Time Providing Care Outside Visits in a Home‐Based Primary Care Program

Abstract

Background/Objectives Homebound elderly patients with chronic medical illnesses face multiple barriers to care. Primary care physicians (PCPs) devote a significant amount of time to care apart from actual office visits, but there is little quantification of such time by physicians who provide primary care in the home. This article assesses exactly how much time physicians in a large home based primary care (HBPC) program spend providing care outside of home visits. Unreimbursed time, as well as patient and provider-related factors that may contribute to that increased time, are considered. Design Mount Sinai Visiting Doctors (MSVD) providers filled out research forms for every interaction involving care provision outside of home visits. Data collected included: length of interaction, mode, nature, and whom the interaction was with for 3 weeks. Setting/Participants MSVD is an academic home-visit program in Manhattan, NY. All PCPs in MSVD (n=14) agreed to participate. Measurements Time data were analyzed using a comprehensive estimate and conservative estimates to quantify unbillable time. Results Data on 1151 interactions for 537 patients were collected. An average 8.2 hours/week were spent providing non-home visit care for a full-time provider. Using the most conservative estimates, 3.6 hours/week was estimated to be unreimbursed per full-time provider. No significant differences in interaction times were found among dementia vs. non-dementia patients, new vs. non-new patients, and primary-panel vs. covered patients. Conclusion Findings suggest that HBPC providers spend substantial time providing care outside home visits, much of which goes unrecognized in the current reimbursement system. These findings may help guide practice development and creation of new payment systems for HBPC and similar models of care.

Homebound Patient and Caregiver Perceptions of Quality of Care in Home‐Based Primary Care: A Qualitative Study

“…Around‐the‐clock access to on‐call providers is a basic tenet of HBPC . Access can often be offered through telephone triage; in one study, urgent or emergency department visits were only required approximately 5% of the time . Participants perceived that emergency department visits and hospitalizations decreased because they were able to access someone over the telephone or have a physician visit when problems arose.…”

“…12,16 Access can often be offered through telephone triage; in one study, urgent or emergency department visits were only required approximately 5% of the time. 17 Participants perceived that emergency department visits and hospitalizations decreased because they were able to access someone over the telephone or have a physician visit when problems arose. Several studies have found fewer hospital and skilled nursing facility admissions with HBPC programs, confirming participant perceptions.…”

Operation and challenges of home-based medical practices in the US: findings from six aggregated case studies

“…Through observations and discussions with practitioners and staff we learned about each practice’s organizational structure, patient population, and challenges faced as a practice delivering medical care in the home. Combining observations from site-visits at six diverse practices delivering ongoing home-based medical care builds on previous single practice case studies [ 10 , 12 , 17 , 18 ].…”

“…Home-base primary care patients in the U.S. primarily receive medical coverage through Medicare, in which care delivery is reimbursed on a fee-for-service basis for physician face-to-face patient visits [ 17 ]. This payment structure does not work well for coverage of a multi-discipline care team approach where care coordination outside of the home visit is necessary to meet the needs of HBPC patients [ 18 ]. In a study of the Mount Sinai Visiting Doctors HBPC program, it was estimated that 20.5% of providers’ time was spent on care coordination activities outside of home visits, and 2.4 h each week were not reimbursed [ 18 ].…”

“…This payment structure does not work well for coverage of a multi-discipline care team approach where care coordination outside of the home visit is necessary to meet the needs of HBPC patients [ 18 ]. In a study of the Mount Sinai Visiting Doctors HBPC program, it was estimated that 20.5% of providers’ time was spent on care coordination activities outside of home visits, and 2.4 h each week were not reimbursed [ 18 ]. When factoring in additional time spent during weekend hours, late nights, or on call, providers were unable to obtain reimbursement for nearly 4 to 8 h of care coordination each week.…”