House Calls

August 15, 2020

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Volume 102, Number 4 www.aafp.org/afp American Family Physician 211

House calls, also referred to as home visits, are increas-

ing in the United States.

Approximately 40% of patient

visits in the 1930s were house calls.

1,2

By 1996, this

decreased to 0.5% because insurance reimbursements

for house calls decreased.

1,2

e pendulum in the United

States is swinging again to house calls because of the need

to develop care models for the growing aging popula-

tion.

1,3,4

e proportion of house calls to outpatient clinic

visits conducted by family physicians in the United States

is unlikely to reach the 1930s levels; however, the num-

ber of house calls conducted from 1996 to 2016 doubled.

Medicare Part B billing and reimbursement for house

calls are also increasing, with nearly 2.6 million house

calls paid in 2015.

e increasing popularity of and call for home-based

care have led to an increased need to study the outcomes

and design of home-based primary care models in the

United States. e two largest home-based primary care

studies are the Centers for Medicare and Medicaid Ser-

vices Independence at Home Demonstration and the U.S.

Department of Veterans Aairs home-based primary care

program.

6,7

e Independence at Home program demon-

strated a 23% reduction in hospitalizations, a 27% decrease

House Calls

Caitlyn M. Rerucha, MD, MSEd, Uniformed Services University of the Health Sciences, Bethesda, Maryland

Ruben Salinas, Jr., MD, Carl R. Darnall Army Medical Center Family Medicine Residency Program, Fort Hood, Texas

Jacob Shook, DO, Fort Richardson, Alaska

Marguerite Duane, MD, MHA, Georgetown University, Washington, District of Columbia

See related Editorial at https://www.aafp.org/afp/ 2020/

0701/ p8.html.

Additional content at https:// www.aafp.org/afp/2020/0815/

p211.html.

CME

This clinical content conforms to AAFP criteria for

CME. See CME Quiz on page 207.

Author disclosure: No relevant ﬁnancial aliations.

The demand for house calls is increasing because of the aging U.S. population, an increase in patients who are homebound,

and the acknowledgment of the value of house calls by the public and health care industry. Literature from current U.S. home-

based primary care programs describes health care cost savings and improved

patient outcomes for older adults and other vulnerable populations. Common

indications for house calls are management of acute or chronic illnesses, coor-

dination of a post-hospitalization transition of care, health assessments, and

end-of-life care. House calls may also include observation of activities of daily

living, medication reconciliation, nutrition assessment, evaluation of primary

caregiver stress, and the evaluation of patient safety in the home. Physicians

can use the INHOMESSS mnemonic (impairments/immobility, nutrition, home

environment, other people, medications, examination, safety, spiritual health,

services) as a checklist for providing a comprehensive health assessment. This

article reviews key considerations for family physicians when preparing for and

conducting house calls or leading teams that provide home-based primary care

services. House calls, with careful planning and scheduling, can be successfully and eciently integrated into family med-

icine practices, including residency programs, direct primary care practices, and concierge medicine. (Am Fam Physician.

WHAT’S NEW ON THIS TOPIC

House Calls

There were more than 1,100 direct primary care practices in

the United States in 2019, and 68% of these practices oered

house calls, including eight practices that were completely

mobile (i.e., had no actual oce).

A systematic review of nine studies (N = 46,156) evaluating

home-based primary care outcomes for homebound older

adults reported fewer hospitalizations, hospital bed days of

care, emergency department visits, long-term care admis-

sions, and long-term bed days.

Illustration by Jonathan Dimes

commercial use of one individual user of the website. All other rights reserved. Contact copyrights@aafp.org for copyright questions and/or permission requests.

212 American Family Physician www.aafp.org/afp Volume 102, Number 4

◆

August 15, 2020

HOUSE CALLS

in 30-day readmissions, and a cost savings of $111 per bene-

ciary per month, which is a $70 million savings over three

years.

7-10

Similarly, a large systematic review (N = 46,154;

nine studies) evaluating home-based primary care out-

comes for homebound older adults reported fewer hospital-

izations, hospital bed days of care, emergency department

visits, long-term care admissions, and long-term bed days

of care.

e U.S. Department of Veterans Aairs home-

based primary care study of chronically ill, frail adults (N =

179) in urban populations also found fewer hospital admis-

sions and bed days of care, but no change in emergency

department use.

House calls benet patients post-hospitalization by

reducing readmission rates, associated health care costs,

and errors related to transitions of care.

13,14

ere is an

increased need for home-based care for the most vulnerable

populations because of the recent shi in the United States

toward value-based health care.

1,3

In 2011, there were 2 mil-

lion homebound people in the United States, of which only

12% reported receiving home-based primary care.

is

number is expected to increase to 4 million by 2030.

House calls also benet patients with socioeconomic

barriers to care, including pregnant patients and children

who are at high risk of abuse.

Nurse- or social worker–led

home visiting programs have reduced child maltreatment,

decreased child health care overutilization, and improved

cognitive skills of children born to a low income house-

hold with limited psychological resources.

16-18

Outcome

data for physician-led house calls are limited for younger

populations because most data are from studies on older

adults. A meta-analysis of 51 studies of home-based family

care reported small, statistically signicant improvements

in child cognitive outcomes, maternal life outcomes, and

parental behaviors and skills.

Additionally, a Cochrane

review of 11,000 newly postpartum patients receiving fre-

quent in-home visits from interdisciplinary teams showed a

decrease in infant health service utilization and an increase

in maternal interest in exclusive breastfeeding.

Historically, family physicians have been the workforce

that meets the critical needs of the United States’ most vul-

nerable populations. Family physicians need to learn how to

incorporate house calls into their practices. e Accredita-

tion Council for Graduate Medical Education requires fam-

ily medicine residents to conduct house calls.

Varying the

type of calls and including patients with complex needs of all

ages add training value that is consistent with the American

Academy of Home Care Medicine clinical competencies.

