home visit from gp

House Calls – We Bring the Doctor’s Office to the Patient

At Mobile Physician Services, we provide comprehensive care to improve the health and quality of life of our patients – in the convenience and comfort of their own home. Our team of board-certified doctors, advance nurse practitioners, and physician assistants specialize in providing care for patients with medically complex and chronic conditions.

Our Services

We accept Medicare, many insurance plans, and self-pay.

To find out more about our services:

Call Toll-free: (855) 232-0644

E-mail us at [email protected]

Primary Care

Pain management, palliative care.

At Mobile Physician Services, our customized care teams provide patients with both comfort and familiarity as they work with a dedicated primary care provider and care coordinator to improve their health. Our physicians and staff take a proactive approach to preventive care, chronic disease management, and chronic illness support right where you live.

Each home visit includes an in-depth examination and individualized treatment plan, which is monitored and adjusted through routine follow-up visits. The primary care provider will deliver your ongoing care and will recommend to you specialty services as needed.

• Annual Wellness visits : This wellness visit allows your primary care provider to create or update your personalized prevention plan. This visit includes a review of your medical and social history related to your health and may include counseling about preventive services. This plan may help you to prevent or reduce the chances of future illness based on your current health and risk factors.
• New Illness Exams : When a new symptom or ailment arises, call us. Early indications of not feeling well could be a clue that you may be getting sick. A symptom in one part of the body may also be a sign of a problem in another part of the body. Moreover, unrelated symptoms that might seem minor on their own, could be warning signs of a more serious medical disease or condition. The new illness exam can be very brief or more detailed depending on your concerns and the provider’s findings.
• Follow-up Care: Involves a regular medical checkup, which may include a physical exam and laboratory testing. Follow-up care checks are a proactive way of assessing the potential for and preventing health problems from returning after treatment of a disease has ended or an illness has seemingly passed.
• Referral for Specialty Care : Referrals are the link between primary and specialty care. The referral coordination includes the documentation of patient care activities, the transfer of information, the inter-provider communication itself, and the integration of care services to the patient. Mobile Physician Services is a multi-specialty practice so many of these specialty referral services can be made seamlessly with little inconvenience or disruption to the patient and caregivers regular routines.
• Medication Management: Medication management is a treatment structure that ensures our patients are receiving optimal therapeutic results from their prescription medications, both in the short and long term. Our team’s goal is to mitigate medication noncompliance and monitor all prescriptions treatments so that drug interactions complement one another for the most optimal outcome for our patients.

The provider may be a physician, advanced practice nurse or a physician assistant. A dedicated care coordinator will also be assigned for each patient to help arrange comprehensive services and assist patients and their caregivers.

• Online Patient Portal: You and your designated caregiver, if you choose, will be able to connect with your provider through a convenient, safe and secure environment which allows access to your health records and a way to communicate with our staff in a timely manner.
• Telephone Assistance : On call providers are available 24/7 weekdays and weekends.

Our psychiatry team specializes in the diagnosis and management of mental, emotional and behavioral disorders. They carefully evaluate each patient to develop an individualized treatment plan to improve the patient’s overall mental and physical well-being.

• Depression : Depression is a common and often serious medical illness that negatively affects how you may feel, the way you may think, and how you may act. Depression can cause feelings of sadness, despair and hopelessness, which may lead to a loss of interest in activities you once enjoyed.
• Anxiety : Intense, excessive, and persistent worry and fear about everyday common situations. The worry or anxiety could make you feel fatigued, irritable, and interfere with your regular sleep habits.
• Dementia : An overall term that is used to describes a collection of symptoms related to an individual’s decline in memory or other thinking skills. It may be severe enough to diminish a person’s ability to perform everyday common activities. The effects of dementia can negatively influence your memory, thinking and social abilities.
• Phobias : A phobia is when you experience excessive panicking or an irrational fear reaction to a situation. If you have a phobia, you may experience a deep sense of dread or fright when you encounter the source of your fear. The fear may be a certain place, situation, object, animal or even another person.
• Behavioral disorders : Attention deficit, hyperactivity, bipolar, learning, defiant or conduct disorders are all examples of complaints that may have a detrimental impact on a person’s interpersonal relationships with family, friends, and co-workers.

Our team can provide behavioral counselling and medical therapy, when appropriate, to help a patient feel better about themselves and to assist them with better coping and managing their condition.

Our wound care specialists have been trained in the attention and treatment of all types of acute and chronic wounds. They have skill and experience in wound debridement and wound care procedures – managing chronic, non-healing wounds and infections, with a demonstrated care that fosters healing… right in the patient’s own home.

We specialize in serving homebound patients who may also be bed-bound or have difficulty in walking or moving around. As a result, immobility compression sores develop at pressure points on the body when the weight of an immobilized individual rests continuously on a firm surface, such as a mattress or wheel chair. Often these same patients are on oxygen or have high-risk medical conditions which makes it an even more challenging and stressful effort for them to travel to a doctor’s office for an appointment. Thus, the necessity for in home care and treatment.

Wounds that benefit from specialized wound care techniques include:

• Diabetic foot wounds and ulcers
• Post-surgical wounds
• Traumatic wounds caused by injury
• Arterial and vein stasis caused by lack of circulation
• Immobility pressure sores. (Bed sores from stillness)

We work closely with home health agencies to provide ongoing care and monitoring of patient’s wounds.

Our board-certified podiatrists treat foot pain, wounds, and more. Treatments may include but are not limited to treating conditions of the lower extremities which could hinder mobility.

• We will review each patients’ medical history to evaluate the condition of the feet, ankle or lower leg
• Carry out a diagnosis on the feet and lower legs through examination and medical tests
• Order physical therapy when deemed necessary
• Treat wounds of the lower extremities using various wound care modalities. This may include debridement to improve the healing potential
• Promote prevention, health & well being, the treatment and management of the foot and related problems, disability, deformity, and the pedal complications of chronic diseases for the elderly
• Prescribe and fit prosthetic appliances such as diabetic shoe inserts and evaluate for bracing if necessary
• Refer patients to other specialists for treatment, including conditions such as diabetes or arthritis
• Advise patients on ways to prevent future leg problems and increase speed of recovery
• Monitor the recovery progress of patients to determine the need for change in treatment

We know it’s not always easy to leave home to get the care you need for your eyes. Our optometrists bring state-of-the-art diagnostic eye equipment and technology to your home – making it much easier for you to get the vision care you need.

During a visit, your doctor will exam each eye for signs of serious issues such as glaucoma, cataracts, macular degeneration, and detached retinas, among other conditions.

Receiving regular eye exams regardless of the state of your vision can help detect serious eye problems at their earliest stages ─ when they are most treatable. During an eye exam, your doctor will observe and evaluate the health and condition of the blood vessels in your retina, which can be good indicators of the health of your blood vessels throughout the rest of your body.

• Comprehensive eye exams : This exam goes beyond a simple vision screening. A comprehensive eye exam includes a host of tests in order to do a complete evaluation of the health of your eyes and your vision.
• Annual retina exams : A retinal exam allows your doctor to evaluate the back of your eye, including the retina, the optic disk and the underlying layer of blood vessels that supply the retina.
• Eyeglass fittings : A prescription works best when your eyeglasses are properly fitted. Improper fitting may cause pinching, distorted vision, headaches, and even dizziness. Our doctors will make sure your prescription lenses and frames are working together for you.
• Diabetic eye exams : Diabetes does not have to lead to vision loss. Taking an active role in managing your diabetes can go a long way in curbing later complications. Regular eye exams, good management of your blood sugar and blood pressure, along with early intervention for vision problems can help prevent vision loss caused by diabetic retinopathy. Retinopathy is caused by damage to the blood vessels of the light-sensitive tissue at the back of your eye.
• Refractions: This test is given as part of your routine eye examination. It is often referred to as a vision test. This test assists your eye doctor in measuring you for the exact lens prescription you will need.
• Eye injuries: Eye trauma could be the result of a sudden blow to the eye. It may cause the eye to suddenly compress and retract which could cause damage to your eye and the surrounding tissue. Even if the injury may seem minor, all eye injuries should be furthered examined by a doctor for possible more serious and underlying injuries.
• Eye infections: The most common eye infection is conjunctivitis, also known as pink-eye. An eye infection can happen in almost any part of your eye, including your eye lid, cornea and optic nerve. Symptoms of eye infections may include redness, itching, swelling, discharge, pain, or problems with vision. Always consult with your doctor before treating, as recommended actions are contingent on the cause of the infection.
• Low-vision exams: A low vision exam is different from a normal eye exam. This functional-vision assessment determines how specific visual impairments affects your ability to perform everyday activities. The exam’s results assist your doctor in prescribing management tools and medications to better enhance and manage your remaining vision.

Pain management is the process of providing medical care that alleviates or reduces pain. Pain management is a subspecialty of general medicine employing an interdisciplinary approach to ease the suffering and improve the quality of life of those living with chronic pain by using a combination of pain medications, joint and muscles injections, and physical therapy techniques.

