House Calls Make a Comeback, Now with Nurse Practitioners

By Glenna Murdock, RN, contributor

September 30, 2010 - What was old is new again. Once the norm, house calls by health care providers all but disappeared decades ago, as technology became more sophisticated.  Hospitals and, eventually physicians’ offices, began offering better diagnostic and treatment tools, requiring that patients leave their homes to take advantage of these new services.

Now, both health care providers and health care consumers are seeing advantages in the resurgence of house call care. Consumers relish the idea of not having to spend time getting to the physician’s office to sit in a waiting room with other people who are sick. Providers find house call care rewarding and efficient.

Once the realm of physicians, today’s house calls — which can also occur at a place of business — are often provided by nurse practitioners (NPs).

Whether provided by an individually-owned practice or a large membership entity employing many NPs, this onsite care is more convenient and practical than traditional office or urgent care visits for many patients. It also allows a more thorough evaluation of the patient by the provider.

Onsite visits can also be more cost effective for the patient and for companies that purchase memberships for their employees. For the individual, avoiding an office visit saves the cost of travel, childcare and lost wages. The employer is spared the expenses of lost productivity and claims against the company’s health insurance.  Fees vary depending upon the area of the country — they are generally higher on the East Coast —and whether the service is engaged by an individual or through a group plan. 

Raymond Zakhari, EdM, MS, NP, RN, is the founder and medical director of Metro Medical Direct, a house call service in New York City. As a board certified nurse practitioner, his house call nursing experience began with treating homebound Medicare patients. He enjoyed the patient care but not the volume of documentation and paperwork Medicare requires. To continue the work he loved while avoiding the bureaucracy he disliked, he established Metro Medical Direct in 2009.

“In Manhattan, because we don’t have cars, it is taken for granted that everything can be delivered, so why not health care?” Zakhari said. “I see patients in apartments, hotels and at their workplace. The patient pays me at the time of service and is given a coded receipt that they may submit to their insurance company for reimbursement; other patients utilize their FSA [flex spending account)] cards. My practice is out-of-network which allows me to spend more time with my patients.”

Zakhari explained that house calls offer a more personal experience with fewer hassles than an office visit.

“During a house call I can establish a degree of trust and intimacy with the patient that can’t be achieved in a traditional practice because the patient is more at ease in familiar surroundings and I have more time to focus on them,” he said. “Busy professionals whose schedules make it difficult to take off work for several hours to see their doctors appreciate that an exam in their office takes only 30 minutes.”

Zakhari’s established patients are also able to take advantage of telemedicine features including a Web camera, e-mail consultations, e-prescriptions, and questions and answers via text messaging. Zakhari helps his patients negotiate cash courtesy discounts for procedures and directs them to the resource page on his Web site for reduced lab and prescription costs.

The genesis of House Call Connections, a mobile medical practice in Denver, Colo., also sprang from the desire of a NP to connect with his patients in a more personal way.

In 2009 he and a colleague, physician’s assistant (PA) Tim R. Johnson, founded House Call Connections (HCC). Vermilyen is the frontline care provider for the practice. Johnson serves as the business director while continuing in his position as a PA with an orthopedic group, but he sees house call patients on consultation. HCC treats adults and children two years of age and older.

“I love the variety of seeing all ages of patients and interacting with them on their own turf,” Vermilyen said. “Children are less anxious when they are examined while sitting on the sofa in their pajamas, watching Sponge Bob.”

House calls provide a better utilization of health care dollars, according to Vermilyen.

“The fee I charge for suturing a laceration, for example, is one-fourth the cost of the same service at urgent care and one-tenth the fee of a hospital ER,” he explained.

In addition to house calls, Vermilyen contracts with companies to provide onsite pre-employment physicals, conduct flu shot clinics and mini-health fairs for basic screenings.

Operating on a larger scale is WhiteGlove House Call Health, a membership provider that serves the five most populous cities in Texas and plans to expand into Arizona and Massachusetts before the end of the year. Subscribers pay an annual per person membership fee and a nominal flat fee for each visit. Employers can provide the membership for their employees, who then are responsible for paying for each visit themselves. Individuals may also enroll in the plan. Aetna, Humana and United Health Care insurance companies cover the membership fees for those living in the service areas and who have health insurance coverage with their firms.

“Our aim is to reduce the cost of care while improving the patient’s health care experience,” said Debi Mazzuca, RN, MSN, NP, chief nurse practitioner officer and director of clinical operations for WhiteGlove.

WhiteGlove NPs drive cars that carry a full complement of medical supplies. As appropriate, the patient is provided a three-day supply of the generic drugs they need, tissues, cough drops, Ibuprofen and Acetaminophen, along with food and beverages.

“We provide chicken soup, saltines, Jell-o, applesauce and ginger ale—everything your mom would give you to make you feel better,” Mazzuca stated. “It is going back in time to the way care used to be delivered. It is good for the patient and good for the nurse practitioner.”

With the advent of health care reform, and the probability of 30 million newly insured patients further taxing an overburdened system, house call services are expected to grow, according to the three NPs interviewed for this article.

“There will always be a primary care shortage,” Vermilyen said. “Of necessity, we will see a trend toward more home care.”

© 2010. AMN Healthcare, Inc. All Rights Reserved. 

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