The Value of Home Visits in Primary Care
Ruvini Amarasekera, MD Candidate (UBC Medicine Class of 2023)
Dr. Sarah Bartlett, MD CCFP, Assistant Dean of Student Affairs (UBC Medicine Vancouver-Fraser Program)
Dr. Judith Hammond, MD CCFP (COE)
The last two and a half years in the COVID-19 pandemic have amplified the importance of being connected to each other. This extends to primary care, one of the foundational pillars of healthcare. During the pandemic, we turned to virtual care to continue connecting with our patients when we could not meet face-to-face. As we look to the future, it will only be increasingly important to reach the most vulnerable patients in our communities, and home visits are a tool we can use address this. Due to a number of factors, home visits have grown to be less common in today’s primary care scope. However, home visits are an opportunity for healthcare providers to meet their patients where they are at, and should be valued as an important piece of primary care services.
I spoke with Dr. Sarah Bartlett, a family physician working in Older Adult Mental Health in Vancouver, and Dr. Judith Hammond, a family physician working at Home ViVE (Home Visits for Vancouver’s Elderly) and three care facilities, to explore how they incorporate home visits into their practices.
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Why did you start doing home visits, and why are they important?
Dr. Bartlett: In my job working in Older Adult Mental Health, most of our patients are unable to get to an office visit, for either physical or mental health reasons. Home visits are so important for these people who have complex care needs, and are unable to make it into the office. It is such a privilege to have people allow you into their private space. You can tell a lot about a person by how they keep their home, and the environment they live in.
Dr. Hammond: I was first exposed to home visits during medical school when I had preceptors on both Gabriola and Salt Spring Island who did visits to home-bound patients. Home visits became a large focus of my practice after I had more exposure to it during my Care of the Elderly Enhanced Skills R3 program. Home visits are important because for some people, it is the only practical way for them to receive regular medical care. There are many people who cannot get to doctors’ offices, either at all, or only with a great deal of effort or expense. Many of these people are elderly and may have some degree of hearing or cognitive impairment, and do not have the technology or skills to do videoconference visits. Although some of their medical concerns can be addressed by phone, they also require home visits as part of their medical care. Can you imagine how stressful it would be and how vulnerable you would feel to have no access to an in-person assessment by a primary care provider without making the decision to go to the emergency room?
What are the most memorable elements of home visits?
Dr. Bartlett: Every home visit is memorable in its own way. I love gardening, and my favorite visits are when a patient will show us their garden with pride. Not only do I enjoy those connections, but I find it helps patients feel more comfortable with me as a person, so they are more likely to accept my treatment suggestions or open up about their concerns.
Dr. Hammond: It is hard to choose a favourite part about home visits. Many of my elderly patients who are home bound are not in a long-term care home because either they have a very strong personality with a solid independent streak, or they have very supportive families (or, even more impressively, friends or neighbours). These are interesting people to know: often real characters with interesting histories, and the kindness of their families, friends or neighbours is inspiring. Helping support their goal to maintain their quality of life and stay at home in their final years is very rewarding.
Another joy of this work is the collaboration with nurses, physiotherapists, occupational therapists, nurse practitioners and other physicians. My colleagues are amazing, and the mutual support we provide for each other is a real highlight.
It is also intellectually challenging and very interesting medicine. Many of my patients will have complex medical histories with all sorts of complex variables to untangle. Tailoring our medical decision-making to the person and their goals of care is at the forefront of our work; we cannot automatically assume we will order the standard tests to workup any given presentation. Will our patient who fell and hit their head go to the ED for a CT head? Our recommendations will be informed by their baseline frailty, their medical situation, how difficult it would be for them to get tests, and their goals of care. The providers and the patient or their caregiver will make these decisions with incomplete information, balancing probable risks and benefits.
Importantly, some of the most memorable visits have occurred when I am on call and a patient takes a turn for the worse and appears to be dying. Supporting those patients and their family caregivers, often providing palliative care at home, is very meaningful and rewarding.
What do patients say about home visits?
Dr. Bartlett: The gratitude of my patients always astounds me. Most people are quite appreciative that their health care team will come to them.
Dr. Hammond: One of the nice things about doing home visits is that, for the most part, patients and their caregivers greatly appreciate the service. They especially appreciate the responsiveness of the Home ViVE program in urgent medical situations, including the availability of a doctor overnight and on weekends in emergencies. Before they had a family doctor or nurse practitioner who did home visits, there was a certain amount of stress and vulnerability that has now been lifted.
What are some challenges you have faced with home visits?
Dr. Bartlett: The biggest challenge is when a patient is not home, or will not let you in! We also have to worry about bed bugs and cockroaches.
Dr. Hammond: In my case, home visits are a core part of my practice and I do not blend it with a full-time office practice. I anticipate urgent visits to patients’ homes or long-term care homes will happen regularly and have flexibility in my schedule to respond. I think it would be harder to manage this with a busy office practice, especially if your patients do not live in the same part of the city as your office or your home.
Supporting home bound patients with multiple comorbidities and cognitive impairment is also very challenging logistically unless they have very high functioning caregivers, because our medical system is not designed to support these patients.
How have home visits changed during the COVID-19 pandemic?
Dr. Bartlett: Well, we had a time when we were unable to do home visits, and had to use virtual means. This is extremely difficult with our patient population, since many of them have hearing difficulties, or are unfamiliar with technology. Now we wear masks when visiting patients, which they find frustrating when they cannot read our lips. It can be a huge communication barrier.
Dr. Hammond: Initially we switched to phone visits and triaged only urgent visits for home visits. However, we found that many of our patients have difficulty giving reliable histories or communicating over the phone, and so we returned to home visits quite quickly, with infection precautions.
Do you see home visits continuing in the future of primary care? Why or why not?
Dr. Bartlett: Home visits are so important for that portion of the population who cannot make it into a physician’s office. I cannot see their care needs being met without them.
Dr. Hammond: There is no way around it. Home visits will need to be an increasing part of primary care because the need is not being met now, and we are still not at the demographic peak of our aging population.
How can family physicians incorporate home visits into their care model effectively? How can they be better supported to do so?
Dr. Bartlett: Home visits take time, and so the physician’s “office day” needs to be scheduled to allow adequate time for both the visit, and the transportation to and from the visit. The physician also needs to be adequately remunerated for their time.
Dr. Hammond: This is an incredibly important question and some of the Divisions of Family Practice, health authorities, and others are trying to figure out this challenge. The hardest part is not necessarily the scheduled visits, but the unpredictable urgent ones, especially in communities where our patients may be widely dispersed. A stronger home and community care system in which a family physician could access a home care nurse who could do a same-day visit and perhaps video-conference or otherwise liaise with the family physician in their office would help. Funding to support family physicians within primary care networks to provide a call service to home-bound patients, with a shared EMR for this patient roster, would be helpful. Right now family doctors are not remunerated to provide call service to community patients.
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Home visits are an opportunity for healthcare providers to gain more insight into our patients’ lives. In this way, we can become better advocates for our patients and address their health issues in a preventative manner. Importantly, for home visits to be practical in primary care, remuneration models must reflect the resources it takes for healthcare providers to do this invaluable work. For medical students like myself who are hoping to enter the world of primary care, this is an important moment for us to consider incorporating home visits into our practice in the future.
A special thanks to Dr. Sarah Bartlett and Dr. Judith Hammond for their contributions to this article.