A pain management specialist is a provider with advanced training in diagnosing and treating pain. Our pain management specialists treat pain stemming from a variety of different causes, whether it’s neuropathic pain or headache, or the result of injury, a surgical procedure, cancer or another illness.

Palliative care is an approach to the holistic care of patients, including family and caregivers, to improve the quality of their lives after the diagnosis of a chronic debilitating disease or life-limiting illness that may cause a host of complaints.

Palliative care can begin at diagnosis and continue to be offered while the patient is continuing active treatment through different phases of their life limiting condition. Palliative care is for any patient with a chronic illness who is experiencing a decreased quality of life because of symptoms related to their illness or treatment, like renal dialysis, oxygen therapy or chemotherapy. The care is provided by a specially-trained team of doctors, nurse practitioners, physician assistants, and other specialists who work together to provide an extra layer of support to the patient and their caregivers.

Palliative care can help in symptom control including not only pain, but nausea, weakness, shortness of breath, fatigue and weight loss at any time during their diseases, not only at the end of life.

In Home Medical Senior Care Services | Landmark Health

• Patient or Caregiver
• Community Provider

Are you a new Landmark patient?

Burn-out is real. landmark is different..

Living with chronic health conditions? We can help.

Our providers and care teams come to you, bringing care through house call visits. This in-home medical care is designed around understanding your health needs and goals. We work with you and your regular doctors to help you stay well and stay home.

House calls and video visits in 37 states.

Landmark partners with health plans to bring medical, behavioral health, and palliative care, along with social services, to patients in communities across the U.S. Our mobile providers visit patients in their homes through in-person house calls and telemedicine visits over video and phone.

We are the future of health care.

Landmark is one of the nation’s largest healthcare companies focused on in-home care of complex, chronic patients. Our physician-led provider groups support collaborative ties between community-based organizations, primary care providers, specialists and patients and their families.

patients nationally for which Landmark bears risk

reduction in hospital admissions

reduction in mortality

Discover the benefits.

• For Patients + Caregivers
• For Community Providers
• For Partners

Health care in your home

Old-fashioned house calls by medical doctors, nurse practitioners and physician assistants bring modern medicine to you. Feel better and stay well at home.

Covered by your health plan

The Landmark program works with health plans to improve access to care for patients with multiple chronic conditions. Landmark’s team-based care is available often at no cost to you.

Keep your current doctors

Landmark coordinates its care with your primary care provider, specialists and other community resources. Landmark provides added support to those who need it most.

Available 24 / 7

Our provider-staffed call center answers any time of the day or night. We also provide urgent visits to help you avoid unnecessary trips to the emergency room.

No waiting room

With Landmark house calls, you won’t need transportation to clinics and hospitals, and you avoid waiting rooms and exposure to germs.

Reduced stress

Patients and caregivers enjoy peace of mind with Landmark support. Landmark cares for the whole patient.

Landmark house calls put patients at the center of health care.

Collaborative care for complex patients.

Landmark’s community-based mobile providers bring coordinated care to patients with multiple chronic health conditions. We augment your care in the patient’s home.

Covered by health plans

The Landmark program is included in eligible patients’ health plans to improve care coordination and healthcare access for home-limited patients.

You remain the primary care provider

Landmark care is coordinated directly with you. Our providers reinforce your care plan in the home through physician-led interdisciplinary care teams.

Access our interdisciplinary team

Landmark’s interdisciplinary care team is available to you and your patients, including behavioral health specialists, social workers, palliative care specialists, nurse care managers and pharmacists.

Reduce administrative burden

We can help your highest acuity patients by managing post-acute care, home health orders, face-to-face encounters, and more.

24 / 7 availability

You can reach us any time, including weekends and holidays. We do urgent home visits to intervene if your patient experiences a chronic disease exacerbation.

Landmark supports your patients with complex health and social needs.

Chronic care management.

We’re one of the nations’ leading risk-bearing medical groups. We focus on giving your most complex members care when they need it, right in their home.

Over 250,000 patients across the country

We bear risk for over 250,000 complex, chronic patients, spanning Medicare Advantage, Medicaid, Dual, and Commercial, populations.

Behavioral, social and palliative care

Our team of multidisciplinary clinicians may include behavioral health specialists, palliative care practitioners, social workers, nurse care managers, dietitians and pharmacists.

Urgent in-home visits

One in four of our home visits is urgent. We bring medical care to your members when they need it, to avoid unnecessary emergency room trips and hospitalizations.

Built-for-purpose infrastructure

Our technology platform is designed specifically to support the medically vulnerable, clinically complex population.

Meaningful outcomes

Landmark commonly helps health plans achieve 4- and 5-star performance on Medicare STARS clinical quality of care, while caring for the most complex patients.

Landmark provides care for complex, chronic patients to positively impact access, satisfaction, outcomes and cost.

The doctor and nurses show they care about you and your health they are really there for you when you need them I love that they come to your house we did a zoom meeting with the nurse practitioner and she gave suggestions I really appreciate them

It was a pleasure to talk and see the doctor, she was very knowledgeable of all my conditions and gave me great advice to improve my health.

Joan was very helpful. It was nice getting to know her. How Landmark can help me

Practice health care the way you always wanted — with those who need it most.

Expert insights.

Prioritizing Mental Health as a Universal Human Right

By: Neltada Charlemagne, DNP, APRN, PMHNP-BC, PHN, BHC

Outsmart Unplanned Medical Costs: 10 Steps for Managing the Unexpected

Older adults can safeguard themselves from the physical, mental and emotional toll of unexpected medical costs.

Optum Care Network – Monarch and Landmark Health bring care to you at home.

Optum Care Network – Monarch has teamed up with Landmark to deliver in-home medical care to members with multiple chronic conditions.

Have questions about Landmark? We’d love to hear from you.

Look out for your health

A UnitedHealthcare® HouseCalls visit is a no-cost, yearly health check-in that can make a big difference. 

Call 1-866-799-5895 ,

TTY 711,  to schedule your visit.

HouseCalls brings yearly check-in care

To you at home.

Connect for up to a full hour of 1-on-1 time with a licensed health care practitioner. Every visit includes a physical, tailored recommendations on health care screenings and plenty of time to ask questions that matter to you.

After your visit, HouseCalls connects with your primary care provider (PCP) to help keep them informed about your health. It's a great way to feel confident knowing an extra set of eyes is looking out for you between regular PCP visits.

What is a HouseCalls visit? 

[Text On Screen – SAY HELLO TO HOUSE CALLS]

Say hello to HouseCalls.

[Text On Screen- PAID ACTOR PORTRAYAL.]

HouseCalls is our way of looking out for your health, so you can focus on your future. Here’s what it’s all about.

[Text On Screen – HERE’S WHAT IT’S ALL ABOUT]

Once a year, a licensed health care practitioner can come to your home to spend up to an hour with you on your health and wellness.

[Text On Screen- EASY, CONVENIENT, INFORMATIVE]

It's designed to be easy, convenient and informative.

[Text On Screen- HEAD-TO-TOE EXAM]

[Text On Screen- IMPORTANT HEALTH SCREENINGS]

[Text On Screen- HEALTH GOALS DISCUSSION]

You'll get a head-to-toe exam, important health screenings and plenty of time to talk about your health goals.

We'll also provide guidance on managing your health and if you need it, give you referrals for other health plan resources and services.

HouseCalls is a great way to stay on top of your health between regular doctor's visits.

At the end of your visit, you'll get a personalized checklist so you can feel more confident in what to discuss with your regular doctor.

[Text On Screen- COST? NO EXTRA COST TO YOU]

[Text On Screen- INCLUDED IN YOUR HEALTH PLAN]

If you're wondering how much all of this is going to cost, the best part is, there is no extra cost to you. It's included in your health plan.

[Text On Screen- HOUSECALLS VIDEO VISITS ARE NOT AVAILABLE WITH ALL PLANS.]

A HouseCalls visit takes place in the comfort of your own home or by video if you prefer.

So, say hello to HouseCalls and invite us in for a visit today.

[Text On Screen – SAY HELLO TO HOUSE CALLS TODAY]

Access one of the most popular UnitedHealthcare offerings, at no cost to you

Schedule your visit

Call 1-866-799-5895 , TTY 711

Monday–Friday, 8 a.m.–8:30 p.m. ET

Your in-home health check-in

• Up to a full hour with a licensed health care practitioner
• Ask the questions that matter to you and get valuable health tips
• No cost — it's included in your health plan

Get rewarded

Meet your friendly housecalls medical staff.

Just like the professionals you see in your regular doctor’s office, our licensed health care practitioners may be nurse practitioners, physician assistants or medical doctors. They’re state licensed and maintain national certification.

We perform background checks on these professionals to provide additional peace of mind for our members. Your loved ones, caregivers or friends are welcome to be present during the visit — it’s up to you.

