A Healthcare Team Without Doctors…Really???

There are 624,434 U.S. physicians (AHRQ, 2010), but only 0.6% of them would ever consider entering an Assisted Living Community (ALC) to provide on-site care.  There are more than 36,000 ALCs in the US caring for over 1 million fragile older adults (ALFA 2011), but you are literally more likely to be struck by lightning than to ever see a doctor walk through the doors of any of these communities!

The first ALC began in 1981 to care for the Founder’s mother who was in her early 60s (The History of Assisted Living, www.assistedlivinghistory.com).  These Communities were originally promoted to provide a supportive, primarily non-medical living environment to bridge the gap between independent living and the nursing home.  But the landscape for ALCs has dramatically changed since their inception.

The average age of an ALC resident is now 87 years (Harris-Wallace et al, 2011, Seniors Housing & Care Journal).  Thirty-seven percent of residents receive assistance with 3 or more activities of daily living (NCAL 2012), greater than half of the residents have 2 or more chronic medical conditions and are taking multiple medications having a variety of potential side effects, and 42% have at least some degree of memory impairment or dementia (NCAL 2012).

ALCs are no longer predominantly non-medical communities.  They have high acuity residents, and this will only intensify in the future due to a very competitive market as well as resident expectations to age in place and experience the progression of chronic medical conditions in one setting that provides ongoing care and monitoring.

In other words, times have changed.  But the problem is…our thinking hasn’t!  Our thinking is stuck back in the 1980s and hasn’t kept pace with the changing demands and expectations residents impose on ALCs.  The healthcare team that provides medical oversight of residents in ALCs is led either by non-medically trained administrators or by nurses with additional support from aides and assistants.  But there is a glaring omission:  WHERE ARE THE DOCTORS???

Just as in the 1980s, we keep hauling our residents off-site all over town to a variety of doctor’s offices just to get their basic primary care needs met.  But this isn’t the 1980s any longer!  These residents are 20 years older, much more fragile on average, and all these off-site trips are incredibly stressful not only on the residents but also their families as well as the ALCs and their employees.  We can and must do better!

It is no longer appropriate to be thinking as we did in the 1980s and have predominantly off-site physician care.  And it is no longer acceptable to have the supervisory medical team not include a fully engaged physician who provides on-site care.

ALCs and physicians MUST come together and meet the demand of caring for high acuity patients in the community setting.  The direction of modern healthcare delivery is TOWARD THE COMMUNITY to proactively keep people as healthy as possible at home and AWAY FROM HIGH COST INSTITUTIONS that only care for patients reactively after they become ill.  This reversal in the direction of healthcare delivery falls right in the laps of ALCs, and the pressure to care for higher acuity residents will therefore only increase.  This also means that on-site care by physicians offered to ALL residents should no longer be a luxury but MUST be a REALITY.

There are a few innovative healthcare models now available that encourage ALCs and physicians to each put “skin in the game” and come together as PARTNERS (http://housecalls-llc.com/articles/physicians-must-partner-with-retirement-communities-and-heres-why).  To meet the new demands that confront this partnership is surprisingly easy and not intimidating and can happen overnight.  The biggest obstacle is in our thinking:  WE MUST THINK DIFFERENTLY (http://housecalls-llc.com/articles/think-the-same-stay-the-same-think-differently-and-thrive/).

If we think differently…if we bring physicians and ALCs together as partners, we will discover that EVERYBODY  WINS!


The Future is Now: Doctors Contradict Business Model to Bring Back House Calls

What if your Retirement Community opened its doors to every employee from every health care company that wanted to get into its building to provide services – Home Health, Hospice, Personal Care, DME, PT/OT, etc.?  It would be over-run with literally hundreds of community employees roaming around everywhere!


Now, for an interesting contrast…

What if your Retirement Community opened its doors to all the local physicians seeking to provide on-site services?

HellOOooooo…Anybody there???


In one case – out of control chaos!  In the second – emptiness, silence…

Why?  Why this difference?

What’s the difference between doctors and all the rest of the community healthcare services that results in such disparity in where their services are performed?  Is it that doctors aren’t interested in providing on-site care in the community whereas everyone else is?  Hardly!  Doctors should be the leaders of a collaborative healthcare approach that includes all these services, so why are they “missing in action?”

The answer to this question is conspicuously absent in our Retirement Community dialogue, and understanding the answer is crucial to reversing this shortcoming.  The answer is the BUSINESS MODEL.  The business model for a doctor’s medical practice is completely opposite the business model of all the other services.