House calls, with careful planning and scheduling, can be

successfully integrated into a busy oce-based practice or

residency program. Portable technologies, including elec-

tronic health records, battery-powered examination equip-

ment, and point-of-care diagnostic testing, enable health

care teams to bring oce capabilities to patients’ homes.

is article provides tools for conducting house calls and

reviews strategies for implementing house calls into a vari-

ety of outpatient practices, including residency programs,

direct primary care (DPC), and concierge medicine models.

Conditions for the Initiation of House Calls

House calls may be needed for acute reasons because of a

change in health status, serial visits for chronic conditions,

or a one-time visit requested by caregivers or the physician

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation

Evidence

rating Comments

Family physicians should refer eligible older adults with fre-

quent hospitalizations to home-based primary care programs

because of decreased hospitalization rates and 30-day hospital

readmissions.

6-12

B Large-scale patient-oriented evidence including

systematic review of observational studies and a

randomized controlled trial from the U.S. Department

of Veterans Aairs home-based primary care program

and the report to Congress on Medicare’s Indepen-

dence at Home Demonstration Year 3

For patients with terminal cancer, the patient’s goals for

end-of-life care and preference for dying at home vs. in the

hospital should be assessed.

18,26-28

B Limited patient-oriented results from an international

systematic review and cross-sectional data

Family physicians should consider using a house call checklist,

such as INHOMESSS or similar mnemonics, to prepare for and

guide the geriatric assessment of older adults in their home.

C Clinical review and expert opinion, recommendations

from the American Geriatrics Society

A house call supply bag should include equipment to check

vital signs, supplies to take samples for laboratory tests and

perform minor procedures, personal protective equipment for

the physician, and digital or paper records for documentation.

C Clinical review and expert opinion

INHOMESSS = impairments/immobility, nutrition, home environment, other people, medications, examination, safety, spiritual health, services.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented

evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https:// www.aafp.org/afpsort.

August 15, 2020

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HOUSE CALLS

to evaluate for a specic concern. e type of house call

guides the goals and objectives for each patient encoun-

ter

(Table 1

18,21,23,24

). For older adults, consider assessing

for geriatric syndromes (e.g., recurrent falls, polypharmacy,

frailty, memory loss). Evaluation for suspected elder abuse,

neglect, or self-neglect may provide valuable information.

Illness or injury prevention house calls for frail, older,

homebound adults should focus on preventing functional

loss and avoiding hospitalization.

A patient who is enrolled in Medicare must meet two cri-

teria to be considered homebound (Table 2).

Most patients

who are homebound have chronic medical conditions

including heart failure, chronic obstructive pulmonary

disease, renal failure, or advanced dementia. e goal of

the house call for patients who have a chronic illness is to

ensure safety at home, prevent exacerbation of symptoms,

and evaluate caregiver burden and ability to care for the

patient.

Patients enrolled in Medicare who do not meet

homebound criteria for home health care may be eligible for

home-based primary care services. ese services include

hospital-based, veterans aairs–based, or freestanding

home-based primary care that provides acute and chronic

management of medical conditions, polypharmacy man-

agement, improved access to durable medical equipment,

community resources for the patient and caregivers, and

symptom management in end-of-life care.

Medical neces-

sity should be documented (i.e., frequently missed appoint-

ments, poor medication adherence, high use of emergency

department services, or a need to assess function in the

home environment).

For patients reaching the end of life, care focusing on com-

fort (rather than function or longevity) is a common reason

for house calls. Most patients with terminal cancer want to

die at home; therefore, home care is a valuable service that

helps reduce the likelihood of death in the hospital.

18,26-28

House calls made by family physicians for patients who are

dying are primarily to provide symptom management such

as pain relief for patients not using hospice services, and to

provide psychosocial support to the patient and caregivers

before death, and to family members and caregivers aer

the patient’s death.

Preparing for and Conducting House Calls

Previsit planning is essential to ensure the patient’s maxi-

mum benet from a house call. A member of the care team

should call the patient in advance of arrival to verify the

patient’s availability and home address. Physicians should

review the patient’s medical record and medication list in

advance, and bring a copy of the most recent information

to the house for reconciliation during the visit. Once the

physician is at the home, it is important to follow safety

precautions (Table 3

) to prevent personal injury or infec-

tion.

18,30

Table 4

18,31

and Table 5

18,29,32

list recommended sup-

plies for house calls.

If needed, a house call checklist, such as the INHOMESSS

mnemonic (impairments/immobility, nutrition, home

TABLE 1

Conditions for and Types of House Calls

Conditions for initiation

Patient is homebound (see Table 2)

Patient, family member, or member of the home health team

requests a house call that is medically necessary, or the

patient is willing to pay for a house call

Physician needs to negotiate care or clinical decision-making

with the patient and caregivers

Physician needs to assess the home environment or patient

and caregiver interactions

Physician needs to verify eligibility for third-party reimburse-

ment for home health services

Required family medicine resident education*

Types

Concierge medicine service

Direct primary care visit

Family medicine resident education*

Family visit (e.g., well-child examinations and immunizations

for multiple children; prenatal and postpartum visits)

Hospitalization follow-up

Illness and injury prevention for patients who are homebound

(e.g., immunizations, patient home safety evaluation, strength

conditioning, health promotion, disease prevention)

Illness management for patients who are homebound (e.g.,

emergency care, acute care, management of chronic condi-

tions including rehabilitation services and palliative care for

any stage of a serious, life-limiting illness)

Patient assessment* (e.g., polypharmacy, multiple medical

problems, excessive health care use, social isolation, frailty,

suspected abuse, suspected neglect or self-neglect, need for

family meeting, recent major change in health, consideration

for long-term care admission)

Patients who are dying (e.g., terminal care, death pronounce-

ment, grief support)

Travel medicine

*—A comprehensive geriatric patient assessment is often ideal for

a resident’s or trainee’s initial exposure because it allows time for

teaching and working through the INHOMESSS mnemonic (impair-

ments/immobility, nutrition, home environment, other people, med-

ications, examination, safety, spiritual health, services) checklist and

assessment tools. Patients with private insurance who are aging and

request home-based services or patients enrolled in Medicare who

meet homebound criteria for ongoing management of chronic ill-

ness are optimal for trainees, speciﬁcally when the home environ-

ment is familiar, safe, and known to be supportive of learners.