Ready to open the door to better health?

Getting ready for your housecalls appointment, tips to help you prepare:  .

• Wear shoes that are easily removed to have your feet checked
• Make a list of upcoming appointments with your PCP and specialists
• Make sure all of your medications, both prescription and over-the-counter vitamins and supplements, are in their original bottles for our review
• If you record blood pressure readings, please have your results available for review
• If you have diabetes, please have your blood glucose meter handy
• Make a list of questions and concerns you’d like to discuss

During your appointment

• You'll have up to a full hour of 1-on-1 time with your health care practitioner for a physical, select lab tests, health screenings and more
• A HouseCalls visit can be completed while sitting at your kitchen table or in the living room, and you can use the time to ask any health-related questions
• The visit is tailored to your individual needs, so screenings and conversation topics can vary

After your appointment

Less travel time. more face time..

Think of HouseCalls as an extra layer of care — valuable 1-on-1 time you don't always get in the doctor's office. And it's tailored to your individual needs.

Schedule today

To secure your spot, call us at  1-866-799-5895 , TTY 711

Have a question?

Find answers to frequently asked questions.  

If you have a specific question about your upcoming appointment or need to reschedule, call us at 1-866-799-5895, TTY 711 , Monday–Friday, 8 a.m.–8:30 p.m. ET

We're here to help.  

House Call Doctor Visits Make Life Easier for Seniors and Caregivers

Important: This is an informational article to explain how house call doctor visits can benefit seniors. DailyCaring isn’t a medical organization, we aren’t medical professionals, and we aren’t affiliated with any healthcare organizations. We aren’t qualified to respond to any medical questions.

House call doctor visits benefit older adults and caregivers

Getting your older adult to the doctor’s office for an appointment can be difficult or sometimes impossible.

Whether they’re frail, can’t walk on their own, or have Alzheimer’s or dementia , getting out of the house is hard on both of you. Going to a doctor’s office can also expose seniors to germs or harsh weather.

We explain what a house call doctor is, what type of insurance they accept, how to find one, and what to look for in terms of services.

What is a house call doctor?

Today, many doctors are bringing back the old practice of visiting patients in their homes. With house calls, older adults don’t have to go through the stress and difficulty of getting to the doctor’s office. And neither do you.

Another bonus is that these doctors usually spend more time with patients. You won’t have to fit all your questions into a 15 minute visit.

Do they accept Medicare?

Yes, many house call doctors accept Medicare , private insurance, and sometimes Medicaid . It usually costs the same as a regular office visit.

But every house call doctor is different, so make sure you understand their fees and accepted insurance plans before making an appointment.

How to find a house call doctor

Some large health care systems like Kaiser Permanente or the VA have programs that include home visits by doctors and nurses. For example, Kaiser’s home-based palliative care program includes house calls.

Even your older adult isn’t part of a large health network, it’s worthwhile to ask your older adult’s doctor if they have home doctor visit programs.

The American Academy of Home Care Medicine’s provider directory is another way to locate a house call doctor in your area.

You can also use Google to search for “house call doctor” + your city or county or “home doctor visit” + your city or county (don’t include the quotation marks).

What to look for in a house call doctor

Before booking an appointment, make sure you understand the doctor’s services, fees, and billing.

Questions to ask:

• Do you specialize in treating seniors, people with Alzheimer’s or dementia , or those with  multiple chronic conditions ?
• Do you accept Medicare , Medicaid , or my older adult’s private insurance plan?
• If we want, can we also keep my older adult’s primary care doctor?
• Will you communicate with my older adult’s existing doctors and specialists so their care is coordinated?

Examples of house call doctor private practices

We want to be clear that we’re not recommending any specific home doctor services or companies and aren’t affiliated with any of these businesses. These are examples to give you an idea of what a house call doctor looks like and the type of services that are typically offered.

Examples of what a house call doctor looks like:

• Visiting Physicians Association (VPA)
• Bay Area House Call Physicians
• Kindred House Calls

Recommended for you:

• 4 Expert Tips for Managing Multiple Chronic Health Conditions in Seniors

7 Tips for Helping Seniors at the Doctor: Being a Health Advocate

• Should Seniors See a Geriatrician?

By DailyCaring Editorial Team Image: Now It Counts

This article wasn’t sponsored and doesn’t contain affiliate links. For more information, see How We Make Money .

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18 Comments

Tony carrancho.

My parent s lives in [redacted for privacy]. How do i get started locating a house call doctor. I am pretty sure there insurance covers this. Thank you. TONY

DailyCaring

We hope the tips and suggestions in the article above will help you find a house call doctor in your parents’ local area.

Susan Quercio

My 95 year old father has a deep cough and he is disoriented. Temp 99 degrees.

Please contact your father’s doctor immediately or the local hospital to find out how to safely get him examined by a doctor (to reduce risk of exposure to Covid-19).

DailyCaring isn’t a medical organization, we aren’t medical professionals, and we aren’t affiliated with any healthcare organizations.

Ruby m VanNostern

I live in [redacted for privacy] and need a doctor visit in home.

This article includes suggestions for how you can find house call doctor services in your area. At DailyCaring, we aren’t doctors and don’t provide any medical services. We hope you’re able to find a great house call doctor in your area.

Stewart Goldman

need Doctor for a home visit Andrews N.C.

Joseph Artusa

I need a doctor

Linda Williams

I was released from the hospital on Thursday after 5 days.I am not able to go to Dr office but most definitely need to be checked.Still having breaking problems and am very week.I have severe asthma and blood pressure was running very high from so much steroids.Could I possibly get help.Thanks so much.

I’m so sorry to hear that you’re not feeling well. Since you’re noticing some issues with your recovery, it’s essential to call your primary doctor immediately. Since they’re the ones who have been treating you and are familiar with your recent hospitalization, they’re the best people to advise you on what you need. If you need help getting to your doctor’s office, you may want to contact your local Area Agency on Aging or a ride sharing service. Or, use the tips in this article to search for a doctor in your area who makes house calls.

Here are some articles that may be helpful: — 8 Ridesharing Services for Seniors https://dailycaring.com/8-ridesharing-services-for-seniors/ — 6 Affordable Senior Transportation Options https://dailycaring.com/6-affordable-senior-transportation-options/ — Local Community Resources for Seniors and Caregivers: Area Agency on Aging (to connect you with local organizations that may be able to help) https://dailycaring.com/local-community-resources-for-seniors-and-caregivers-area-agency-on-aging/ — 4 Ways to Know If Seniors Need to Return to the Hospital https://dailycaring.com/4-ways-to-know-if-seniors-need-to-return-to-the-hospital/

(DailyCaring doesn’t provide any services and isn’t affiliated with any medical providers.)

What areas do you service?

This article explains that house call doctor services are available and could help senior and caregivers. We also share suggestions for finding one in your area, but we do not provide any services ourselves. I hope you’re able to find a great local house call doctor!

What areas do you service

This article includes suggestions for finding house call doctor services in your area. We at DailyCaring aren’t doctors and don’t provide any medical services. I hope you’re able to find a great house call doctor in your area.

need a home care doctor

I hope the information above helps you find a great home care doctor in your area.

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There was a time when doctors treated patients in their own home. This old-fashioned care matched with new medical technology is here again. At HouseCall Primary Care, we serve homebound patients wherever home may be...a patient's house, a nursing home, or assisted living. Our team of providers stay with our patients wherever they go.

HouseCall Primary Care offers these general areas of specialty. Select one of the services below to learn more.

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GP home visits: essential patient care or disposable relic?

Introduction.

The GP home visit has long been regarded as an integral element of NHS general practice that is needed to support both proactive and reactive care to patients in the community. 1 , 2 There are increasing numbers of people living with multimorbidity and frailty, many of whom have complex healthcare needs and limited levels of social support. Now with the new challenges around providing care at home due to the COVID-19 pandemic, it could be argued that home visits or virtual consultations with patients in their homes are set to become a more essential element of general practice, including in the provision of acute care out of hours. Consulting with patients in their homes provides unique opportunities to develop insights into how illness affects their lives. However, with workloads in NHS primary care rising, and increasing pressures on the GP workforce, the place of home visits in core general practice provision is facing increasing challenge.

GPs DEBATE HOME VISITING

The requirements of the current GP General Medical Services (GMS) contract in relation to home visiting are broad. 3 The contract is not prescriptive about who should visit or where the visit should take place, and states that the decision to visit is dependent on the opinion and agreement of the GP contractor. In November 2019, the Local Medical Committee (LMC) conference debated the current contractual requirements and a motion was narrowly passed to instruct the General Practitioners Committee (GPC) (the negotiating arm of the British Medical Association) to ‘remove the anachronism of home visits from core contract work’ . 4 The majority backed a motion to negotiate a separate acute service for urgent visits.