The doctor’s business model is that his practice is located in his office (http://housecalls-llc.com/articles/why-doctors-dont-go-to-retirement-communitiesunless/). This is where he has everything he needs to conduct his business.  You take him out of his office, and he’s helpless…he has none of the support he needs to conduct his medical practice – no exam room, no supplies, no  schedule, no receptionist, no billing clerk, no nurse, no medical assistant, no lab, no EKG, no x-ray.  Consequently, if patients want medical care, they must go to the doctor, or they simply don’t get care.  If you try to break this paradigm and encourage the doctor to go to the patient, the doctor’s medical practice becomes unprofitable because of the inefficiency that results from contradicting his business model.  And since no one can sustain a successful business by being unprofitable, doctors rarely practice outside their offices.

Contrast this with the OPPOSITE business model of nearly all the other healthcare services.  Their place of business is in the patient’s home.  Their business operates on the principle of providing home based care.  They don’t need to equip an office in which to provide their customary care, and so they couldn’t provide office based care even if they wanted to.

But there’s a way to bring doctors and community healthcare services together to work as a team in Retirement Communities.  This requires an innovative healthcare model that offers doctors the ability to contradict their usual paradigm and practice profitably on-site outside of their office (http://housecalls-llc.com/articles/physicians-must-partner-with-retirement-communities-and-heres-why/).

What if doctors were willing to adapt this new paradigm and reach out to Retirement Communities to provide regularly scheduled on-site full primary care services in the residents’ rooms?  Would this be the kind of valuable service a Retirement Community might consider investing in, assuming their investment was not cost prohibitive?  Or, would Retirement Communities continue with ‘business as usual’ and be unwilling to innovate and achieve what was previously unattainable – offering regularly scheduled on-site physician services to every resident?

Think the same, stay the same. Think differently, and thrive!

Think the same, stay the same.  Epitaph?  Or opportunity?  If you are a Retirement Community who thinks this way, then your competitors are silently thanking you.  That’s because, slowly but surely, they will be assimilating YOUR residents (or perhaps already are!).  Make no mistake about it…while you’re playing it safe and not investing in and promoting new services and amenities that distinguish YOU, your successful competitors are doing just the opposite.

Ask yourself:  what do we offer today that we didn’t offer 3 months ago, 6 months ago, a year ago, that brings real value and meaning to our residents and that truly distinguishes us?  Many Communities won’t have an answer, and their silence is just another nail in their coffin.

But to those of you who do have an answer, have you really promoted these services?  Do the homeowners and others who live and work within a 10 mile radius of your Retirement Community (where 70% of your referrals come from) even know what you offer and the ways you are different from your competitors?  Or is your advertising exactly the same as everyone else in your town?

What would be your response to a prospective resident or baby boomer family who were to ask you:  “What distinguishes YOU from all the other Communities we’re going to tour today?”  Would you have an immediate and enthusiastic response?  Or, would you find yourself mumbling and getting all tongue-tied attempting to escape a VERY uncomfortable, yet very basic and ESSENTIAL question.

A follow-up blog will be coming out soon that will offer a suggestion.  In the meantime, think about the following:


House Calls Featured in Idaho Business Review!

Most people see the physician’s house call as an anachronism. Steven Fuller sees the house call as his ticket into the ballooning health care industry.

Fuller, a physician who took care of open heart surgery patients in Washington, D.C., and Idaho for two decades, quit his practice a year and a half ago to design a system that he believes can bring back the days of the home doctor visit, at least for the elderly.
His company, House Calls, acts as a kind of general contractor for health care that brings doctors into assisted living, independent living and memory care retirement homes. For a monthly fee from the operators of the homes, Fuller organizes doctor visits, lab work and x-rays to be done inside living rooms, not offices.
Fuller said he always saw a need for house calls for the elderly when he ran his own practice, as transportation costs and other obstacles often kept seniors away from doctors’ offices.
“If they don’t come to the doctor, they don’t get care. That’s the current model,” Fuller said. “What we’ve done with House Calls is to reverse the doctors’ business model and allow them to profitably come out of their office and go to a retirement community to provide care.”
Fuller doesn’t pay any doctors or sign contracts with other mobile health services. His company organizes other private businesses that bill their usual rate. House Calls’ sales pitch is that they can pay for the administrative overhead it takes to court and schedule patients, while physicians simply have to show up with a doctor’s bag.
“I do not have any sort of guarantee with the physician, and I do not have any financial relationship with the physician whatsoever,” he said. “The only way I can keep his or her interest in continuing to work with us is if I do good service to the physician.”
Mark Phelan, a registered nurse and owner of Park Center Assisted Living, a memory care home in Boise, said he uses House Calls to help market his business to potential customers.
“This is probably the first time in three years that I have had a waiting list, and I attribute it to the fact that I can tell them we have our own physician,” Phelan said.
He said the service reduces transportation costs and provides his residents with better care. In an office setting, Phelan’s residents – most of whom have dementia – often behave very differently. The stress of getting out of their familiar environments make memory patients more on edge, or even hostile, and can affect the doctors’ treatment plan.
The model also gives Phelan the opportunity to give input to physicians about his residents’ treatment and a direct line to the doctor if paperwork needs to be changed or some other effort needs a doctor’s approval.
Phelan said he looked for a service like this for eight years before he found out House Calls had been formed.
Steve Millard, president and CEO of the Idaho Hospital Association, said he had never heard of this model in modern medicine, and he did not think it had been used in Idaho. But Millard said the model has the potential to fit nicely into the future of health care.
With more hospitals and larger health care providers moving toward a health care system where one large entity is charged with keeping an entire community healthy, with a set amount of funds, the House Calls business model could be used to prevent emergency hospitalization of the elderly and infirm, he said. Keeping emergency room visits and other catastrophic health problems down is a big money saver, he said.
“Even though it’s an old-time mechanism … I think it very well may be the wave of the future,” Millard said.
Fuller has made the model work so far, but he said it’s difficult to recruit doctors. His biggest challenge in starting the company was finding two doctors willing to do the work. The problem is that most assisted living residents use Medicare, and many private practice doctors do not accept Medicare patients because of low reimbursements and red tape.

