House calls and home care.

HOUSE CALLS AND DOMICILIARY VISITS Introduction A growing number of people in the United States are homebound and need in-home health care services. “House calls” refer to the provision of physician services to patients in their homes or apartments, including independent living centers. Domiciliary visits refer to physician services provided to patients who reside in assisted living facilities, boarding houses or group homes. Home visits may be provided as part of an interdisciplinary team or by a solo physician; they may be episodic or exist as ongoing care to patients. Furthermore, the diagnostic house call can provide information to the physician about how the patient functions within the home environment. (Table 1). The actual visit1 The history and physical exams in the patient’s home are similar to office work. In addition, permission should be requested to inspect the living quarters. Is the home clean? Is there food in the house? Can the patient get around? Is the environment safe? Are there loose rugs, nightlights, rails in the bathroom? Medications should be reviewed. An office visit, no matter how comprehensive, cannot provide a complete understanding of the patient’s daily routine. In many situations, a family member or other caregiver should be present during the visit. When the patient’s condition requires substantial nursing care, the visiting nurse should be present during some visits, enabling the team to discuss the care plan. Observing the interaction between caregivers and patients is also a valuable source of information. In the home setting, people may be more likely to display their usual patterns of interaction. In some cases (e.g. abuse or neglect), the physician may need to contact an agency that provides adult protective services. The goals of house calls vary. A “sick” visit may simply address an acute complaint (e.g., respiratory symptoms, a fall). In the case of home-based long term care, the data described in Table 1 should be collected over time or during a comprehensive intake session; included are information on medical problems, physical function (e.g., ADL, IADL) and social and role function, such as visits by friends and relatives; and mental function, affect and advance directives. Unlike the office setting, much of this information can be collected by direct observation during a home visit. Blood and urine tests, electrocardiograms and portable xrays can be obtained in the home but they must be scheduled in advance and are rarely available on an emergency basis.