Information from references 18, 21, 23, and 24.

214 American Family Physician www.aafp.org/afp Volume 102, Number 4

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August 15, 2020

HOUSE CALLS

environment, other people, medications, examination, safety,

spiritual health, services; Figure 1), can be used as a guide

for performing a complete geriatric assessment.

A typical

approach begins with observing how the patient enters their

home and evaluating for transitions of ooring in entryways

and the need for extra grab handles, ramps, or rails. Once

inside the home, begin by addressing any urgent patient con-

cerns, then shi the conversation to focus on the items found

on the checklist if time permits. is process typically takes

45 to 90 minutes, and frequent breaks are common.

Allocate time to review the patient’s prescribed medica-

tions, herbs or supplements, and over-the-counter medica-

tions. e patient or caregiver should show the physician

where these medications are kept and organized to provide

further insight into medications that may not have been

mentioned, issues with compliance, and identication of

stockpiles of old or expired medications. Laying out the

TABLE 3

House Call Safety Tips

Ask the patient in advance to cage their pets to avoid the risk

of animal bites or other injuries

Avoid attracting unwanted attention when arriving and enter-

ing the home; consider leaving your white coat and expensive

equipment at the oce

Bring equipment for sharps handling and disposal that is in

compliance with Occupational Safety and Health Administra-

tion Bloodborne Pathogens Standard

Call ahead to remind the patient of the visit; avoid surprising

the patient, in particular those with weapons in the home

Coordinate house calls with other members of the multidis-

ciplinary care team; alternatively, bring a learner (e.g., medical

student, resident, nurse practitioner, physician assistant) or

other oce member for assistance and to enhance personal

security by traveling as a team

During the house call, sit on nonclothed furniture, avoid

pet droppings, wear gloves or respiratory masks if there is

concern for environmental exposure or acute infections; use

hand sanitizer before, during, and after the visit

Keep other trusted individuals (e.g., oce sta members,

partners, care team members) informed of the location and

appointment time in the event that something does not go as

planned

Preplan emergency and safety-concern codes (i.e., yes-or-no

questions) with another person; these codes should alert that

person to send emergency personnel to your location if needed

Schedule check-ins with a designated person on arrival and

after completion of the visit

Travel in a well-maintained vehicle appropriate for anticipated

terrain and weather conditions

Information from reference 30.

TABLE 2

Medicare Deﬁnition of Homebound

To be eligible for home health services, a Medicare beneﬁ-

ciary must meet both criteria

Criterion 1:

The patient must either:

Because of illness or injury, need the aid of supportive

devices such as crutches, canes, wheelchairs, and walk-

ers; the use of special transportation; or the assistance of

another person to leave their place of residence

Have a condition such that leaving their home is medically

contraindicated

If the patient meets one of the criterion 1 conditions, then

they must also meet two additional requirements deﬁned in

criterion 2.

Criterion 2*:

There must exist a normal inability to leave home

and

Leaving home must require a considerable and taxing eort

Additionally, the following should not disqualify a person

from being considered conﬁned to the home:

Participation in therapeutic, psychosocial, or medical treat-

ment in an adult daycare program that is licensed or state

certiﬁed

Any absence of short duration for the purpose of attending

a religious service

Any absence for the need to receive health care treatment

(e.g., ongoing outpatient kidney dialysis, outpatient chemo-

therapy, outpatient radiation therapy)

Any other absence from the home that is infrequent or of

relatively short duration

For examples of homebound status, see the Medicare Ben-

eﬁt Policy Manual (Chapter 7, §30.1.1)

*—Longitudinal clinical information documented in the patient’s

chart about their health status is typically needed to suciently

demonstrate a normal inability to leave the home and that leav-

ing the home requires a considerable and taxing eort. Clinical

information about the patient’s overall health status may include

the patient’s diagnosis, duration of the patient’s condition, clinical

course (i.e., worsening or improving), prognosis, nature and extent

of functional limitations, and other therapeutic interventions and

results. When determining whether the patient meets criterion 2 of

the homebound deﬁnition, it is important to note the illness or injury

for which the patient met criterion 1 and to consider the illness or

injury in the context of the patient’s overall condition. Physicians are

not required to include standardized phrases reﬂecting the patient’s

condition (e.g., repeating the words “taxing eort to leave the home”)

in the patient’s chart. Additionally, these types of phrases are not suf-

ﬁcient, by themselves, to demonstrate that criterion 2 has been met.

Adapted from Centers for Medicare and Medicaid Services. Medi-

care Beneﬁt Policy Manual: Chapter 7 – Home health services.

Accessed October 30, 2019. https:// www.cms.gov/Regulations-

and-Guidance/Guidance/Manuals/downloads/bp102c07.pdf

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HOUSE CALLS

medications is recommended to perform true medica-

tion reconciliation, in addition to checking for drug-drug

interactions.

While the patient is still seated, check vital signs, and

perform a focused examination. Once that is completed,

the physician should observe the patient as they stand

and note if they have diculty changing positions, need

an assistive device to stand (e.g., chair with arms, cane),

and how they move around the house (e.g., with a walker,

cane, grasping onto furniture). Ask permission to follow

the patient through the most frequented areas of the house

while observing the patient’s gait and noting any balance

issues. Looking for transitions in ooring; stairwells; rug

placement; pathway obstructions; height of chairs, bed,

and toilet; type of showers (walk-in vs. tub); and location of

smoke detectors, re extinguishers, and rearms helps pro-

vide an understanding of the patient’s functional status and

identify potential patient safety and fall hazards (Table 6).

