Wheaton doctors work to spread positive message about house calls

On a recent Tuesday morning, Bernard and Margaret Sloan got flu shots, had their blood drawn and discussed medications with their doctor.

The couple — married 67 years — had their procedures done by a nurse and Dr. Paul Chiang, home health care provider extraordinaire, while they sat on a red, floral sofa in the comfort of their Wheaton home.

“There's just something unique being in the home that you can't get in the hospital, ER or doctor's office,” Chiang said. “I'm going into your world. I'm stepping into your life.”

This summer, Chiang completed his 25,000th house call since 2000, when he started working for HomeCare Physicians, a Wheaton-based medical house call program.

He may not carry the same black bag as did doctors who routinely made house calls in the 1950s and earlier, but Chiang's motivation and mission are the same.

“The heart of medicine is about service. It's about caring for my patients,” he said. “I have such an opportunity to get a better feeling and a better understanding of my patients, their families, their joys and their struggles by being at their house.”

Some predict a revival of physician house calls brought on by a perfect health care storm that includes:

• Changes wrought by the Affordable Care Act, including hospitals facing fines for too many re-admissions.

• The financial crisis in Medicare and Medicaid.

• Increasingly advanced and portable medical technology that can be brought into the home.

• A rapidly aging population. The number of people age 85 and older is expected to more than triple between 2012 and 2060, to more than 18 million, according to the U.S. Census Bureau.

“With all those pieces moving and changing, we're hoping this will be a new health care delivery model, for not just us and the community here, but across the country,” Chiang said.

‘Refrigerator biopsy'

While there are hundreds of home health agencies in the Chicago area, the majority of them are for-profit and provide either hospice services or palliative care, which focuses on relieving pain without dealing with the underlying cause, Chiang said.

Home health care is given primarily by nurses, along with physical therapists, social workers and other health care professionals.

Chiang and HomeCare Physicians founder Dr. Thomas Cornwell, however, are unique because they are physicians who provide not only hospice and palliative services at home, but also primary care through house calls.

They duplicate the office setting by bringing along nurses, medical assistants or other workers who can help during the appointments.

Supporters say house calls allow a doctor to provide better care by really seeing what's going on in the home. They can meet caregivers and family members and see if there is clutter or bad smells.

For example, Chiang and Cornwell say they do a “refrigerator biopsy” when they visit patients' homes.

Often, they find expired items or shelves lined with unhealthy foods. It's one of the many advantages, they say, over meeting the patient in a medical building.

The visits can save homebound patients money, too, as they prevent costly emergency room visits and ambulance rides.

Medicare pays for house calls for those who are homebound or have trouble leaving their home without help.

Cornwell, who also serves as the president of the American Academy of Home Care Medicine, said house calls have been shown to reduce nursing home placement and hospital re-admissions, too.

That's turning the heads of leaders for health care systems, as they start to realize the potential for shared cost savings.

‘Right thing to do'

In the suburbs, Cadence Health ­— the health care system that runs Central DuPage Hospital in Winfield and Delnor Hospital in Geneva ­— recently helped launch the Home Centered Care Institute, yet another brainchild of Cornwell. The partnership is one that, until recently, was rarely heard of, considering health care systems turn little or no profit in such initiatives.

“Cadence felt this was the right thing to do for our community, even though they knew it wasn't economically good for the hospital,” Cornwell said.

Several missions the institute hopes to accomplish locally and nationally include:

• Educating health care systems, hospitals, doctors and patients on why doctors should be making house calls. When they're not part of the equation, money is lost. The other caregivers “cannot make active medical decisions. They rely on calling a doctor, who oftentimes, when there is a problem, will say, ‘Send them to the emergency room where we can treat them.'”

• Collaborating with health care systems to expand the reach of services like those offered by HomeCare Physicians. For example, the institute has helped the University of Chicago secure a grant to do a study on house calls and is working with Rush University Medical Center, where leaders are considering launching a house call program.

• Encouraging legislative changes in the payment systems and laws applying to Medicaid and Medicare. One hope is that doctors can be paid for discussing end-of-life care with patients, as they can currently bill for discussions on such topics as quitting smoking.

• Recruiting more medical students and nurse practitioners to go into home health care, and training physicians to do house calls. Currently, medical students are not required to do house calls, and there are few residencies, or postgraduation programs, focused on house calls.

What changed?

In 1930, between 40 percent and 60 percent of all health care happened in the home, Cornwell said. That decreased to about 0.6 percent in the 1980s.

Chiang said that slip was due partially to technology because new machines like CT scan systems could not be brought into the home.

In addition, doctors can make more money in a clinic, where they often see 20 to 30 patients a day, compared to doing house calls, where they may see nine to 11 patients daily.

Now, however, technology has swung back in the home health care providers' favor. There are apps available on cellphones that work like an EKG machine, which checks the electrical activity of the heart, and portable, pocket-size ultrasound devices.

In addition, an estimated 50 percent of people age 85 and older will need assistance with everyday activities. And it's already well-known that the 85-and-older population is the highest user of costly hospital and nursing home services.

Cornwell said the average age of his patients is 80.

About 5 percent are age 65 and younger. Those patients, he said, primarily have neuromuscular disorders, such as multiple sclerosis or spinal cord injuries.

Like family

Back at the Sloan home, Chiang asks the couple about their eating habits, if they have fallen recently. He talks with them about their interests, including Notre Dame football. He makes them laugh.

Margaret said that when she was diagnosed with Parkinson's disease several years ago, Chiang became “the light of my life.” There were times, she said, that he came by every day to check up on her.

“He's so cheerful, and he's so personable. I can't say enough good things about him,” she said.

The Sloans' caregiver, Debra Budner, said Chiang is like family to the couple.

“If you interviewed the doctor they go to at the hospital, they're not going to know as much because it's more personal here,” she said. “Dr. Chiang takes his time, and he wants to make sure everything is taken care of.”

Chiang agreed that his drive to care for and respect his patients is heightened when he meets them in their own space.

A black-and-white engagement picture of the Sloans that hangs on the wall near their front door, for example, reminds Chiang that they once were young, filled with ambitions and dreams like everyone else.

“It reminds me of the humanity and reminds me of my own mortality,” he said. “(Doing house calls) reminds me that we share the humanity. I'm a human being just like you, even though I wear a white coat.”

At the end of the visit, Chiang kneels in front of Margaret and holds her hand. Together they make a list of things to pray for — physical strength, safe travels for one of her children coming to town.

They share a peaceful moment, and it's clear this experience is unlike any that would be found if the Sloans had to get their care elsewhere.

“I truly think it's a remarkable thing to do,” Chiang says of his work. “(My patients) bring blessings to me — tell me their stories, how they met, raising their kids, what they did for a living, what they're proud of and so on. It's an honor and privilege for me to do this.”

Call: Doctors see an average of 9 to 11 people in their homes a day