Reporting of the LMC debate in the national press and social media highlighted how emotive the issue of home visits is, and the diversity of views among GPs that exist around their value. They were described by some as a service that is regarded by patients as an entitlement, available for purposes of convenience. 4 It is likely that GPs working in practices that are short-staffed and overwhelmed by workload pressures are more likely to view home visits as an inefficient use of their scarce resources. Others considered home visits a vital component of general practice, arguing that when patients are unwell at home it is generalist doctors who are best placed to assess them. There were concerns that removing home visits from the GP contract would compromise the values of general practice, sending a message to patients that their doctor no longer cares for those who may have pressing clinical needs but wish to be treated at home.

WHAT DO WE KNOW ABOUT GP HOME VISITING?

In a healthcare system where it is expected that contracts are informed by robust evidence-based medicine, the lack of evidence regarding GP home visits, including out of hours, is striking. There has been relatively little research to understand the circumstances in which patients request GP home visits, when and why GPs undertake home visits, and how outcomes can be optimised within a resource-constrained health service. What is known is that over the last 50 years there has been a steady decline in the extent to which GPs visit patients in their homes in the UK and internationally, 2 , 5 , 6 and that not all GPs are convinced of their benefits. 1

Some GP consultations with patients at home are reactive when there is an acute and sudden deterioration in their health, including out of hours. The visiting professional must skilfully balance the risks of continuing care at home against admission to hospital. Others are more proactive, to monitor and plan care for those with long-term health conditions that may prevent them from attending the surgery. Research suggests that GPs do not tend to dispute visit requests for vulnerable, older people. 1 For patients who are dying, there is a positive association between GP home visit rates and achieving home as the preferred place for end-of-life care. 7 GPs who gain experience of home visiting during their training are more likely to undertake home visits post-qualification. 8 GP visits to residential and nursing care homes, and the quality of care delivered, have been described as particular areas of concern. 9 Little is known about responses to other patient groups who may benefit, including: those with mental health concerns; physical disabilities; complex care needs; or those who are unwell with potentially infectious diseases, such as children who may be advised not to attend the GP surgery. Patients appreciate home visits and feel that their relationship with their GP improves as a result. 10

Although GP consultations in patients’ homes are likely to require different consultation skills from those that apply within the surgery setting, the requirements for training in the conduct of GP home visits are ill defined and are largely left for the trainee and their trainer to negotiate. For many trainees, there may be limited opportunity for their home visits to be observed, because of logistical and time constraints. 11 Formative assessment tools (Clinical Observational Tools) for home visits are lacking, and summative assessment of a simulated home visit (within the MRCGP Clinical Skills Assessment) occurs in only half of exams.

Many types of home visit have already been subsumed by other services, such as specialist community teams, early visiting services, and care home teams. Although this can be seen as relieving pressure on overstretched general practice, an unintended consequence is the fragmentation of care associated with multiple specialist teams providing care in the patient’s home. It also calls into question the role of general practice in the management of such complex patients. Obtaining timely information, communicating with each visiting specialist team, and overseeing such care risks adding to the GP workload. 12 As Abrams et al highlight in their realist review of delegated home visiting services in this issue, there is more to be done to understand how such services can be implemented effectively. 13 Research is needed to inform delegation processes, and effective system implementation is needed to support such services and to understand the impact on patient satisfaction, long-term health outcomes, and cost. 13 A pertinent issue is the need for clarity around roles and responsibilities, so that the professional status and autonomy of all involved are understood and valued. This is most likely when trusted professional relationships are developed over time and where the facility to share information effectively exists. 13

‘Good general practice will always consist of patients feeling at home with their doctor and of doctors feeling at home with their patients.’ 12 In the context of burgeoning demand and underfunding of workforce and resources, there is a need to listen to the diversity of views among GPs and primary care colleagues concerning the future of home visits. Robust research is needed to provide understanding into the value of GP consultations in patients’ homes, both through visiting and using telemedicine, and how best to optimise the delivery of primary medical care, particularly for housebound patients, 24 hours a day, 7 days a week. Increased understanding into the nuances and impact of GP home visits on patient care and the wider healthcare system would form an important evidence base to inform NHS policy and the training and development of the primary care workforce, and is necessary before changes are made to the GP core contract.

Freely submitted; externally peer reviewed.

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How to Get a House Call in the Time of COVID-19

If you’re worried about the coronavirus, you may be able to get healthcare at home, either virtually or in person

If you’re not feeling well and want to see a doctor, you may be concerned that going to a physician’s office , an urgent care facility , or a hospital could expose you to COVID-19.

“People are understandably worried that they are going to get sick if they go to the doctor,” says Ateev Mehrotra, M.D., an associate professor of healthcare policy at Harvard Medical School who conducts research on the use of telemedicine to improve healthcare. “This is a situation where going to get care can put you more at risk, and people may want to seek other options.”

In March, the World Health Organization and the Centers for Disease Control and Prevention began calling for hospital and healthcare providers to increase the use of telehealth services to ease pressure on healthcare facilities and treat people quarantined at home, as well as to reduce exposure risks for those who don’t have the virus.

And now, there are a host of options for receiving non-emergency care in your own home, from a medical doctor, physician assistant, nurse practitioner , or nurse, depending on your particular health concerns.

Possibilities range from on-demand house calls you request through an app to telemedicine services, such as virtual doctor visits via smartphone or computer. Some services will diagnose you via video consultation, then determine whether you need to see an in-person provider at home.

Telemedicine can also be as simple as emails or phone calls with your regular doctor or having a healthcare provider email you a treatment plan based on your answers to a symptom questionnaire you fill out online, Mehrotra says.

House call and telemedicine services are generally used for issues such as minor burns and cuts, conjunctivitis, back strains, rashes, flu , and urinary tract infections. House call providers can also help people manage chronic conditions like high blood pressure and provide preventive care such as vaccines.

Home healthcare is appropriate even for many people diagnosed with COVID-19, according to the CDC, because the majority are only mildly to moderately ill and can manage their symptoms at home .

And people are taking advantage of these opportunities. A representative for Kaiser Permanente, a large integrated care organization, says it is conducting approximately 8,000 televisits a day. And Nick Desai, CEO of the app-based Heal, says, “We are seeing a 340 percent increase in demand for Heal telemedicine and house call services.”

Many of the services above are covered by insurance. Of course, you may still have copays, coinsurance, or deductibles, but some fees, like copays, may be lower than those for in-person doctor’s visits. And if you don’t have insurance, you may be able to choose from a menu of services with flat fees, which run from about $50 to $200, depending on your medical needs.

5 Ways to Get Healthcare at Home

Your regular doctor. Your physician may not be able to make an old-fashioned home visit, but there’s a lot she can do by phone or by video chat via computer, tablet, or smartphone. Just under 30 percent of doctors used such telemedicine and virtual visit tools before the coronavirus pandemic, but that number is now expected to rise.

Even if your doc isn’t online yet, many will answer follow-up questions, refill prescriptions, or advise you on managing a chronic condition by phone, email, or text, or through the office’s patient portal.

Your health insurer. You may have access to at-home healthcare through your health insurance. Nearly 9 out of 10 employers with 500 or more workers that provide health insurance have a telemedicine program.

Insurers typically partner with outside vendors such as Teladoc Health, a network of primary care physicians who diagnose routine, non-emergency medical problems via the telephone or video. They can also prescribe medications, send your records to your regular doctor, and make referrals, and are available around the clock seven days a week.

Right now, Teladoc and other telehealth companies are touting themselves as a first stop for coronavirus information, and sometimes other resources as well. Amwell, another telemedicine company that often works with employers and health insurance plans, for instance, now has an infection control officer on call at all times.

For those without insurance, many of these telemedicine services charge a flat fee. Amwell, for example, charges $69 for an online urgent care visit and can provide prescriptions and recommendations for in-person follow-ups with specialists. MDLive urgent care consultations are $75 without insurance.

Local urgent care and walk-in retail clinics. An increasing number of these kinds of facilities, which may be freestanding or located in or next to chain pharmacies or big box stores, are offering video consults that allow you to get in touch with a healthcare provider quickly.

CVS, for example, which operates more than 1,000 MinuteClinics inside its stores, has video visits 24/7 for $59. These visits aren’t covered by insurance, but you can pay for them with money from a flexible spending account or health savings account, if you have one.

Through Westmed, a chain of urgent care clinics in New York and Connecticut, you can get a virtual phone or video consult between 9 a.m. and 6 p.m. Monday through Friday. Westmed takes insurance and charges $49 for those without coverage.

House calls on demand. The old-fashioned house call is making a comeback, fueled by advances like portable X-ray machines and apps that can make your cell phone function like an ultrasound machine. This option may be especially useful for people who are too ill to get to a doctor, and currently, those who are quarantined at home.

The on-demand house call company Heal promises to get a healthcare provider to your home within a few hours between 8 a.m. to 8 p.m. seven days a week. While Heal’s doctors can’t test for COVID-19, they can refer symptomatic patients to state and federal health officials. Heal, which operates in more than a dozen cities, accepts many insurance plans, but if yours isn’t covered, the cost is $159.

