House calls

Date: 7|6|2023

As Senior Medical and Practice Advisor at HCCI and Medical Director for Northwestern Medicine HomeCare Physicians in suburban Chicago,  Dr. Paul Chiang has made over 37,000 house calls to more than 3,600 patients during his 23-year career. We talked to Dr. Chiang about his impressive track record, why he started making house calls and his advice for those interested in getting started in home-based primary care.

HCCInsights: Why did you go into providing house calls? 

Chiang: I have a sheet here on my desk of inspirational words and sayings, just things that motivate and help refocus us, and the first thing on the sheet is “Providence,” which is what I think drew me into the whole house call arena.

I had some opportunities to take care of patients in their homes, and it sparked a desire to do more — to take care of patients who are really in need and marginalized. Then providence provided Dr. Tom Cornwell, who started HCP back in 1997. We met during a time when I was transitioning from one career option to the next. We talked about his vision and his dream, and the opportunity we have to take care of these patients.

HCCInsights: What brought you to the Home Centered Care Institute?

Chiang: Well, it was Dr. Cornwell, who started the Home Centered Care Institute (HCCI) with a mission of not only caring for homebound patients in our local community but of taking the house call model and trying to spread it across the entire country. Studies confirm there is a desperate need for house call clinicians to take care of the homebound — there are simply not enough of us doing this type of work. Dr. Cornwell’s vision was that HCCI would serve as a professional community where we can inspire and teach others how to build, equip, and run successful house call practices.

HCCInsights: What happens to these patients when they end up in emergency rooms?

Chiang: If a patient goes to the emergency room because they have a new or worsening problem, the emergency room takes care of that problem and sends the patient back home with instructions to follow up with a primary care provider. The ER is not meant to provide comprehensive longitudinal care; it’s set up to deal with acute problems. So, if a home-limited, medically complex patient is not getting consistent supportive care at home, the patient’s condition can deteriorate and result in a trip to the ER or a hospital admission.

HCCInsights: Do the patients tell you how it feels to have you spend extra time with them?

Chiang: I’ll answer that by sharing this story from a recent visit with a new elderly patient and her husband. The patient has moderate to advanced dementia and is lovingly cared for by her husband. He is very devoted to her health and care but also worn from coping with some dementia-related behavioral issues.

So, we took some time to sit down and go over all of her medical problems and each medication she takes. I explained why they were needed, why some were changed, etc. At the end of the conversation, the husband started to cry. He said he’d been wanting to do this for years, but the doctors didn’t have time. I’ve experienced many such moments over the years — it’s a privilege to minister and care for these patients. And taking the time to build relationships based on trust and respect absolutely does make a difference for both patients and caregivers.

HCCInsights: What does a typical day of house calls look like for you?

Chiang: The day begins when I boot up my computer in the morning before I go to the office. I might start by going over results from tests that were done the day before and sending messages to my nurse, who will carry out my instructions and relay them to patients.

Then I’ll look at the day’s schedule and pre-chart my patients, trying to make my day efficient. I also take time to organize my thoughts. These patients have a lot of very complex needs, so having a clear mindset going into each visit is important. All of this helps allow me to spend less time looking at a screen during patient visits — patients will complain that the doctors hardly look at them because they’re typing on their computers and make very little eye contact. Pre-charting allows me to close my computer and fully engage with the patient, talk to them eye-to-eye, and they can have uninterrupted attention to make sure I take care of their concerns.

We’ll make anywhere between eight to 10 house calls per day. We may do blood tests or procedures such as G-tube changes or knee injections.

After the day’s visits, I come back to the office in the early afternoon and we process the blood or labs, getting them ready for the courier; we restock the bags for the next day; and I spend the rest of the afternoon answering messages, talking to patients or caregivers, and communicating with my nurses.

HCCInsights: What would you tell someone who was considering going into house calls but was concerned about the sustainability?

Chiang: I would acknowledge that a house call practice using a fee-for-service model can be difficult to sustain. Though I would then tell this APN or PA that the healthcare landscape is changing. Payment models are evolving — and will continue to evolve — from where they’ve been in the past and where we are right now. As payment models shift, there will be a different payment mechanism to fund house call practices. The future of house call medicine is bright for many reasons — demographics, technology — and, most importantly, because payment reform is going to drive the house call phenomenon to the next level.

HCCInsights: How would you tell someone to get started in house calls?

Chiang: They can start by going on a ride-along. It’s hard to explain a house call to somebody who is new to it. A ride-along is a great way for APNs or NPs to experience the rewards and challenges of house calls, and — of course — they should also explore what HCCI has to offer. We have a ton of resources that have been developed through the years to help practices with everything from the front office to the back office to billing and coding to managing complex conditions at home. [See HCCI’s education, consulting, and Confer Analytics™ business intelligence resources.]

HCCInsights: What do you know now that you wished you knew when you first started providing house calls?

Chiang: That it takes a team to take care of this group of patients. That a physician or APN alone is not sufficient because these patients have needs that extend beyond what a doctor or an APN can provide. They have social needs. Spiritual anguish. Mobility barriers. They may have food insecurity. These are all things that require the help of others beyond the physician or APN to adequately support patients and their caregivers. So, if I could go back to the beginning of my house call journey, I would tell myself, “You need a team.”

HCCInsights: What would you most like to tell those considering a career in house calls?

Chiang: The house call field is a rewarding, challenging, and unique way for them to deliver care. We have a resident from Northwestern rotating with us, and I also debrief with her when she comes back from the field by asking what she thought or if she was surprised by anything. I hear comments like, “I didn’t know you could do so much at home.” Or, “It gives you a new perspective into a patient’s life.” Other observations touch on how personal the experiences are because you’re a guest in the patient’s home — not in an office or hospital. You witness first-hand how patients live day-to-day, the family dynamics, both good and bad.

Watch our interview with Chiang here.