TABLE 4

Recommended Supplies for House Calls

Physician supplies

Antibiotic ointment, hydrogel

ointment, petroleum jelly

Bacterial culture swabs

Bandage scissors

Batteries (including extra for

otoscope, ﬂashlight)

Cell phone

Cerumen spoons and ear

irrigation kit

Face mask

Flashlight

Gauze, tape, packing

materials

Gloves (sterile and nonsterile)

Glucometer, alcohol pads,

test strips, lancets

Hand sanitizer

Lubricant

Otoscope or ophthalmoscope

Patient address and directions

Phlebotomy equipment

Pulse oximeter

Reﬂex hammer

Sharps container

Sphygmomanometer (variety

of cu sizes)

Sterile specimen cups

Stethoscope

Tape measure

Thermometer

Toenail clippers

Tongue depressor

Tuning fork

Physician supplies (optional)

Catheters

Complementary alternative medicine supplies

(e.g., acupuncture supplies, osteopathic manip-

ulation table)

Device to access electronic health record

Dictation software or equipment

Disposable bed pads

Drug identiﬁcation and drug-drug interaction

checker on smartphone app, computer, or a

drug-reference manual

Externally worn hearing ampliﬁer

Garbage bags or biohazard bags

Hazardous materials suit (disposable) including

a mask and booties

Hemoccult cards and developer

Laptop computer with accessories

N95 disposable masks

Portable electrocardiograph machine

Saline ﬂushes, intravenous supplies

Silver nitrate sticks

Specimen cups

Splint or casting materials, crutches, external

musculoskeletal brace

Suture kit, small forceps, scalpel, staple remover

Syringes and needles

Vaccines (properly stored)

Vaginal speculum

Venipuncture supplies

Wound care supplies (i.e., sterile and nonsterile

gauze, silver impregnated [antibacterial] gauze,

iodine impregnated [antibacterial] gauze, methy-

lene blue dressing [antifungal], thin hydrocolloid

dressings, staples, sutures, replacement collection

bags, tape, wound vacuum supplies, or other sup-

plies based on wound care needs of the patient)

Patient supplies

CPAP (continuous positive airway pres-

sure) or other home breathing machine

Glucometer and glucose testing supplies

Home blood pressure monitor

Nebulizer

Peak ﬂow meter

Scale

Documentation

Advance document preparation (e.g.,

names, phone numbers, policies, scope

of services, advance directives, ques-

tionnaires, patient forms)

Billing documentation

Business and appointment reminder

cards

Cognitive assessment tools (e.g., Mini-

Cog, Mini-Mental State Examination,

Montreal Cognitive Assessment, Saint

Louis University Mental Status, Lawton

Instrumental Activities of Daily Living,

Katz Index of Independent Activities of

Daily Living, Mini Nutritional Assessment

[Nestle Nutrition Institute], Geriatric

Depression Scale, Screen for Caregiver

Burden, Clinical Assessment of Driv-

ing-Related Skills)

List of essential community resources

and services with websites (e.g., https://

www.care giver.org/family-care-navigator,

https://alz.org, https://family doctor.org,

http://www.Healthy Aging.org, https://

www.aafp.org/afp/handouts/view All.htm)

Medication reconciliation list

Patient record

Prescription pad, laboratory slips,

radiology forms

Adapted with permission from Unwin BK, Tatum PE III. House calls. Am Fam Physician. 2011; 83(8): 929, with additional information from reference 31.

216 American Family Physician www.aafp.org/afp Volume 102, Number 4

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August 15, 2020

HOUSE CALLS

Provide written safety recommendations to the patient

and caregiver addressing all urgent concerns and provide

additional comments based on ndings from the completed

checklist. Some durable medical equipment recommenda-

tions, such as hospital beds, may be covered by insurance,

including Medicare Part B; however, other equipment, such

as grab bars or shower chairs, is not typically covered by

insurance. e use of assessment tools (Figure 1

) can be

incorporated into the house call based on the complexity of

the patient’s condition, the time allowed, and the purpose of

the visit. Having an in-depth discussion of end-of-life care

choices, guided by the patient’s goals, may be appropriate,

even if they have already been addressed in a clinic or hos-

pital setting. End-of-life care choices should be conrmed

or readdressed as the patient’s health care situation changes.

Providing prescriptions, supplies, handouts with helpful

websites, or local resources communicates further support

to the patient and caregivers.

Incorporating House Calls into Oce-Based

Practice

e benets of house calls are substantial for physicians and

their patients. Physicians experience a change of pace from

typical clinic appointments, and house calls can provide

additional important information about the patient, includ-

ing insight into a patient’s actual home situation, medication

management, diet, and overall lifestyle. Patients report expe-

riencing peace of mind, increased respect and trust in their

physicians, and better access to care aer a house call.

2,4,33

However, integrating house calls into oce-based practice

is challenging. Barriers include geography, travel time, and

perceived loss of revenue.

Grouping house calls together

within a half-day, grouping locations, and conducting the

visits aer the conclusion of a clinic day may minimize this

barrier. A multidisciplinary strategy for house calls can help

decrease physician burden and improve care. e care team

commonly includes a customized combination of a physical

therapist, occupational therapist, speech therapist, dieti-

cian, licensed social worker, clinical pharmacist, licensed

practice/vocational nurse, registered nurse, psychiatric

nurse, wound care nurse, and nurse practitioners or phy-

sician assistants. With a multidisciplinary team, improved

tracking and scheduling of patients can optimize time man-

agement, allowing for greater spacing and eciency of phy-

sician visits, and can decrease loss to follow-up.

A travel bag, dedicated house call vehicle, and a mobile

oce are tools that help keep house calls organized.

Besides regular oce equipment needed for a focused

examination and gathering vitals, an emergency supply kit

(Table 5

18,29,32

) may be useful. House calls for dying patients

are unique because of the symptoms and treatment needs

specic to that population. American Family Physician

has previously published an article on managing common

symptoms in end-of-life care.

Additional specialized

equipment may be necessary based on the patient’s needs

(Table 4

18,31

). It is important to have a good understanding

of patients’ individualized needs and commit to goals for

the visit in advance. When applicable, physicians should

provide educational materials, medication reconciliation

forms, do-not-resuscitate and do-not-intubate forms,

out-of-hospital resuscitation forms, home health forms,

and hospice-required documents.