Remedy, another on-demand house call service, says it will send a healthcare provider to your home within 2 hours. It takes insurance, but if you don’t have coverage, it charges $199 for a house call.

High-tech healthcare hybrids. A growing number of technology companies moving into the healthcare space offer both virtual and in-person care. These hybrids are mainly in major metropolitan areas, and some are still small.

Forward, for example, which launched in 2016, is based in San Francisco and also has several locations in Southern California, New York City, and Washington, D.C. It doesn’t accept insurance, instead charging a $149-per-month fee for 24/7 remote access to its doctors, as well as unlimited in-person doctor visits.

One Medical, a network of primary clinic providers that offers virtual and in-person care, is larger, with 70 clinics in nine cities. It accepts insurance but charges a $199 fee on top of that to use its services. It also has relationships with 6,000 employers who cover the membership fee for workers. Carbon Health, which is based in California, accepts many insurance plans and also offers a virtual visit for a $49 flat fee.

Know the Limitations

Of course, getting care outside a traditional healthcare facility has its limits. “I can ask someone about their breathing, but I can’t look into their lungs,” Mehrotra says. “A telephone or video call can be a good place to start, but where you get care really depends on the condition being addressed.”

Those limitations are especially important to keep in mind right now. “The symptoms of COVID-19 are difficult to differentiate from those of the typical seasonal flu or a common cold,” says Will Kimbrough, M.D., senior medical director of clinical services at One Medical.

At all times, checking with a telehealth provider or calling your doctor can help you decide whether you need to be seen in an office setting or an emergency room, or can safely remain at home, Kimbrough says.

If you suspect an emergency in your household, call 911 right away. That includes difficulty breathing, chest pain or other severe pain (especially abdominal), broken bones, coughing up or vomiting blood, unresponsiveness, bleeding that can’t be stopped with direct pressure , and signs of a stroke , such as facial drooping, arm weakness, and speech difficulty.

Additional reporting by Jessica Branch

Donna Rosato

As a journalist on the special projects team at Consumer Reports, I investigate issues that affect consumers' health, finances, privacy, and safety. My particular focus is on helping people untangle problems with medical bills, cover steep healthcare costs, finance the skyrocketing cost of college, and manage student debt. I was previously a writer at Money magazine, wrote for The New York Times and was a business reporter at USA Today. If you have a tip, follow me on  Twitter  (@RosatoDonna).

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Home Doctor Visits: What Does Medicare Cover?

Since the beginning of the Covid-19 pandemic, patients have been hesitant to schedule in-person doctor visits ­– hence the increase in telehealth and telemedicine services. Yet, there are many conditions, services, and treatments for which virtual appointments are far from ideal.

Medicare beneficiaries may have Covid-related anxieties regarding face-to-face appointments in a medical setting, because of their higher risk. This begs the question: Does Medicare cover home doctor visits?

Types of Medicare Coverage

Before you try to figure out whether Medicare will cover a home doctor visit, you’ll need to know which doctors you can visit with your coverage. When you have Original Medicare (Parts A and B), with or without a Medicare Supplement (Medigap) policy, you’ll have coverage for any practitioner accepting Medicare assignment. Fortunately, most doctors in the United States accept the coverage.

With a Medicare Advantage (Part C) plan, you’ll need to stick to your policy’s network of doctors to receive coverage for any care you receive. Additionally, you’ll require referrals for coverage through your plan when seeing any specialist. Part C includes the coverage Parts A and B provide, which are inpatient and outpatient services, respectively.

When Does Medicare Cover House Calls?

Unfortunately, Medicare doesn’t typically cover the type of house calls with which people are most familiar. Even in the age of Covid, it’s not as simple to make an appointment for a home visit from your primary care physician as it is to schedule a telehealth visit.

Ultimately, Medicare will pay for you to receive care at home ( home health care ) if your circumstances qualify you for such. Again, you’ll need to make sure your provider accepts Medicare assignment (if you have Original Medicare) or is within your Advantage plan’s network for your care to receive coverage. This rule of thumb applies regardless of whether the care will take place at your home.

Medicare’s guidelines for home health care dictate that the visit must be medically necessary. Thus, you must be under the care of a doctor for your condition(s) and your doctor deems certain at-home care to be a necessity.

You must qualify as homebound, meaning you have difficulty leaving your home independently (i.e., without the use of an assistive device, such as a cane). Further, your practitioner must document a face-to-face meeting with you to verify your eligibility.

An eligible individual can receive physical, speech, or occupational therapy, or intermittent care from a skilled nursing professional at home. The practitioner providing the service must accept Medicare assignment or contract with your Advantage plan.

Independence at Home

In 2011, the Centers for Medicare & Medicaid Services (CMS) launched a program called the Independence at Home Demonstration. It is a voluntary, primary care program for patients with multiple chronic conditions who are still living independently but would benefit from a doctor’s visit at home. Yet only an extremely limited number of sites across the country participate in the model.

The program has resulted in savings for CMS. While the program was supposed to end at the close of 2020, it is now extended through the end of 2023 . If further success results from this endeavor, Medicare may see changes regarding this type of care.

The Future of Home Doctor Visits on Medicare

Hesitancy to attend in-person medical appointments due to possible Covid-19 exposure increases the need for alternative options. While Medicare now includes more coverage for telehealth than ever, the same cannot be said for house calls.

When an individual needs a face-to-face appointment with their primary provider to determine necessity for home health care, it’s clear that coverage is far from comprehensive. With the need to fill this gap in coverage and the success of the Independence at Home Demonstration, Medicare will hopefully see more coverage for primary care house calls – including routine check-ups – in the future. The health of beneficiaries depends on it.

How often have you visited your doctor’s office in the past year and a half? How often have you used telehealth services? Would you ask for a home doctor visit if it were available? How would that help you?

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Yes I’d love home Dr visits, im wheelchair dependent and getting out and dressed for the appointment is an all day thing, not to mention wating to be seen is extremely painful.

Tags Medicare

Jagger Esch

Jagger Esch is a Medicare expert and the founder, president, and CEO of MedicareFAQ. He has been working in the Medicare space for over 10 years. Jagger has a passion for sharing his expertise on Medicare to beneficiaries so they can be better prepared for health care costs after retirement. His YouTube channel features various videos that help Medicare beneficiaries discover all their options.

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House Call Program - MedStar Total Elder Care

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Promoting the health and dignity of frail elders

Many elders struggle with disability and severe chronic illness and have difficulty getting to the doctor’s office. As a result, their health may suffer and lead to unnecessary ER visits, hospitalization, or nursing home care. In 1999, recognizing the needs of such elders and their families, we created the MedStar House Call program - MedStar Total Elder Care to provide full medical and social services that help elders remain in their homes with dignity. These teams now serve both Washington, D.C., and Baltimore, MD.

The MedStar House Call Program - MedStar Total Elder Care is nationally recognized for the quality and outcomes of our care. We serve patients at home with a team of geriatricians, nurse practitioners (NPs), social workers, office nurses, and coordinators. We make routine and urgent house calls (in-person or via telehealth with video or audio-only phone visits). Our medical staff is also available by phone 24/7 for urgent issues. We provide access to state-of-the-art hospital and specialty care. Additionally, our physician team follows our patients if and when they are admitted to the MedStar Washington Hospital Center.

The House Call program serves our neighbors in Washington, D.C., and Baltimore.

Medstar house call program .

(operating under MedStar Total Elder Care, LLC) 

Our program services

Medical house calls and primary care by doctors and nurse practitioners with expertise in the care of older adults

Counseling and caregiver support by social workers and team staff

We offer tests and treatments at-home, and at the hospital as needed

Home delivery of most medications and equipment

Coordination of specialist care at MedStar Washington or MedStar Good Samaritan

Coordination of home nursing, rehab therapy, and hospice

Coordination of support services such as home aides and legal assistance

On-call physicians: 24 hours a day, 7 days a week (by phone)

Mobile electronic health record (EHR)

D.C. Neighborhood only – Case management for Medicaid Elderly Persons with Disabilities (EPD) Waiver

Hospital care and specialists

Our team coordinates emergency, hospital, and specialty care at MedStar Washington and MedStar Good Samaritan. Patients may keep their previous specialist doctors; we work with them as needed. We refer to MedStar Good Samaritan, MedStar Washington, for home-based podiatry or other new specialist care. If House Call patients require hospitalization, and 911 is not needed, our team can arrange transportation and admission to MedStar Good Samaritan or MedStar Washington when beds are available.

Social work services

Our dedicated team of social workers provides:

Psychosocial assessment

Care Coordination

Development of an individual treatment plan

Information and referral to community resources and supports

Caregiver education, support, and counseling

Advocacy to connect with other service networks and legal counseling

Crisis intervention

Assistance with identifying alternative living arrangements, as needed

Eligibility

Enrollment and insurance.

