
• New Patient
• Established Patient
•
•
•
•
•
•
•
•
•
99324- $55.04
99325- $79.50
99326- $134.89
99327- $177.36
99328- 207.26
99334- $58.44
99335- $90.38
99336- $121.74
99337- $183.47
http://www.cms.gov/apps/physician-fee-schedule/search/search-results.aspx
Care Plan Oversight and Certification for Home
Health Agency Patient
• These are also billable for your clinic patients receiving skilled HHA
services in the community
• G0181 $104.31 (home health)/ G0182 $105.67 (hospice)
• Must document 30 minutes of time spent coordinating care
unrelated to a face to face visit for a patient
• Time spent includes telephone calls to other health professionals
(NOT FAMILY), ordering and reviewing tests etc.
• Time must be at least 30 minutes in 1 calendar month
• a template for documentation is available in from AAHCP
• G0179 $44.17 (initial) G0180 $53.00 (recertification)
• Billable after reviewing and signing the ‘485’ orders from Home
Health agencies
Making House Calls a Part of Your Practice- AAHCP
Collaborate with Home Health Agencies and
Hospices
• HHA have invaluable resources to improve health outcomes in frail
elderly patients
• Many homebound patients will qualify for this intermittent
medicare benefit and these services may help you provide excellent
quality care with these added resources
Documentation
• H&P
• Progress notes
• EMR
• Must be complete and comprehensive in order to provide high
quality patient care and communication, maximize billing, prevent
potential mismanagement/ litigation
Building up your home care practice
• Gradually add another patient or 2 from a similar locality
• Set aside one afternoon weekly or bimonthly as the practice grows
• Typically you should be able to see 3-4 patients in a half day at
home depending on accessibility, less in rural areas
• Consider building a team to help you if you have access to a Social
Worker, RN case manager, pharmacist these can be invaluable
members of the home care team
• Many physicians now make house calls full time!
Summary
• House calls are a rewarding addition to a medical based practice
• Start with one or two patients and build up
• Collaborate with home health agencies
• Now…..go make a home visit!