Documentation for a house call is similar to that for an

oce visit. A note template can help with consistent doc-

umentation and serve as a checklist (eFigure A). Recom-

mendations for continued care and changes to the care plan

TABLE 5

Suggested Emergency Kit Supplies

Condition Treatment

Acute coronary

syndrome

Nonenteric-coated aspirin to be chewed

Nitroglycerin

Agitation and

delirium

Risperidone (Risperdal) or haloperidol

Allergic reaction Epinephrine autoinjector

Dehydration Intravenous ﬂuids, infusion set, butter-

ﬂy needles (21-gauge), tape, occlusive

dressing

Dyspnea Benzodiazepine* for subcutaneous or

sublingual administration

Albuterol inhaler with spacer

Opioid† for subcutaneous or sublingual

administration

Heart failure Furosemide (Lasix) for subcutaneous

administration

Hypoglycemia Glucose tablets, glucagon kit

Pain Opioid† for subcutaneous or sublingual

administration

Seizure Benzodiazepine‡

Trauma Tourniquet for extremity injuries

*—Consider lorazepam (Ativan, 2 mg per mL) for patients receiving

hospice services.

†—Consider morphine, 20 mg per mL sublingual administration, for

patients receiving hospice services.

‡—Consider diazepam (Diastat, 10 mg) for rectal administration.

Information from references 18, 29, and 32.

August 15, 2020

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Volume 102, Number 4 www.aafp.org/afp American Family Physician 217

HOUSE CALLS

should be included in the documentation with proper cod-

ing and billing information (eTable A).

Direct Primary Care and Concierge Medicine

House Calls

DPC is an innovative practice model that oers patients a

variety of primary care services for a low, periodic member-

ship fee.

34,35

Integrating house calls into this type of practice

may be easier because the DPC model enables physicians

to spend more time with patients, and DPC physicians typ-

ically have smaller panel sizes. According to Phil Eskew,

DO, founder of DPC Frontier, there were more than 1,100

DPC practices in the United States in 2019, and 68% of these

practices oered house calls, including eight practices that

were completely mobile (i.e., had no actual oce). House

calls may be included as part of the membership, or DPC

FIGURE 1

Sample House Call Checklist (Based on the INHOMESSS Mnemonic)

Impairments/immobility

Evidence of cognitive impairment?

l Yes l No

Demonstrated activities of daily living (check

problem areas):

l Ambulating

l Bathing

l Continence (bowel/bladder/both)

l Feeding

l Toileting

l Transferring

Demonstrated instrumental activities of daily

living (check problem areas):

l Driving

l Finances

l Housework

l Meal preparation

l Shopping

l Taking medications

l Telephone

l Transportation

Demonstrated advanced activities of daily

living (check all that apply):

l Employment/volunteering

l Hobbies

l Music

l Reading

l Socialization

l Other

Falls assessment (follow CDC-STEADI algo-

rithm [https://www.cdc.gov/steadi/materials.

html]; check all problem areas):

l Balance (consider 30-Second Chair

Stand [https://www.cdc.gov/steadi/pdf/

STEADI-Assessment-30Sec-508.pdf]

and 4-Stage Balance Test [https://www.

cdc.gov/steadi/pdf/4-Stage_Balance_

Test-print.pdf])

l Gait (consider using the Timed Up &

Go Assessment [https://www.cdc.gov/

steadi/pdf/TUG_Test-print.pdf])

l Strength

Left: arm swing, stance, leg swing, step

Right: arm swing, stance, leg swing, step

Sensory impairments (check problem areas):

l Hearing

l Smell

l Tactile

l Taste

l Vision

Comments:

Nutritional status and eating habits

Variety and quality of foods

Freezer:

Pantry:

Refrigerator:

Other food storage/sources:

Description of daily eating habits:

Nutritional status (consider using Mini Nutri-

tional Assessment [www.mna-elderly.com])

Malnutrition:

Obesity:

Other:

Fluid intake:

Alcohol presence/use:

Swallowing diculty:

Oral health:

Comments:

Home environment

Neighborhood safety:

Exterior of home:

Interior of home (check all that apply):

l Books

l Crowding/hoarding

l Good housekeeping

l Hominess

l Information and communication

technology

l Internet

l Memorabilia

l Pets

l Privacy

l Television

Comments:

Other people

List name of caregiver(s):

Tasks:

Abuse concerns?

Coping?

Hours of caregiving per day:

Need for respite?

Physically or emotionally capable?

Stress? l Yes l No

Social supports? l Yes l No

If yes, what is/are their greatest source(s) of

social support?

If no, were community resources pro-

vided?

Living will? l Yes l No

If yes, where is it located?

If no, were resources provided?

Advance directives (https://polst.org/;

https://prepare for your care.org)?

l Yes l No

If yes, where are they located?

If yes, has the patient provided an updated

copy for the medical record?

If no, were resources provided today?

Medical power of attorney? l Yes l No

If yes, whom (list all):

If no, were resources provided today?

Consider this resource for downloadable

state-speciﬁc medical power of attor-

ney (https:// www.aarp.org/care giving/

financial-legal/free- printable- advance-

directives/)

Code status (check all that apply):

l Do not intubate

l Do not resuscitate

l Full code

Documented discussion of patient’s care

goals? l Yes l No

If yes, is this information current (recom-

mend updating information after any major

changes in the patient’s health condition)?

If no, what was the date of the last discus-

sion of patient care goals?

Financial resources:

Comments:

continues

INHOMESSS = impairments/immobility, nutrition, home environment, other people, medications, examination, safety, spiritual health, services.

218 American Family Physician www.aafp.org/afp Volume 102, Number 4

◆

August 15, 2020

HOUSE CALLS

physicians may charge a at rate or a variable amount based

on travel time or mileage.