To qualify for the MedStar House Call Program, patients must:

Be 65 years or older and have difficulty getting to the doctor’s office

Have Medicare, Medicaid, or another participating insurance plan

Stop seeing their previous primary doctor and agree to have us take on that role following the first visit

Live in a qualifying ZIP code

Our office is open 8:30 a.m. to 4:30 p.m., Monday - Friday.

When calling about new patient enrollment, please have the following information:

Patient's name, address, telephone number

Patient's date of birth and social security number

Patient's next of kin and emergency contact information

Patient's health insurance information (including type and group number)

Patient's current medical conditions and concerns

Ability to retrieve patient's recent medical records

Baltimore neighbors, print and complete our  Intake Questionnaire form

As in most doctor's offices, your main health insurance (such as Medicare) covers 80 percent of House Call visit fees, and any secondary insurance covers the other 20 percent. The patients who do not have any secondary insurance are responsible for the 20 percent co-pay.

Qualifying ZIP codes

View the map below to check if you live in a qualifying ZIP code. Call our Washington, D.C., or Baltimore location to confirm MedStar House Call Program eligibility at your exact address.

Washington, D.C.,

View our brochures

Baltimore region brochure

Washington, D.C., region brochure

Washington, D.C., region team - 202-877-0570

Physicians Eric De Jonge, MD, – Section Director Guy (Binny) Chang, MD Nurse Practitioners Nancy Sassa, CRNP - Chief Alexandra (Caitlin) Geary, CRNP Michelle Sullivan, CRNP Office Nurse Kendel Ogbeab, RN Social Workers Gretchen Nordstrom, LICSW - Chief Kellie Jones, LICSW Ruth Shea, LICSW Operations Manager Isi Koroma Care Coordinators LaWanda Holeman Sandra Mills Carrie Carmon Yvette Williams

Baltimore region team – 443-444-6100

Physicians George Taler, MD Sharareh Badri, MD Nurse Practitioner Dorothy Were, CRNP Adama Panda, CRNP Nurse Nerland Dimanche, RN, MSN Social Worker Marina Nellius, LMSW Operations Director Shereen Greene, MBA Care Coordinator Taurshica Lee

Operational support

Executive Director George Hennawai, MD AVP Operations Julie Beecher, MS, MPH

Baltimore Neighborhood

To learn more about our services in the Baltimore region, call us today.at 443-444-6100.

Washington, D.C., Neighborhood

To learn more about our services in the Washington, D.C., region, call us today at 202-877-0570

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• Research article
• Open access
• Published: 22 April 2011

Home visits - central to primary care, tradition or an obligation? A qualitative study

• Gudrun Theile 1 ,
• Carsten Kruschinski 1 ,
• Marlene Buck 1 ,
• Christiane A Müller 1 &
• Eva Hummers-Pradier 1  

BMC Family Practice volume  12 , Article number:  24 ( 2011 ) Cite this article

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Home visits are claimed to be a central element of primary care. However, the frequency with which home visits are made is declining both internationally and in Germany despite the increase in the number of chronically ill elderly patients. Given this, the question arises as to how to ensure sufficient primary health care for this vulnerable patient group. The aim of this study was to explore German general practitioners' (GPs) attitudes with regard to the feasibility, burden and outlook of continued home visits in German primary care.

Qualitative semi-structured interviews were carried out with 24 GPs from the city of Hannover, Germany, and its rural surroundings. Data was analysed using qualitative content analysis.

The GPs indicated that they frequently conduct home visits, but not all of them were convinced of their benefit. Most were not really motivated to undertake home visits but some felt obliged to. The basic conditions covering home visits were described as unsatisfactory, in particular with respect to reimbursement and time constraints. House calls for vulnerable, elderly people remained undisputed, whereas visits of a social nature were mostly deleted. Urgent house calls were increasingly delegated to the emergency services. Visits to nursing homes were portrayed as being emotionally distressing. GPs considered good cooperation with nursing staff the key factor to ensure a successful nursing home visit. The GPs wanted to ease their work load while still ensuring quality home care but were unable to suggest how this might be achieved. Better financial compensation was proposed most often. The involvement of specially trained nurses was considered possible, but viewed with resentment.

Conclusions

Home visits are still an integral aspect of primary care in Germany and impose a considerable workload on many practices. Though the existing situation was generally perceived as unsatisfactory, German GPs could not envisage alternatives if asked to consider whether the current arrangements were sustainable in the future. To guarantee an unaltered quality of primary home care, German GPs and health care policy makers should actively initiate a debate on the need for and nature of home visits in the future.

Peer Review reports

Home visits are claimed to be a central element of general practice as this represented the primary mode of healthcare delivery by community physicians from the mid-20 th century [ 1 ]. Today in most European countries and the United States home visits are the exception and are no longer the standard method of health care delivery - although there is diversity between individual general practitioners (GPs) and different countries [ 2 ]. Self-employed GPs visit more patients at home than salaried GPs; house calls are less frequent in health care systems where GPs act as gatekeepers and patient lists are maintained [ 2 ]. Male GPs make more visits than female doctors, but the latter take more time per visit. In every system there are opponents and supporters of home visiting, e.g. in the United States special house call practices are run. There are however two facts common to all countries and doctors: the number of home visits is continuously declining while the primary target group, namely older, multimorbid people, is growing.

These contradictory findings are the results of several studies published in the last two decades, which have analysed the number of home visits from either quantitative surveys or practice data. They are also true for Germany. However, an analysis conducted at our institute has demonstrated that, despite an overall decreasing frequency of house calls, the number of house visits per home patient has been stable [ 3 ]. This finding has supported the assumption of other authors that only house calls of questionable medical importance have been eliminated [ 2 , 4 ].

Despite these considerations, the number of house calls in Germany is still comparatively high with a mean number of 34 visits per GP per week. In Austria, Benelux, and France more than 20 visits were counted on average [ 2 ]. At the same time many GPs complain of the heavy workload, the insufficient remuneration and the minimal benefits associated with home visiting. Boerma stated nearly ten years ago that patients prefer home visits much more than their doctors do. As the German primary health care system is dominated by self-employed GPs and is thereby competitive, patients' perspectives undoubtedly account for the German "traditionalism" with respect to home visits. But what are incentives for German GPs to continue or discontinue to make home visits? Who do German GPs visit at home and why? Do German GPs prefer this "delivery service" or can they suggest other models of care? Answers to such questions may be meaningful in the context of considering new potential home care models. Thus, the aim of this study was to explore the attitudes of GPs with regard to the feasibility, burden and outlook for home visits within German primary care in the future.

We chose a qualitative approach as our study focussed on subjective GPs' attitudes. As we wished to create a relaxed atmosphere that would allow the GPs to speak freely, we conducted semi-structured interviews at GPs practices or homes.

Participants

Our intention was to create a purposive sample balanced for the following characteristics: gender, years of occupation, practice location (urban/rural) and practice size (less/more than 2000 patients per quarter). GPs with an entry in the telephone book were contacted initially by telephone and subsequently, if the above mentioned characteristics were compatible, in writing. If a GP was willing to participate, a second call was organised in order to provide more detailed information about the topic and the aim of the study, and to schedule an appointment for the interview. Participants received no remuneration.

The development of the interview guideline was steered by the goal of obtaining opinions, facts and ideas related to home visiting. Potential points of interest and the wording of the questions was discussed by the two main researchers (GT, MB) and finally agreed. The following aspects were included: motivation and organisation of home visits, home visits in nursing homes, procedure and organisation, future perspectives. In addition, the interview started with a provocative warm-up question; a conclusive question at the end allowed a short résumé. (The elaborated interview guideline is depicted in Table 1 .) Two pre-tests were conducted to check comprehensibility and fluidity of the guideline. Its final version was condensed into a list of catchwords that were serving as memory hooks representing the detailed questions in order to create a natural conversation. The interviewer (MB) was trained in communication skills. In addition to voice-recordings, handwritten memos were taken in order to document specific or important aspects of each interview. After the interview, GPs filled in a short questionnaire to provide demographic data.

All interviews were digitally recorded and transcribed verbatim by the interviewer herself. Data analysis was conducted independently by two researchers (GT, MB), one of them using ATLAS.ti software, the other coding "by hand". The basis of the analysis was a predefined system of categories, which were generated by the interview guideline. This categorising system was enhanced by codes, which emerged from the text material and were agreed by both researchers after exhaustive discussion and consideration of the additional information from the handwritten notes. In situations where it was not possible to resolve a disagreement, a third researcher was involved until consensus was obtained. By using this iterative approach we refined the initial categorising system and built new codes and subcategories that accounted for themes or aspects of specific topics that had not been considered previously. Furthermore, we analysed some data from the text quantitatively, i.e. number of home visits per week, length of the visits, radius (km) around the practice for home visits as well as demographic data.

