By Sarah Klein
Soon after graduating from college, Daniel Stokar turned down a job offer from an accounting firm to start House Calls for the Homebound, a Brooklyn, N.Y.–based company that provides medical care to seniors in their homes.1 Stokar was joined in the venture by his grandfather—an internist who visited long-time patients in their homes—and his father, a software engineer. And together they built a business model that's been profitable in a sector that depends heavily on philanthropy.
One of the ways they did so was to concentrate their efforts in population-dense areas, creating efficiencies that ensured physicians didn't spend their days in traffic and could instead see 10 to 12 patients a day, the threshold necessary to sustain the business. They've also found it's been critical that doctors not spend time doing nonmedical tasks—such as gathering pill bottles or looking for parking—as a few minutes spent on each task accumulates to hours of their time. Instead, a medical assistant takes on these assignments.
The company now has a census of 800 homebound patients, many with multiple chronic conditions and complex medication regimens, who were referred to the service by area agencies on aging, community-based organizations, and home health agencies. Their patients receive visits as often as needed from a geriatrician or primary care physician, who in addition to developing a care plan focuses on activities known to reduce the risk of hospitalization and readmissions, such as medication reconciliation and patient and caregiver education. The doctors can also arrange for mobile X-rays, sonograms, and blood draws. And between visits, patients and their families can use a nurse hotline to ask questions or alert the doctor if additional help is needed.
When patients do need to go to the emergency department or hospital, 95 percent of admissions are orchestrated by the House Calls physicians, Stokar says, rather than the result of a call to 911, which helps to improve communication among the physicians caring for them. "Often these patients have dementia or Alzheimer's and they are not able to advocate for themselves. If the doctor had not been communicating with the emergency department, they would not know what that patient was there for or what medications they were taking." The company's doctors also consult with the discharging physicians and follow up with patients within 48 hours of their discharge. These high-touch handoffs may contribute to the company's readmission rate of less than 3 percent—results that make Stokar hopeful that House Calls for the Homebound will be able to enter into shared savings agreements with both public and private payers. For now, it relies on fee-for-service reimbursement from Medicare.
Even with the company's success, Stokar says the field is challenging. "All of the issues that doctors face and complain about in primary care in the office are exponentially exacerbated when you take doctors out of the office setting. The charting, scheduling, the electronic medical records—they are built on the assumption you are in a networked environment with a reliable Internet connection," he says. Because such connections can be a problem, especially in high-rise buildings, the team developed an "Office Anywhere" system that synchronizes a database of patients' charts with physicians' laptop computers each day.
The Independence at Home demonstration, if successful, may also give these programs a boost, says Sam Lupin, M.D., Stokar's grandfather and House Calls for the Homebound's medical director. "It's a great way to demonstrate the benefits of home-based primary care. By moving the care back to the community, we are able to provide these high-risk, frail seniors with the right care at the right time in the right setting. This directly achieves the triple aim: enhanced quality, improved outcomes, and a reduced cost."
1 House Calls for the Homebound is not part of the Independence at Home demonstration.
