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Vital Signs

Residents make themselves right at home

By Laura Evancich

Physician house calls are making a comeback—especially for the elderly. Although declared a vanishing practice 10 years ago, the number of U.S. house calls has risen from 1.4 million in 1998 to over 2 million in 2004, according to the Journal of the American Medical Association. About a year ago, Dartmouth- Hitchcock began requiring its general internal medicine residents to make house calls on geriatric patients.

Routine: Dr. Adam Schwarz, who heads the DHMC house calls project, suspects that many elderly people postpone coming in to have a routine checkup or even to see a doctor when they are ill because they are too frail to travel easily or lack transportation. Instead, they wait until they get so sick that they wind up in the emergency room or a hospital bed.

Although many patients are reluctant to ask their physicians to call on them, they "are universally appreciative [of] seeing doctors in their home," Schwarz says. Residents appreciate the opportunity to make house calls, too. They learn firsthand how patients' lifestyles or living conditions may help or hinder their illness, he explains. They are then better able to assess patients' functional status and to evaluate them for depression and cognitive impairment.

The household gets a "checkup," too. For example, the residents keep an eye out for tripping hazards, such as electrical wires stretched across a floor. They also assess patients' hygiene and nutritional status, evaluate their transportation and support systems, and check for other factors that can provide insights into their health. House calls add "another dimension to the ability to assess a patient's health risks to allow us to make health-care recommendations," says Dr. Sally Scott, a third-year resident.

The residents also make follow-up phone calls to "help solicit from the patient any concerns they have" about their health, says Schwarz. This allows doctors to map a patient's progression between visits. Although assumed by some to be an unaffordable luxury, house calls can actually be an economical option for patients who can't afford—or choose not—to reside in a nursing home, Schwarz adds. In recognition of that fact, Medicare's reimbursement rate for house calls has increased in recent years.

Choices: That's all to the good, Schwarz feels. For example, he says, "nursing homes are great places for half of their residents," but the other half would be better off in their own homes, if they had a good support system and proper outpatient care. "Your economic status doesn't predict successful aging," says Schwarz, but "it enhances options and choices."

The DHMC house calls project, which received initial funding from the New Jersey-based Arnold P. Gold Foundation, is a collaborative effort of the General Internal Medicine (GIM) Residency Program and the Dartmouth Center for Aging. Each GIM resident is required to take part in at least three house calls during his or her residency, as part of a team made up of an attending physician and one or two other residents.

Some 300 elderly residents of the Upper Valley are participating in the project as patients.

Relationships: Schwarz observes that he has found—from making about 100 house calls a year himself—that "80% of house calls is dialogue" with patients. "Even a brief sensitization to house calls," he maintains, increases physician awareness of the needs of geriatric patients and cultivates better doctor-patient relationships.

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