Do You Make House Calls? For Lee Memorial Doctor, the Answer is ‘Yes’

By Liz Freeman, The Naples Daily News

FORT MYERS — A modern-day version of a doctor who makes house calls pulls up in her Honda Civic, grabs her black carry-on bag on wheels, then heads inside with her portable computer and hand sanitizer.

Dr. Rabia Khan, an osteopath who specializes in geriatrics, lets patients ramble on a bit when she sees them in their home, knowing their contact to the outside world is restricted.

Her patients have something in common: All recently were discharged from a hospital run by the Lee Memorial Health System.

Hired by the public hospital system in October, Khan is heading up Lee Memorial’s House Calls program to head off Medicare reimbursement penalties and cuts that loom this coming October.

“You’re looking good. You’re looking better than you did last week,” she told Betty Dehmlow, 84, who lives in the Seven Lakes retirement community in Fort Myers.

Dehmlow, who has atrial fibrillation, chronic obstruction pulmonary disease and a compromised immune system, is troubled by her weakness and not being able to do anything for herself. She has a history of going to the emergency room every three weeks.

Khan’s goal is to put a halt to that, when possible, with Dehmlow and other recently discharged patients.

“One of the things (researchers) know is after a discharge within seven to 14 days, you should get back to your primary care doctor,” Khan said. “Some patients don’t have a primary care physician. Some don’t have insurance and some don’t have transportation.”

This fall, the federal Centers for Medicare & Medicaid Services will start penalizing hospitals that have a higher than expected 30-day readmission rate for patients with three conditions — heart failure, heart attack and pneumonia.

The penalty starts with a one percent reimbursement cut and will climb to three percent in subsequent years. The federal agency also intends to expand the penalties to other medical conditions and readmissions.

Nearly 2.3 million elderly Americans, or 20 percent of all Medicare patients, are back in the hospital within 30 days of being discharged, according to a study published in 2009 in the New England Journal of Medicine using data from 2003 and 2004.

The readmission cost to Medicare is huge, estimated at $17 billion out of the total $102 billion that Medicare paid to hospitals in 2004. Researchers said many of the readmissions could have been avoided.

Some reasons why patients are readmitted include premature discharge in the first place, poor medication management or inadequate care at home. Some suffered from a hospital-acquired infection.

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The penalty is making hospital administrators anxious for several reasons, not the least of which is that the federal agency isn’t excluding readmissions that have nothing to do with the targeted three conditions, said Nancy Foster, vice president for quality and patient safety policy with the American Hospital Association.

So, if a patient with a heart condition breaks an ankle at home and is rehospitalized within 30 days, it still counts.

“They were instructed to eliminate for unrelated readmissions but they did not,” she said.

In addition, the penalty is one percent of total Medicare payments for those three conditions and will be far in excess of what hospitals would have been paid by Medicare for any of those readmissions, she said.

“It tallies up really quickly,” Foster said.

The federal agency estimates 14 percent of U.S. hospitals will face the one percent payment cut this coming year but the Hospital Association believes that estimate is too low.

The house call approach is one that other hospitals are beginning to take, Foster said, such as at Boston University Hospital. Others are looking to develop ties to federally subsidized clinics; however, that won’t work in rural areas that don’t have those clinics, she said.

The NCH Healthcare System in Collier County is confident that its readmissions rate for heart failure, heart attack and pneumonia will be below the federal expectations to avoid the penalty, said Dr. Aurora Estevez, NCH’s chief medical officer.

Still, NCH has been taking part in the Hospital Association’s “no place like home” initiative, which has a goal of reducing readmissions by five percent each year for all causes, Estevez said.

In addition, NCH staff members are working with health-care entities on post-discharge care coordination.

“NCH physicians, case managers and nurses collaborate daily to make sure the timing of discharges are appropriate and that patients who go home have achieved competency in self-care and have appropriate follow-up care,” Estevez said. “Members of the NCH (registered nurse) case manager and social worker teams also meet monthly with the skilled nursing facilities and home health agencies to coordinate transitional care for patients.”

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Khan makes house calls three days a week for Lee Memorial. That includes seeing patients in assisted living units and skilled nursing centers. The program also has a nurse practitioner.

Khan likes the freedom of spending more time with each patient, compared to the confines of practice settings.

“We see between three and five (patients) a day. They must be home-limited,” she said.

Lee Memorial is modeling its house calls program after one at Orlando Regional Medical Center. Khan expects more hospitals will follow suit down the road.

During her second visit with Dehmlow in the patient’s apartment, Khan focuses on her reaction to medications and checks her vital signs. Khan can access all prior test results from her portable computer.

She gently emphasizes to Dehmlow that she needs to start physical therapy to get stronger. The patient resists.

“You can do the therapy here, if you want to stay home,” Khan said. “You are not too weak. You can handle it. Why don’t you give it a try?”

With each patient visit, Khan spends time making sure they understand their illness and what their medications can do and the side effects.

“Communication is huge from the inpatient world to the outpatient world,” Khan said. “When family is (nearby), we ask them if they want to be around for the appointment.”

Another of Khan’s recent house calls was to Felicia Lopez, 45, who lives east of Fort Myers. Lopez is morbidly obese and house-bound except when she was in the hospital in March. She suffers from heart failure, sleep apnea, fluid build-up and gastrointestinal problems. She’s on oxygen.

“I’m not sleeping, barely,” Lopez tells the doctor. She talks about the painful swelling in her legs and her stomach pains.

Khan has good news for Lopez this time around.

“The director of the sleep lab will set up for a respiratory technician to come in and get it electronically set up (here),” Khan tells her. “They are making an exception for you.”

Lopez is pleased; they also talk about weight loss medication and the side effects.

“She’s a good doctor and I think they need a lot more like her because there are a lot of patients who can’t get out to the doctor,” Lopez said. “For everything, you have to make it into the office and you can’t always make it into the office.”

Dehmlow, the Seven Lakes patient, agrees the home visits are good for her and others who are home-restricted.

“I don’t know what I would have done,” Dehmlow said. “I can’t get to the doctor’s office. I don’t drive.”

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