Although DPC physicians oen provide house calls to

older adults and to patients who are disabled, terminally

ill, and to patients who are homebound, some physicians

may also oer newborn visits and well-child examina-

tions. Additionally, house calls are commonly made for

sick visits and postoperative care. Large families or fam-

ilies with young children may benet from house calls

because of the convenience and comfort of seeing multi-

ple members at once in a familiar and safe environment.

DPC physicians report that oering house calls is useful

for recruiting new patients, and families appreciate the

home-based service.

Concierge practices also routinely oer house calls but

charge higher membership fees and may continue to bill

insurance for covered services.

Concierge practices may

also provide hotel calls for travelers seeking more personal,

convenient care.

This article updates a previous article on this topic by Unwin and

Tatum.

Data Sources: A PubMed search was conducted using the key

terms home visits, house calls, home-based primary care,

post-hospitalization visits, homebound, and direct primary care.

FIGURE 1 (continued)

Sample House Call Checklist (Based on the INHOMESSS Mnemonic)

Medications

Allergies to medications:

Dietary supplements:

Medication adherence? l Yes l No

Medications organized? l Yes l No

Multiple prescribers? l Yes l No

If yes, whom?

Date state-speciﬁc prescription monitoring

program last checked?

Nonprescription/over-the-counter drugs:

Polypharmacy? l Yes l No

Prescription medications (including date,

quantity, and prescriber name for controlled

substance):

Summary of medication discrepancies iden-

tiﬁed:

Written instructions:

Comments:

Examination

Blood pressure:

Cognitive assessment (e.g., Mini-Cog, Saint

Louis University Mental Status, Mini-Mental

State Examination, Montreal Cognitive

Assessment or other resources [https://mini-

cog.com/; http://aging.slu.edu/pdf surveys/

mental status.pdf]):

Depression screening (i.e., Geriatric Depres-

sion Scale [https://consultgeri.org/try-this/

general-assessment/issue-4.pdf]):

General physical condition:

Glucose:

Heart rate:

Height:

Incontinence assessment:

Pain assessment:

Pulse oximetry:

Respirations:

Unintended weight loss? l Yes l No

If yes, include percentage and time period

over which weight loss occurred.

Urinalysis:

Weight:

Other:

Findings from focused examination:

Comments:

Safety

Assess the following for safety concerns.

Document ﬁndings and recommendations

for correction in the comments section

(check all that apply):

l Access to emergency services

l Adaptations/modiﬁcations to home

needed

l Alternative power source if needed

l Bathroom

l Carpets, rugs, and other transitions in

ﬂooring

l Cell phone availability

l Electrical cords

l Emergency plans, bracelet or necklace

that alerts emergency personnel

l Evacuation route

l Fire and smoke detectors

l Fire extinguishers

l Gas or electric range

l Heating and air-conditioning

l Hot water heater

l Internet availability

l Kitchen

l Lighting

l Stairs

l Tables, chairs, and other furniture

l Water source

Comments:

Spiritual health (or cultural and ethnic inﬂu-

ences):

Obtain a spiritual history (https:// smhs.gwu.

edu/gwish/clinical/fica/spiritual-history-tool)

Religious services/support? l Yes l No

Comments:

Services

Assess access to/response time/recent use

of the following services:

l Assistant/visiting angels

l Emergency medical services

l Financial advisor

l Fire department

l Food delivery service/Meals on Wheels

America

l Health beneﬁt advisor

l Home health agency

l Home health equipment

l Hospice agency

l Lawn care services

l Legal services

l Means of transportation

l Pet care services (if applicable)

l Police

l Social services

Comments:

INHOMESSS = impairments/immobility, nutrition, home environment, other people, medications, examination, safety, spiritual health, services.

Adapted with permission from Unwin BK, Tatum PE III. House calls. Am Fam Physician. 2011; 83(8): 928.

August 15, 2020

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Volume 102, Number 4 www.aafp.org/afp American Family Physician 219

HOUSE CALLS

The search included systematic and clinical reviews, meta-

analyses, reviews of clinical trials and other primary sources, and

evidence-based guidelines. Also searched was the Cochrane

database. References from these sources were consulted to

clarify the statements made in publications. Search dates: April

2019, August 2019, December 2019, and March 2020.

The opinions and assertions contained herein are the private

views of the authors and are not to be construed as the o-

cial policy or position of the Department of Defense or the

U.S. government.

The Authors

CAITLYN M. RERUCHA, MD, MSEd, FAAFP, is an assistant

professor in the Department of Family Medicine at the Uni-

formed Services University of the Health Sciences, Bethesda,

Md., and is a military physician stationed at Fort Bragg, N.C.

RUBEN SALINAS, JR., MD, FAAFP, is a geriatrician and faculty

family physician at the Carl R. Darnall Army Medical Center

Family Medicine Residency Program, Fort Hood, Tex.; an

assistant professor in the Department of Family Medicine at

the Uniformed Services University of the Health Sciences;

and an assistant professor at Texas A&M Health Science Cen-

ter College of Medicine, Temple.

JACOB SHOOK, DO, is a military physician at Fort Richard-

son, Alaska. At the time this article was written, he was a

senior resident in the Carl R. Darnall Army Medical Center

Family Medicine Residency Program.

MARGUERITE DUANE, MD, MHA, FAAFP, is an adjunct

associate professor in the Department of Family Medicine

at Georgetown University, Washington, D.C.; an associate

physician at Modern Mobile Medicine, a direct primary care

house call–based practice, in Washington, D.C.; and the

TABLE 6

Home Safety Assessment

Bathroom

Are handholds sturdy and in appropriate places?

Can the toilet seat be reached?

Does the bathtub or shower have a nonslip surface?

Is the bathroom ﬂoor slick?

Drug use

Is there evidence of tobacco, alcohol, or other illicit drug use

in the home?

If yes, is the substance used by the patient or other inhabi-

tant of the home?

Electrical cords/appliances

Are cords frayed or damaged?

Do cords cross walking paths?

Emergency actions/evacuation route

Are emergency numbers available?

Does the patient carry on their person a mode of contacting

emergency services (e.g., bracelet or necklace that alerts

emergency personnel, cell phone)?

