Adding IR to novel physician house call model yields remarkable returns
BY PETER PERL SPRING 2020
Across a 30-mile radius in rural northwest Indiana, more than 1,000 patients with multiple chronic conditions are confined to their homes or to nursing facilities and encounter difficulty receiving care they need for their chronic conditions. Like millions of elderly or impoverished Americans in small towns and villages, they often have no personal physician, no easy access to care, insufficient resources to get the specialized treatment they need and no way to find affordable transportation.
Among these patients is a wheelchair-bound man who is morbidly obese and badly needs to go to the hospital, just to have a gastrostomy tube replaced. A very frail 92-year-old woman with a urinary infection who is terrified at the prospect of leaving home to be taken to a distant clinic. A nursing home patient with severe bedsores who is told that three large foot wounds may require amputation unless she takes a round-trip ambulance to the hospital at a cost of well over $1,000.
These patients were the fortunate ones. Those hospital trips did not have to happen because they were being served by an innovative home-visit medical practice called Housecall Doctors P.C. in Highland, Indiana, which has made more than 100,000 visits to more than 6,500 home-bound patients since its inception in 2010.
Two years ago, Housecall Doctors partnered with Yale-trained vascular interventional radiologist Nazar Golewale, MD, of Modern Vascular and Vein Center in northwest Indiana. This partnership combined the house call services infrastructure with the expertise, technology and experience provided by an IR.
The Housecall Doctors team provides internal medicine, podiatry, laboratory services and wound care delivered by physicians, nurses, nurse practitioners and technicians. The addition of Dr. Golewale in 2018 with portable technology enables the practice to now provide ultrasound-guided needle biopsy, gastrostomy tube management, paracentesis and thoracentesis, ultrasound-guided joint injections for pain, wound care, drug infusions, and more.
In a 12-month period ending last August, this expanded version of the collaborative house call model treated more than 1,000 patients, reduced emergency department usage by 77% and cut hospital readmissions by 50%, according to a study co-authored by Dr. Golewale. This novel IR-assisted care model is able to provide advanced specialty care on an outpatient basis at homes or in local offices, preventing common complications of chronic diseases, sparing patients from stressful, painful trips to distant hospitals and, in the process, saving substantial amounts of money.
“Adding the IR role to our team was imperative because so many of our patients needed invasive procedures,” said Saket B. Sinha, MD, the internist who founded Housecall Doctors and co-authored the study. “Life is very, very complicated for these patients: Immobility, multiple co-morbidities and sometimes five or six different consultants scheduling them for appointments—but there is nobody to take them. These patients are incapable of handling the logistics, so they just drop out of treatment with catastrophic outcomes.”
After 10 years treating this population, Dr. Sinha said he realized that “the only way to do these procedures was in these patients’ homes, to have an IR do it with the proper technology, the trained eyes and the ability to see that it’s done right. Now these patients barely ever see the emergency room. Everything gets done in their home.”
“Our older, homebound patients have so few resources available for specialty care that they often delay seeking treatment until preventable issues become urgent and acute,” Dr. Golewale said. “They often were waiting months to see a specialist. By providing image-guided treatments in a patient’s home, we are improving access dramatically and avoiding countless hospitalizations.”
Payments for care provided by the Housecall Doctors team are covered by Medicare reimbursement for homebound patients.
“We are really making a difference in these patients’ lives. I am quite sure this type of practice is going to continue to grow, and is going to explode, particularly with Medicare interest in the cost savings,” Dr. Golewale said. “We are essentially bringing hospital care to patients’ bedrooms. Medicare and insurance companies love this. We have healed difficult wounds, prevented amputations, prevented hundreds of hospital visits and saved millions of dollars.” For example, fine-needle aspiration biopsy under ultrasound guidance reimburses at home between $130–$180, while a similar procedure in a hospital would cost roughly $500. Similarly, repositioning of the gastronomy reimburses $125–$140 when performed at home. But this same procedure can cost five times that much in a hospital, in addition to the transportation costs.
Another major benefit of the collaborative house call model is a dramatic improvement in patient satisfaction, according to the study, which reported that satisfaction scores increased from 17% before implementation of the program to 84% after implementation.
“Patients are very excited about this. They will say ‘I saw this as a kid, where the doctor used to come to my home!’” said Dr. Sinha, adding, “Now it has come full circle and the doctor is coming to their home again. The patients end up feeling very attached to the doctor. They buy into the whole system and say, ‘Oh wow, they’re really trying to help me.’ And the results are phenomenal.”
Jose L. Agusti, MD, an internist with Tumi Medical Home Services who has worked with Dr. Golewale to serve homebound patients, said he was initially “a little resistant” to collaborating with an IR because of his past difficulties in working with a variety of consulting doctors whose priorities and practices did not always match his own. Specialists who want to order additional tests or perform additional procedures can be particularly irritating, Dr. Agusti said, because that approach is often totally inappropriate for the homebound population.
But Dr. Agusti said his experience with Dr. Golewale has been very positive. “With him and his team, I have drained abscesses with ultrasound guidance” and the IR presence has been highly beneficial, he said, and aids the doctor–patient relationship. “It’s a mutual feeling. You are happy to see the patient, and they’re happy to see you, even though the medical situation may be sad.”
“The patient is more comfortable and less stressed,” Dr. Golewale said. “The doctor ends up spending more time and learning more about the patient, and you end up doing a thorough evaluation and management of that patient,” preventing grueling trips to the emergency room.
With the addition of Dr. Golewale, Dr. Sinha is more convinced than ever of the efficacy of practices like his. “I really feel this model is going to be the norm in the future, as the hospitals will be mainly an acute care setting and sick patients will be managed in their homes where they recover better and faster with much fewer complications.”
“I would encourage interventional radiologists to look for partnerships with local internists, home health nursing agencies and assisted living facilities, and to emphasize that they can get procedures done in a timely manner,” Dr. Sinha said. “The other physicians have to trust their judgment and know that the IR is not going to steal their patient, but is going to be their partner.”
As interest grows in the house call practice, Dr. Golewale cautioned: “This is not an easy task. This is not for everyone. There are difficulties with scheduling, equipment, documentation and reimbursement. It takes close collaboration and good teamwork.” To IRs considering house call services, he advises awareness.
“Homebound patients have complex medical problems with higher acuity than ever before and there are still challenges in managing them at home,” he said. “However, IR has always been very innovative. If you think outside the box and have passion and drive to make a difference in patients’ lives, then it’s a very professionally satisfying experience.”