Mary Venturacci is 98 years old and lives by herself in her northeast Salem home.
It’s an ideal situation for most older adults, who prefer to continue living in the comfort of their home and maintain independence. But it takes some work.
Much of it falls on her daughter, Wanda Urban, who helps Venturacci with her health care, medications, grocery shopping and more. Another good portion falls on Venturacci’s Kaiser Permanente nurse practitioner, Marty Surface, who provides her with primary care services at her home.
When Surface made his first visit with Venturacci, he immediately recommended changes — to the home. The bathroom needed bars to help her get down and up. The bed’s wheels needed stoppers to make sure it doesn’t move around too much when Venturacci lands on it. Surface then taught Venturacci how to use her walker.
These are all things a typical primary care doctor in a clinic setting would not have been able to do, yet they could have a profound impact on Venturacci’s health outcomes.
One out of three adults aged 65 and older fall each year, which can lead to hospitalizations, loss of independence, worsening health and death, according to the Centers for Disease Control and Prevention. More than 95 percent of hip fractures are caused by falls.
Fall prevention is key to keeping frail, older people healthy.
House calls, which may conjure an image from a different generation, when doctors traveled with black satchels, are gaining recognition for their effectiveness in lowering costs and improving outcomes for the most fragile, complex — and, in turn, most costly — health care consumers.
Kaiser Permanente began its Primary Care at Home program in 2007 and started expanding its reach to Salem a year and a half ago. Its patient base has grown from 500 to 1,500 people, but more could be helped.
Surface, who serves 102 patients, is currently the only house call provider in the Salem area, but Kaiser is looking to hire another provider, as there are about 100 people on the waiting list.
The only requirement is that the patients be home-bound, or face significant challenges making clinic appointments.
In a cohort of 554 Kaiser Permanente patients, preliminary data show that house calls have helped decrease costs by 40 percent, emergency room visits by 40 percent and hospital admissions by 60 percent.
The federal government’s home care demonstration for Medicare patients showed similar gains.
First-year results of the three-year Affordable Care Act study, Independence at Home, showed that offering house calls to Medicare patients with complex conditions and high needs saved Medicare $25 million. Medicare rewarded participating providers who met certain quality measures with incentive payments, and Portland-based Housecall Providers collected $1.2 million for its first year’s performance.
The U.S. House of Representatives passed legislation to extend the program for two additional years on Wednesday, and now awaits President Obama’s approval.
Oregon Democrat Sen. Ron Wyden, who championed Independence at Home from early on, also helped introduce the extension.
“Independence at Home has shown that providing quality health care to seniors in their home works for beneficiaries, works for health providers, and works for Medicare,” Wyden said in a statement. “Given the strong first year results of the demonstration, a two-year extension is a no-brainer. Independence at Home is an important step towards reducing our nation’s inefficient and expensive patchwork of health care delivery systems.”
Much of what house calls allow providers to do is not medical in nature.
Shari Sanders, chief of geriatrics and long-term care for Kaiser Permanente Northwest, said it allows clinicians to detect a crisis before it begins.
“Who cooks for you? How do you get dressed? How do you go to the grocery store?” Sanders said, listing the type of information providers gather during home visits. “And who’s your social support? What’s in your fridge? Your eyes are opened a little bit more.”
During a recent visit with Venturacci, who experiences swelling in her legs, Surface discussed reducing the patient’s blood pressure medication dose by half to see if that might improve her symptoms.
If the pills are easy to cut, then Venturacci would be able to avoid a separate copay refilling a new prescription, Surface noted.
Urban brought out the pills, and Surface demonstrated how to split them.
When Venturacci misplaced her hearing aids, Surface lent her a personal amplifier.
Housecall Providers has been specializing in home visits for 20 years.
“The need has always been significant,” executive director Terri Hobbs said. “We’ve always had a waiting list. We’ve always been recruiting for more clinicians.”
However, it can be difficult to make a living seeing patients in their homes. House call providers are reimbursed the same way clinic providers are, on a fee-for-service basis, yet house calls take more time and traveling in between patients. Providers weren’t able to see the volume of patients required to keep the doors open. So the nonprofit’s revenue has long been supplemented by grants and donations.
But there’s hope that Medicare’s support for house calls through Independence at Home and its value-based payment model is a sign of change, making the profession a more viable option.
“I do see a tide turning and I think there will be health care systems looking at this as a way to better serve these patients,” medical director Dr. Pamela Miner said.
Keeping older patients out of the hospital isn’t just a cost saving. It could also be life-saving.
Older patients tend not to have great outcomes in hospitals, and they often have to be discharged to a nursing home. The experience also worsens memory problems, Surface said.
Venturacci has no plans to move.
“It’s a quiet neighborhood,” Venturacci said. “I enjoy it here.”
Surface turned to Venturacci.
“At least for the immediate future,” he said, “I see no reason why you’d have to leave.”