Are do-not-resuscitate and do-not-intubate forms displayed

in a location easily spotted by emergency service personnel?

Are there means of egress from home?

Firearms

Are ﬁrearms present?

If yes, are they secured? (e.g., gun lock, locked case or cabi-

net, weapon and ammunition separated)

Who knows how to access?

Fire extinguishers

Are ﬁre extinguishers present?

If yes, are they accessible and in working order?

Is the patient or caregiver able to use them?

Heating and air conditioning

Are controls accessible and easy to read?

Is the home an appropriate temperature year-round?

Hot water heater

Is the temperature set below 120°F (49°C)?

Kitchen safety (especially gas stoves)

Is it easy to tell if a burner is on or open gas ﬂame is present?

Does the patient wear loose garments while cooking?

Where is food stored? Is the food expired?

Lighting and night-lights

Is lighting present and sucient throughout the main living spaces?

Loose carpets and throw rugs

Are carpets and throw rugs present?

If yes, do they need to be secured or removed to prevent falls?

Pets

Are pets present?

If yes, are they easy to care for?

If yes, are they likely to be a fall hazard?

Smoke detectors and carbon monoxide monitors

Are they present?

If yes, are they functioning and monitored?

Stairs

Does the home have external or internal stairs?

If yes, are they carpeted and is the carpeting secured?

Are the stairs well lit?

Are there railings?

Are assistive devices (ramps, chairlifts) present or needed?

Tables, chairs, furniture

Is the furniture sturdy, balanced, and in good repair?

Utilities

Are the systems monitored and maintained?

Water source

Is water from a public source or a well?

Is the source functioning and safe?

Adapted with permission from Unwin BK, Tatum PE III. House calls. Am Fam Physician. 2011; 83(8): 929.

220 American Family Physician www.aafp.org/afp Volume 102, Number 4

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August 15, 2020

HOUSE CALLS

cofounder and executive director of Fertility Appreciation

Collaborative to Teach the Science, a collaborative project of

the Family Medicine Education Consortium, Dayton, Ohio.

Address correspondence to Caitlyn M. Rerucha, MD, MSEd,

FAAFP, Battalion Surgeon, Bldg. X-4836 Chaos Lane, Fort

Bragg, NC 28310 (email: cmreruchamd@ gmail.com). Reprints

are not available from the authors.

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31. Yang M, Thomas J, Zimmer R, et al. Ten things every geriatrician should

know about house calls. J Am Geriatr Soc. 2019; 67(1): 139-144.

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33. Hayashi J, Christmas C, Durso SC. Educational outcomes from a novel

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34. American Academy of Family Physicians. Direct primary care. Accessed

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model: how it works. Accessed December 19, 2019. https:// www.aafp.

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direct-primary-care-vs-concierge-medicine-which-is-right-for-you/

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Volume 102, Number 4 www.aafp.org/afp American Family Physician 220A

HOUSE CALLS

eFIGURE A

Comprehensive Geriatric Note Template

Type of (or reason for) house call

l Care coordination (e.g., visit with care-

givers, other professionals, transition of

care evaluation)

l Evaluation of geriatric syndromes (e.g.,

frailty, falls, cognitive impairment)

l Missed appointments

l Patient request

l Patient safety concerns (e.g., envi-

ronmental assessment, medication/

polypharmacy evaluation, abuse con-

cerns, mobility issues)

l Terminal illness

Chief problem/history of the present illness:

Medical history (ﬁll this section out using the

patient’s health record before the visit):

Advance directives

Code status:

Copy in medical record? l Yes l No

Copies obtained for medical records:

Living will? l Yes l No

Location of documents:

Medical power of attorney? l Yes l No

Location of documents:

Patient/caregiver notiﬁed to provide copies:

Allergies:

Medication list (from inpatient/outpatient

note. Delete medications that are not found

in home):

Additional medications and supplements

found in home:

Impairments/immobility

Activities of daily living:

Bathing:

Continence:

Dressing:

Feeding:

Toileting:

Transfer:

Instrumental activities of daily living:

Doing housework:

Medication use:

Paying bills:

Preparing meals:

Shopping for food:

Telephone use:

Balance and gait problems:

Sensory impairment:

Nutrition

Meals/source:

Nutritional status:

Variety and quality of food:

Home environment

Patient is currently living in:

Type of home (apartment, townhouse,

single-story house, multiple-story house

with stairs, retirement community, nursing

facility):

Size and accessibility of home:

Patient is currently living with:

Other people (list names)

Financial resources:

Living will:

Medical resources:

Power of attorney:

Social support:

Subjective:

Medications

Medication adherence? l Yes l No

Medication list:

Medication organized with list of medication

readily available:

Medication polypharmacy assessed:

Safety, spiritual health, and services

Bathroom:

Electrical cords:

Emergency plans/evacuation route:

Fire extinguisher:

Fire/smoke detectors:

Floors:

Furniture:

Home health services:

Home monitoring/alarm service:

Kitchen:

Lighting:

Spiritual health:

Stairs:

Water source:

Examination

Vital signs:

Physical examination

General:

Head, eyes, ears, nose, and throat:

Neck:

Cardiovascular:

Respiratory:

Abdominal:

External:

Skin:

Neurology:

Special testing:

Assessment and plan

Referral for additional skilled services needed

(e.g., physical therapy, occupational therapy,

speech, nursing, clinical pharm.):

Community referrals (e.g., food resources,

transportation, medication management, day

programs/respite care, case management):

Family follow-up:

Next appointment:

Current procedural terminology coding

(low- to high-severity and complexity)

New patient home visit: 99341-99345

Established patient home visit: 99347-99350

Domiciliary or rest home visit, new patient:

99324-99328

Domiciliary or rest home visit, established

patient: 99334-99337

Care plan oversight: 99339 (15 to 29 min-

utes); 99340 (30 minutes or more)

Advance care planning: 99497 (15 to 29

minutes); 99498 (add on for each additional

30 minutes)

Information from:

Perissinotto C, Aronson L. Housecalls tips sheet. University of California San Francisco. Accessed April 13, 2020. https://geriatrics.ucsf.edu/sites/

geriatrics.ucsf.edu/ﬁles/2018-06/housecallstipsheet.pdf.