A total of 24 GPs agreed to be interviewed, 13 of them male. The median age was 54 years (interquartile range IR 38 - 57 years); the median number of years in private practice was 13 years (4 - 22 years). The GPs came from 14 practices located in Hannover City and 10 in surrounding rural areas. As GPs from group practices were much more likely to agree, single handed practices or group practices consisting of just two partners were underrepresented in the final sample (20.8%). One half of the participating GPs worked in practices with more than 2000 patients per quarter. The mean interview duration was 40 minutes.

Text Analysis

In the following we describe the theoretical framework, which evolved from the coded text material. The first sub-section is about quantitative data collected during the course of the interviews. Although these numbers cannot be representative, they give an impression of the workload and performance characteristics associated with home visits carried out by the interviewed GPs. Subsequently, different types of home visits, as described by the interviewees, are illustrated; house calls in nursing homes represent a specific category. Lastly, motivational and negative factors are discussed together with ideas for the future of house calls and home care.

Home visits in numbers

The average home visit conducted by the interviewed GPs lasted 25 min (IQR 17.5 - 30), and took place in the patient's home within a radius of 6.5 (IQR 3-10) km from the practice. The median of the number of home visits per week carried out by a single GP was 6.5 (IQR 3-17.5). For further information regarding the GPs see Table 2 . Female GPs conducted considerably fewer home visits than their male colleagues, but they invested more time per visit. The workload resulting from house calls was highest within the group of rural GPs. They required more time per house call and visited more patients per week compared to urban doctors. GPs with more than 20 years of experience conducted fewer home visits than more junior colleagues.

Types of home visits

One of the interviewees provided in his own words a very structured differentiation and definition of three types of home visits, which were relevant to most of the other interviews.

"Some of the home visits are of a supportive nature, they actually represent the need for "social interaction" and there isn't a real medical indication. Another class of home visit is to those people who really do need medical care either because they are chronically ill or find it difficult to come to the practice. And then there are those home visits, which are requested due to acute diseases which can be anything from gastrointestinal infection, influenza infection, pneumonia....."

Thus, GPs distinguish between supportive home visits, routine home visits and urgent home visits.

Supportive home visits

Home visits of a supportive nature seem to be more important to rural GPs than to those from urban areas. Provincial GPs often perceived themselves not only as medical advisors but also as real companions for their patients. Such traditional professional ethics, which sometimes cross the boundaries of self-abandonment, were rejected by most urban GPs.

"It wasn't my aim to be a minister. In my opinion it's a social problem, which has been cultivated by all of us for decades. But it's not a physician's job to solve this problem."

Business competition in districts with a high density of GPs is apparent. Home visits are reimbursed poorly in Germany and those without any medical indication are avoided.

Most urban GPs deny conducting home visits of a supportive nature, although there is a smooth transition between supportive and routine home visits.

"I have to admit that some time ago, we were more generous with home visits. If there is an old lady with a decubital ulcer or a tumour, then, of course, we still make a routine visit to her. But we don't travel to see all the elderly once a week so that all the elderly in our town get used to a doctor's visit happening every week - that we won't do."

"That is the point: what has changed in the patient? Does he somehow appear different from the last time? Does he have complaints he didn't mention on the telephone? If there's nothing, then there's some small talk, a little social support."

Routine home visits

Routine home visits for older chronically ill and increasingly immobile patients are the least challenged visits. All interviewed GPs appreciated the usefulness of routine home visits to detect changes in patients' health status, to control drugs or to achieve an overview of the adequacy of the situation at home.

"Well, you have to listen to how the patients are getting on. You've known them for some time. These are home visits you repeat again and again. You look at how they are doing. You ask after their family, their kids, what they always talk about. You have to know the social environment. You have to look not only if they are alright but also you have to look why he's not on form. Whether he's not got a place in a retirement home or such things for example. Of course you need to talk to them about such things."

Urgent home visits

These visits are characterised by an urgent, sometimes immediate need. Most practices have developed an approach to filter the objective requirements related to the patient's concern. Mostly this was done by the GP himself, but in some practices the medical assistants were trained to perform triage on the telephone.

"Yes, you'll assess what awaits you a bit on the telephone. What's good is that we know the patients. For it's either the worsening of a chronic condition, which you can quickly bring under control, or an infection with a high fever or acute diarrhoea. Some call the GP for such illnesses, others don't. In such situations it's possible to establish on the phone, can I help here?"

Only a few of the interviewed GPs left their practice during consultation hours to travel to an extreme case, occasionally after having concurrently informed the emergency services. These GPs argued that no one else knew the medical history of the affected patient as well as they did, and considered themselves the most competent first aider. Most of the other GPs, especially the urban doctors, tended to delegate the real emergency cases -those that could not be delayed- to the emergency services. These GPs rated their competency in real life-threatening situations poorly. They viewed this approach as more reasonable, both with regard to the medical care of the patient and potential economic consequences.

"Well, if I rush out, everything would become so confused - also with the scheduled appointments of other patients and so on. I can't afford that."

In case of febrile exacerbation of an infection or other acute but not life-threatening conditions, most GPs offered their visit after consultation time or during lunch break, and some asked their patients to consider a practice visit regardless of the acute symptoms. Thus, many GPs aimed to reduce the workload associated with urgent house calls.

Home visits in nursing homes

All of the interviewed GPs conducted visits to nursing homes. However, those working single-handed in a practice limited this type of house call to a very small number, just caring for a few selected patients. Whereas GPs from group practices, in particular with more than two partners, cared for a greater number of patients in nursing homes. The average GP of our interview group visited 20 nursing home patients per week within 1.7 hours. In this context, the physicians reported that they did not see every single patient but conducted mainly chart reviews.

"And I do need two and a half hours for 30 patients (....) so that's five minutes per patient. This is not much. Generally, I don't visit every single patient but only those with acute problems."

Visits in nursing homes were perceived to be quite similar to ward rounds in hospitals. They normally lacked the intimate and confidential atmosphere of a doctor's visit in his patient's home. In most cases, a nurse accompanied the doctor and sometimes family members with their own concerns were present.

Therefore cooperation with the nursing staff was an aspect broadly discussed by many of the interviewed GPs. Most of them described having "trained" the nurses of the regularly visited old people's homes with regard to appropriate telephone calls and preparation for their visits. Experienced nurses seemed to be crucial for successful cooperation, but a shortage of staff and employment of unskilled helpers were frequent problems:

"Most of the nurses are well trained and good natured. For financial reasons staffing is kept to a minimum and this is causing problems."

"There are people who know what to do, but there are also housewives and career changers, who panic and immediately call me or the emergency doctor, when someone has high blood pressure."

The everyday care and examination of a patient's health status was accomplished by the nursing staff, whereas the interviewed GPs often defined their role in nursing homes as "supervisory". Therefore, some of them applied for the right to also oversee the quality standards of the nursing homes, which included the minimum standards concerning staff training.

When reporting on nursing home visits nearly all of the interview partners used remarkably emotional language. No other aspect of the interview guide provoked so many emotive, mainly negative, statements.

"It sometimes reminds me of "One flew over the Cuckoo's Nest."

"It's always about excrement, the whole day, from morning till night."

Nursing homes were described as places of resignation, despair and sadness; they appeared to be sterile, depressing and awful. The interviewed GPs' impression was that nursing home residents were living in forced circumstances and didn't take any notice of each other. A synopsis of all the comments used to describe visits to nursing homes is provided in Table 3 . While several GPs mentioned that the nursing homes themselves, i.e. the buildings and facilities had become more pleasant during recent years, only one (female) interviewee was enthusiastic about nursing home visits: "It gives me fulfilment!" She judged these visits, in her role as a GP, as her personal contribution to society. For the other interviewees house calls in nursing homes were an obligation as a result of ethical or financial considerations. Most interview partners did not wish to find themselves in a nursing home in later years.

"I mean, if I knew my children didn't want me to live as an invalid in the area or around the corner, then of course I would have to look out a nursing home. But if I had the choice I would prefer to be run over by a bus."

Motivation for home visits

When asked about their motivation for undertaking home visits, most GPs started with quite vague and general statements, along the lines of: home visits come with the territory.

"It's true, doing home visits is simply part of the job."

"Home visits are obligatory, if you become a general practitioner you have to be prepared to do home visits."

"It's in the nature of the GP's job to be on call."

However, some of the interview partners had good reasons to conduct home visits rather than simply feeling obliged to. For example, the exploration of a patients' home setting and the experience of working in an unfamiliar environment, as opposed to the safe surroundings of their own practice were mentioned in this context.

"And you have a peek on this chaos, a mum with her two kids - there is also a dog bustling around and two cats. Then it's quite clear why these kids have asthma. Father is a smoker. These are things you don't quite realise in your practice, although you can enquire about. But by conducting a home visit you see this at a glance and that's great."

"This is a completely different situation. It's the patient's home. He is the boss and controls the situation. Here in my practice, I do things a certain way and the patient is often very meek. But in his home, he acts completely differently, more independent, and more self-sufficient."

The more positive aspects of performing home visits are summarised in Table 4 .