Arthur C. Jones IV, a doctor who works with the company House Calls, examines a patient in an assisted living facility in Boise. Photo by Patrick Sweeney.



Arthur C. Jones IV, a physician with a clinic in Eagle, said he agreed to work with House Calls because he was trying to build a patient base, which is a tough proposition in a town with major health care providers like Saint Alphonsus and St. Luke’s.
“There are three fairly major groups in Boise and the surrounding area, which makes competition very difficult for patients,” Jones said. “It’s hard to get your name out when you’re trying to compete against giants.”
His relationship works for the moment, because House Calls provides him with patients that he would not have had otherwise, even if they are covered by Medicare.
If he already had a full practice filled with many patients that were not on Medicare or Medicaid, Jones said it would be “very hard to justify” taking an afternoon off to visit all Medicare patients in a home.
“Unfortunately, economics kind of rules everything,” he said.
Fuller acknowledges the problem for doctors.
“Frankly, it’s always going to be an issue,” Fuller said.
To combat the lower reimbursements, Fuller said he has to convince doctors that they can still make money by seeing a large number of patients in a short amount of time. That raises the amount of money a physician can make in an afternoon without raising administrative costs for setting up the appointments.
“He can just go from one room to the next room to the next room,” Fuller said.
His other pitch is that the service can create loyal patients, both for independent doctors and those affiliated with major health care systems. For independent doctors, “practice development is what I’m doing for them, bringing patients to them,” he said. For major providers, he can put those patients directly into their system, which can help keep the patient inside the provider’s system for the duration of their care.
“It would be to their advantage if these patients were aligned to them,” he said.
He now serves four retirement homes in the Treasure Valley, and while he’s meeting operational costs, “we’re not making a lot of profit.”
“We want to start slow, because this is brand-new,” Fuller said. “And with anything that is brand-new you run into bumps in the road.”
If the program goes well, Fuller sees it being exported through major retirement home companies and used as a model across the United States.
“Once we have a certain group of communities here (and) have a smooth operation at where we want it, then we will be ready to export to these other communities,” Fuller said.


House Calls brings the doctor to Country Time Assisted Living!

Better resident health, reduced family stress, and elimination of transportation expenses for routine visits to the doctor’s office.  These are 3 welcomed and much anticipated benefits Country Time Assisted Living in Star, Idaho will offer their 16 residents and families beginning in May 2013.  Full primary care delivered in the residents’ own rooms.   Even more…team based, physician-led healthcare coordination for all residents.

Only House Calls’ partners, small or large, can differentiate themselves from all their competitors with this truly unique and valuable service.



House Calls Offers 10% Discount to IHCA-ICAL Members!

House Calls is proud to announce its association and membership in the Idaho Health Care Association-Idaho Center for Assisted Living.  To commemorate our relationship, we now offer a 10% discount to all IHCA-ICAL members who partner with House Calls to provide primary care services in their Independent Living or Assisted Living Community.  With House Calls, your residents don’t go to the doctor for routine primary care…the doctor comes to them!  We also coordinate on-site blood work, plain x-rays, and EKGs.  Your residents and their families will appreciate compassionate and timely care delivered by a physician in the comfort and convenience of the resident’s own room.  Prospective residents and their baby boomer families will breathe a sigh of relief when they discover that if they choose YOU, they will not have to struggle with transportation for routine doctor visits because YOU bring the doctor to THEM.  You can confidently ask them, “Why would you choose any place else to live?”