Unwin BK, Tatum PE III. House calls. Am Fam Physician. 2011;83(8):928.

BONUS DIGITAL CONTENT

220B American Family Physician www.aafp.org/afp Volume 102, Number 4

◆

August 15, 2020

HOUSE CALLS

eTABLE A

House Call Coding and Billing Information

CPT codes 99341 – 99350 are home service codes used to report evaluation and management services provided to a patient

residing in their own private residence (POS code 12).

Home services: new patient

99341 Level 1, low severity problem, 20 minutes

99342 Level 2, moderate severity problem, 30 minutes

99343 Level 3, moderate to high severity problem, 45 minutes

99344 Level 4, high severity problem, 60 minutes

99345 Level 5, patient is unstable or signiﬁcant new problem requiring immediate attention, 75 minutes

Home services: established patient

99347 Level 1, self-limited or minor problem, 15 minutes

99348 Level 2, low to moderate severity problem, 25 minutes

99349 Level 3, moderate to high severity problem, 40 minutes

99350 Level 5, patient is unstable or signiﬁcant, new, high-severity problem requiring immediate attention, 60 minutes

CPT codes 99324 – 99337 are domiciliary, rest home, or custodial care services codes and are used to report evaluation and

management services provided to patients living in a facility that provides room, board, and other personal assistance services,

generally on a long-term basis (POS codes 13, 14, 33, and 55).

Domiciliary (assisted living, group home), rest home, or custodial care visits: new patient

99324 Level 1, low severity problem, 20 minutes

99325 Level 2, low to moderate severity problem, 30 minutes

99326 Level 3, new patient, moderate to high severity problem, 45 minutes

99327 Level 4, new patient, high severity problem, 60 minutes

99328 Level 5, new patient, high complexity problem, 75 minutes

Domiciliary (assisted living, group home), rest home, or custodial care visits: established patient

99334 Level 1, established patient, self-limited or minor problem, 15 minutes

99335 Level 2, established patient, low to moderate severity problem, 25 minutes

99336 Level 3, established patient, moderate to high severity problem, 40 minutes

99337 Level 4, established patient, unstable or signiﬁcant new problem, 60 minutes

Care plan oversight

99339 Supervision of patient requiring complex or multidisciplinary care, 15 to 29 minutes

99340 Supervision of patient requiring complex or multidisciplinary care, 30 minutes or more

Advance care planning evaluation and management services

99497 Advance care planning including the explanation and discussion of advance directives such as standard forms, face-to-face

with the patient, family members, or surrogate, ﬁrst 30 minutes, minimum 15 minutes

99498 Each additional 30 minutes, list separately and in addition to the code for the primary procedure

continues

CPT = current procedural terminology; POS = place of service.

August 15, 2020

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Volume 102, Number 4 www.aafp.org/afp American Family Physician 220C

HOUSE CALLS

eTABLE A (continued)

House Call Coding and Billing Information

This information applies to public and private health insurance billing for patients of all ages.

The time spent includes telephone calls to other health professionals (not patient family members or caregivers) ordering and

reviewing tests. When applicable, document 30 minutes of time spent coordinating care unrelated to a face-to-face visit.

CPT codes for prolonged services should be used in conjunction with time-based companion codes:

99354, for other outpatient setting, with direct patient contact, ﬁrst hour.

99355, for each additional 30 minutes.

Place of service codes

POS 12 Private residence – patient home, apartment, townhome, etc.

POS 13 Domiciliary care facility – A home providing mainly custodial and personal care for people who do not require medical or

nursing supervision, but may require assistance with activities of daily living because of physical or mental disability (e.g.,

assisted living facility, adult living facility, “sheltered living environment”).

POS 14 Group, rest, or boarding home – A place where people live and are cared for when they cannot take care of themselves.

POS 33 Custodial care facility – Any facility that provides non-medical assistance with the activities of daily life (e.g., bathing, eating,

dressing, using the toilet) for someone who is unable to fully perform those activities without help.

POS 55 Residential substance abuse facility – A facility that provides treatment for substance (alcohol and drug) abuse to live-in

residents.

Checking with the billing department of a patient’s hospice agency for proper documentation and coding tips can help prevent

rejected claims.

Home services are billable to home health agencies in the community. A CMC-485 form must be reviewed and signed.

G0180 Home health certiﬁcation, $53.00

G0179 Home health recertiﬁcation, $44.17

G0181 Home health care, $104.31

G0182 Hospice supervision, $105.67

Eective January 1, 2019, the Centers for Medicare and Medicaid Services announced in the 2019 Physician Fee Schedule Final Rule

that documenting the medical necessity of a home visit instead of an oce visit is no longer needed for billing purposes.

CPT = current procedural terminology; POS = place of service.

Information from:

American Academy of Family Physicians. Advance care planning. Accessed October 30, 2019. https:// www.aafp.org/practice-management/pay-

ment/coding/medicare-coordination-services/acp.html

American Academy of Home Care Physicians. Making house calls a part of your practice. American Academy of Home Care Physicians; 2009.

Accessed June 1, 2019. https:// www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeesched

American Academy of Pediatrics. Coding for medical home visits. Accessed December 19, 2019. https:// www.aap.org/en-us/professional-

resources/practice-transformation/getting-paid/Coding-at-the-AAP/Pages/Coding-for-Medical-Home-Visits.aspx

Department of Health and Human Services. Billing Code 4120-01-P. Accessed November 4, 2019. https:// s3.amazonaws.com/public-inspection.

federalregister.gov/2018-24170.pdf

Noridian Healthcare Solutions. Home and domiciliary visits. Updated August 7, 2019. Accessed December 19, 2019. https:// med.noridianmedicare.

com/web/jfb/specialties/em/home-and-domiciliary-visits