Home Visits By Physicians: Recent Trends And Future Needs #92-1
Hemali Kulatilaka, M.Sc., MPA
Ian R. McWhinney, M.D., FCFP, FRCP
Using information from national health surveys and from the literature, this report reviews trends in home visits* by physicians, in Canada, United States, and Britain, between 1969 and 1989. Until 1982 the rate of home visits per physician and per member of the population decreased steadily. This was the continuation of a decline which began in the 1950's. Beginning in 1982, data from the U.S. Health Interview Survey shows an upturn in the home visit rate and this trend continues in the 1989 survey. Using the population as the denominator, the home visit rate declined from .083 per person per year in 1971, to .039 in 1975, and .031 in 1980. In 1982-83, however, the rate increased to 0.101 visits per person per year, and in 1989 to 0.116.
In Canada, the National Health Survey of 1978-79 showed a home visit rate of 0.075 per person per year - much higher than the U.S. rate in 1980. The rate for Ontario in 1978-79 (0.073) was similar to the national figure. Using April data from the Ontario Health Insurance Plan (OHIP), the rate was 0.051 in 1985 and 0.061 in 1988. Assuming that all other factors remain constant at 1989 levels, we have calculated the home visit per person rate for the years 2001 and 2011, given the projected age distribution of the Ontario population. The rates for those years based on 1988 OHIP levels would be 0.070 and 0.079, and based on 1989 U.S. levels 0.116 and 0.127. The home visit rate for individual physicians will depend on such factors as the age structure and location of the practice.
In all three countries, about half of all home visits are paid to patients over the age of 65. The relationship between age and home visit rate, however, is not a simple one. In the U.S., for example, an increase in the elderly population has been associated, at different times, with both a decrease and an increase in the home visit rate. The following additional factors must be taken into account when estimating future trends:
- The availability of acute and long term care beds. Between 1975 and 1987, the number of public hospital beds in Ontario declined by 23%. Extended care beds decreased by 8% during the same period. With no relaxation in fiscal pressures, the bed to population ratio is likely to continue falling in the next two decades, thus increasing the demand for home visits by physicians.
- The developing roles of other health professionals, especially nurses. Already, nurses are shouldering much of the responsibility for home care in Ontario Home Care Programs. It is doubtful whether physicians' contribution to home care can be further reduced, without jeopardizing the quality of the medical care provided in the home. The involvement of physicians is especially important in the home care of patients with acute, or unstable chronic, conditions.
- Developments in technology. New technologies can either enhance home care or create a need for more hospital beds. In the recent past, technologies like coronary care, renal dialysis and organ transplantation have often had a centripetal effect. Some of the newer technologies are likely to act more centrifugally by enhancing communication and increasing the scope of home monitoring. New surgical techniques are reducing the length of hospital stay. It is now common for intravenous antibiotics, cancer chemotherapy and parenteral nutrition to be provided in the home. Laboratory services, radiology and electrocardiography are available in the home. Our prediction is that, on balance, technology will tend to increase the need for the involvement of physicians in home care.
- Changing patterns of morbidity. With the aging of the population, the trend towards an increase in the prevalence of chronic disease is likely to increase the need for home care. With stable chronic disease this will have most impact on nursing services. Unstable chronic conditions will require more services from physicians.
- The economics of medical practice. Caring for a patient at home involves the physician in time consuming activities, many of which, like phone calls, team meetings and travel, are not remunerated. Since they do not provide continuing care, and usually refer seriously ill patients to hospital, house call agencies are not at this disadvantage. The home care provided by physicians is, therefore, often being done at a loss to themselves, a situation likely to put a brake on development. In Ontario, the potential remuneration for a home visit was increased by the addition of the category "House Call Assessment" to the 1991 fee schedule.
- The organization of medical care. Family physicians can only offer home visits for patients living within a reasonable distance from their offices. When home visits were declining, practices tended to become geographically dispersed, thus putting many patients out of reach of home visits. When patients join a practice there may be no clear understanding as to whether the doctor will do home visits if it becomes necessary. If home care is to become integral to medical practice, some geographical concentration will be necessary, as well as a clear understanding by patients of what they can expect. Group practice may enhance family physicians' ability to do home visits, by ensuring coverage of patients in the office and in hospital while home visits are being done. Some home medical care can be provided by specialized services operating from a hospital base. Oncologists can provide cancer chemotherapy, infectious disease specialists, intravenous antibiotics, and so on. The result, however, is likely to be a fragmentary organization, appropriate only for certain specific needs. The ideal organization for home visits, in our view, is one which integrates nursing, medical and social services, and services by the patient's own family physician and the appropriate specialists. Commercial home visit services have recently emerged in Ontario cities. Since these provide no continuity of care, and act in isolation from hospitals, home care programs and family physicians, they will, in our view, make little contribution to developments in home care.
- The education of physicians. The concentration of medical education in the hospital has tended to produce physicians who are ill prepared to care for patients in their homes. Even family medicine residency programs have been slow to emphasize training in home care. If this is not to act as a brake on development, medical schools will need to produce graduates who expect to care for patients at home and feel confident in their ability to do so.
- Physicians can make little impact on home care unless they are part of an organization, as they are in the hospital. Home care programs and "hospitals at home" are examples of such organizations. Whether these organizations are able to develop will depend on the resources allocated to them. Ultimately, therefore, the future of home care, and the physician's role in it, depends on policy decisions made by the provincial government.
* All the sources of data identified home visits separately from visits to patients in nursing homes.