Is a Modernized “Once Upon a Time” Model of Care the Cure for Rural America’s Healthcare Ills?
Home-based primary care, also known as home-based medical care, or primary care house calls, is not the house call of the past. Practitioners today drive SUVs instead of a horse and buggy and carry a cell phone instead of a black bag.
House calls, once a staple of rural medical care disappeared as a model of care when office-based technology like x-rays, CT scans, and sophisticated lab work required patients to visit an office for care. Medical appointments have become more than just a trip to the family doctor. Non-hospital medical facilities offer not only medical appointments, but labs, diagnostics, and even surgical procedures, as well.
However, advances in medical technology are turning the tide once again, making traditional office-based medicine not exactly a thing of the past, but one of the many sites-of-care options available to today’s patient. Advanced technology in the home is a reality.
Along with changes in technology, the changing nature of the practitioner is bringing care back home to the patient. No longer do patients only see the family physician for their primary medical care. They may see a nurse practitioner or physician assistant. They may see that person in a traditional medical office, a rapid care clinic, a pharmacy, or in their own homes. These non-traditional providers are growing in number; the majority are women, and many choose to serve at-risk populations.
Changes in technology, practitioners, public preference, and the financial realities of healthcare in the 21st century are combining to bring back the house call. But it isn’t yesterday's house call.
Today’s house call practitioner can do as much in the home as many physicians do in their offices. EKGs, X-rays, phlebotomy, even some minor surgeries – can all be performed in the home. Cell phone cameras, Bluetooth and wi-fi technology allow practitioners to connect with specialists for onsite consultations and allow for remote monitoring.
A recent study revealed that Nurse Practitioners are highly suited to this model of care, more likely to find it fulfilling and more likely to remain in the field. House call visit reimbursements are lower than those of office-based visits, making physicians with high student loan debt less likely to enter a field that makes loan repayment more challenging. Nurse practitioners have less debt overall, and the study revealed they tend to be more entrepreneurial than their physician counterparts. The greatest challenge to nurse practitioners who enter the home-based primary care field is scope of practice restrictions that exist in most states.
Americans increasingly seek personalized service and convenience. The pandemic showed that people could work from home and get their meals, groceries, and other household items delivered. Customers can have car windshields and tires replaced in their driveways, get their nails done in the home, and even have their dog’s nails groomed at the same time. Patients with increasingly busy lives or who are unable to get to medical appointments due to transportation or health issues are demanding care in the home.
The spiraling cost of health care is a familiar subject. Federal, state, and local efforts to contain or reduce spending have largely been unsuccessful. Chronically ill patients account for the vast majority of healthcare costs in the U.S.; 5% of Medicare patients account for approximately 50% of Medicare spending. The fundamental reason for this disproportionate spend is lack of access to primary care. Patients in the 5% are among the sickest in the U.S., with multiple chronic conditions. These conditions make it difficult if not impossible to get to a healthcare provider. As a result, when these patients' conditions worsen or become acute, they rely on the 911 system for care. Many states require hospital admission following a 911 call, regardless of necessity. The ER treats the presenting condition – it’s what they do best – but they do not provide proactive primary care. Primary care is simply not in their scope of responsibilities. As a result, chronically ill patients often end up in a downward spiral of repeat ER visits and hospitalizations.
Why Does This Matter for Rural Healthcare?
Approximately 60 million Americans reside in what the Census Bureau defines as rural areas (essentially, outside an urban center), about 19% of the U.S. population. Idealized versions of rural and small-town America paint an attractive picture, a slower, safer pace of life, wide open spaces, friendly neighbors, a healthy place to raise a family or retire. Sadly, however, that nostalgia-tinted version of the small town has become largely the stuff of fiction. When jobs moved out of the small towns, poverty and drug use often moved in. Health profiles of U.S. counties reveal that rural Americans face numerous issues, chronic health conditions and access to healthcare among the most pressing. The USDA’s Rural Information Hub cites high poverty rates, a higher percentage of older adults – who are more likely to have chronic health problems, residents without health insurance, high rates of substance abuse, and high rates of chronic health problems such as obesity and high blood pressure as factors contributing to the rural healthcare crisis.
Unfortunately, as jobs moved to the cities, so did healthcare providers, limiting access to proactive, preventive care. Few healthcare options remain for residents of rural small-town America outside of traveling to more populous cities and towns. Even then, many parts of the U.S. have difficulty filling specialist positions. Federally Qualified Health Centers and Rural Health Clinics increase access to care but patients must leave their homes to access that care and Rural Health Clinics are not required to provide preventive care. Rural Americans, perhaps more than any other group, could benefit from proactive Home-Based Primary Care practitioners who address chronic conditions, identify mental health and substance abuse issues, and assess social determinants of health. Home-based primary care is proven to improve patient outcomes, reduce ER visits and hospitalizations, improve patient satisfaction, and reduce healthcare spending. Home-based primary care providers visit patients not only to provide care but to build relationships. Those relationships build trust. Trust between a provider and patient increases compliance – better adherence to medical instructions, and improved health behaviors. In addition, a house call provider’s unique perspective on the realities of a patient’s home life helps that provider understand which community-based services might be brought to bear on a patient’s situation. Some areas of the U.S. are hard-pressed to provide a wide range of community-based services, but at least the patient has an advocate in the provider.
A program that supports home-based primary care practitioners – not only increasing access to care but establishing healthcare advocates for rural Americans – would positively impact healthcare quality and overall quality of life. Much is needed, however, to attract and retain qualified providers in rural settings, home or clinic-based. While some are attracted to the less hectic pace of small-town or rural life, practitioners have legitimate concerns with professional isolation and lack of career advancement opportunities. Those with spouses and children see few career prospects for working spouses and are concerned about gaps in learning opportunities between rural and more metropolitan school systems. At a minimum, programs that offer student loan forgiveness, housing and transportation stipends, and competitive wages are necessary to attract quality home-based primary care providers. An AAMC (Association of American Medical Colleges) News & Insights post suggests that a critical component of growing the rural healthcare workforce is exposing students early to healthcare in rural settings and including rotations there during medical school. Attracting and retaining providers familiar with and undaunted by the challenges of rural practice could bring welcome change to this underserved healthcare population. It may be overly optimistic, but a patient population with fewer chronic healthcare woes and a more proactive eye toward their own wellness could be better able to cope with and navigate economic and societal change. Most important, the modern-day house call might well bring back more than just a welcome knock at the door. It might bring back a much-deserved sense of dignity to rural and small-town America and the people who live there.