The aforementioned reasons promoting home visiting can not hide the fact that this mode of primary care delivery is not very popular. Just one-third of the interviewed GPs declared that they liked to conduct home visits, the remainder did not.

"It's not the right question [to ask if I like to conduct home visits]. But instead does it make sense to undertake home visits or not? I don't think anybody really likes to do house calls."

When asked for reasons as to why GPs feel reluctant to visit their patient at home pragmatic reasons were initially mentioned.

"Because it is difficult. You are out and about in terrible weather, when it rains or is windy. Most of the people have an awfully untidy apartment. Elderly people always have the windows closed. It's always extremely warm and when you come out you're always sweaty and sticky."

"Then most of the patients - some though are lying in their beds - I have to access in the corner of the living room behind the table in order to get near them. Or I have to move furniture to get to them. I have even visited people in loft beds or in cubby holes, which I have had to crawl into on all fours."

Home visits can put GPs in unpleasant or occasionally even dangerous situations. Moreover, some GPs felt exploited by their patients.

"Yes, I mean, if I'm stressed and have to drive somewhere to an urgent visit, then I sit in my car and complain to myself. My goodness, why can't that guy make a trip to my practice? Doesn't he have any relatives? They all drive to the hairdresser because it is too expensive for the hairdresser to come to them, but the GP can visit."

A couple of GPs referred to the restricted diagnostic options available in the domestic setting, others complained of the poor controllability of consultations in patients' homes. Some GPs even argued home visits promote social isolation because patients were not forced to go outside and meet people on their way to the doctor or in the waiting room. Home visits were perceived as very time consuming. Insufficient reimbursement of such visits in Germany was the most quoted reason for an unwillingness to perform them.

"Well, if I exclusively did home visits, I would go bankrupt. The more I do, the worse it is."

GPs expectations of an adequate payment for house visits were made on the basis of the fees craftsmen charged for their work. Locksmiths, electricians and television engineers were all envied for their hourly wages. Most interviewed physicians proposed a sum at least twice as high as the remuneration currently permitted.

The future of home visits

Whereas proposals for an adequate financing of home visits were made in sufficient numbers, ideas for the future of home visits rarely emerged. Although most GPs admitted that they conduct home visits reluctantly, they accepted their "duty" without looking for alternatives. Some though proposed the formation of a network of several practices to either reduce the workload of individual GPs or to permit the collective financing of a nurse practitioner who could conduct house calls. Such specially trained nurses were seen as the most favourable alternative to the current situation. In contrast, a district nurse who could also perform house calls was judged very cautiously. GPs suspected that this would introduce redundancy into the existing care arrangements.

"The idea to implement district nurses, I mean, that's fine, but to my eyes it's extremely important to ensure a very close connection to the doctor. The observation I have made is that nursing services, district nurses and all the others don't work together. That means we establish redundant structures. I believe it's very important that medical, nursing and preventive care is centralised."

In addition to concerns about interface problems, a certain fear associated with the establishment of multiple health care providers may also be relevant to statements regarding the future. There were GPs who, while they admitted that they had to get used to the idea of district nurses, nevertheless realised that the involvement of non-medical personnel was an indispensable requirement to cope with the care challenges associated with the anticipated demographic population changes.

Some GPs envisioned the involvement of public volunteers such as socially engaged neighbours to visit isolated elderly people. Few GPs anticipated the complete elimination of home visits. They predicted that in future all patients would be transported to practices somehow, or immediately to the hospital if necessary. This would be co-ordinated from a central office, which would also inform the respective GP about a particular patient's whereabouts and health status.

Home visits are still a component of normal general practice services in Germany. However, GPs are dissatisfied with the conditions associated with conducting them, especially reimbursement, and some doubt the additional value of home visits. A number of house calls are perceived as a "luxury" for demanding patients. Only house calls to vulnerable, elderly people remain undisputed. Home visits in nursing homes are often characterised as emotionally stressful. Despite these issues, the German GPs in our study lacked ideas, if asked about possible future alternatives to the current course of action, both in regard to house calls in patients' homes and to nursing home visits. The suggestions most often discussed included improved financial compensation for home visits and the involvement of nurses specifically trained to take on this duty.

The strength of our study is the good number of interview partners and the robust approach to transcript analysis. Qualitative research excels at the identification of subjective attitudes and experiences. The researcher tries to hold back his own assumptions in favour to record the knowledge of experts who are immersed in the field he wishes to learn more about. In this way, a wide range of relevant information and insights is gathered which may form the basis of further scientific research or influence policy. In this particular study we deliberatively focused on GPs' attitudes while ignoring the perspective of patients or health care policy stakeholders, because we wanted to ascertain the views of those who actually performed the home visits.

Our study also has some limitations. Single-handed practices are underrepresented in our sample, because they were less willing to participate. As the organisational and time constraints associated with home visits for those physicians is high, it can be presumed that they would have been even more critical towards this time consuming mode of primary care. Some of our interview partners from group practices admitted that, had they been in a single practice, they would not be conducting home visits. This is mainly because of the high organisational burden. If a single doctor is on a home visit, who is available to attend to unannounced patients at the practice? We assume that the reluctant willingness of single-handed practices to participate in our interview study corresponds to a reluctance to perform home visits or a desire to perform a smaller number of them. Moreover in future, most German general practices will be group practices because the number of single practices is constantly declining. Given this, the under-representation of single-handed practices in our sample not only seems to be "symptomatic" but also, at least with view to implications for policymakers, acceptable. However, we achieved saturation on all aspects of our interview guide and our findings are consistent with previous research published in this field, indicating a sufficient exploration.

Only the noticeable failure of our respondents to suggest ideas about the future of home visits could have been an indicator that our questions failed to elicit their ideas. It is possibly that focus groups could have been more fruitful with regard to this specific issue, as GPs would have had not only to consider their own experiences but to generate new solutions and to be "creative".

It should be emphasised that although many of our results are similar to those from other countries, it would be inappropriate to generalise. The aim of this study was to uncover the perceptions and issues faced by German GPs regarding home visits.

Of those GPs who participated in our survey, male GPs and those practicing in the countryside in particular routinely made a number of home visits per week. Whereas the frequency of home visits in rural areas seems to depend on the health care tradition of the respective country [ 2 ] - e. g. Aylin et al. reported a lower house call rate for the rural population in Wales [ 5 ] - the male dominance of those undertaking home visiting is a more "universal phenomenon". The same applies to the fact that female GPs visit fewer patients but spend more time with them [ 2 , 6 , 7 ]. Our sample of female doctors more frequently worked part-time. But we assume that a different, more patient-centred female working culture is also relevant to the reduced number of patient contacts associated with longer consultation times. Unlike colleagues from the United States [ 8 ], none of our interview partners referred to the risk of meeting potential aggressors during home visits. Therefore, at least in Hannover and its surroundings, the fear of attack didn't seem to be a critical issue with regard to the smaller number of home visits made by female GPs. Although most international studies reveal higher home visiting rates for experienced GPs [ 2 ] in our sample the younger doctors conducted many more house calls than their older colleagues -probably because German practice owners tend to delegate home visits to their vocational trainees. Svab et al. (2003) reported a similar trend in the Slovenian primary health care system of young residents losing their interest in home visits after completing their training [ 9 ].

There is consensus in literature that home visits should be carried out for the old and frail, and critically ill patients [ 3 , 4 , 10 – 15 ]. The respondents of our study therefore acted similarly to the majority of their colleagues in Europe, USA and Canada. Nevertheless, house calls for the elderly living at home in Germany were not always of a medical nature and this is also true in other countries [ 16 ]. This type of visit was debated by many GPs: whereas some physicians believe this form of interaction not only pleases the patient, but it additionally establishes and improves the reputation for their practice, others propose that such house calls are completely dispensable as their omission would not reduce quality of care. Although supporting data were not available, it can be assumed that a considerable proportion of home visits in Germany are of a supportive social nature. GPs in our interview group as well as in other health care settings [ 17 ] responded to this by sharpening their criteria for home visits and "educating" their patients [ 18 ], but apparently they still responded to patients' needs [ 2 , 4 ]. Boerma et al. additionally remarked in 1996, that "the strong variation between individual GPs as well as countries in the practice of home visiting suggests a lack of urgency or a need for some of the visits." This "lack of urgency", seems to be true even for genuine emergency visits (those unscheduled house calls, which are made to people with acute conditions). According to our analyses, rural GPs regarded themselves as competent first-aiders because they possessed useful information about patients` history, while urban GPs tended to delegate such emergency house calls more and more to the emergency services. This was not only due to their concerns of dealing with a life-threatening situation when there is an excellent urban emergency ambulance system, but also for economic reasons. Leaving during consultation hours is problematic and if the visit can be delayed into lunchtime or after hours, the question arises if it would not be equally justifiable for the patient to contact a hospital ambulance. Nevertheless all German doctors including specialists working in the ambulant sector are legally bound to conduct home visits. Generally GPs more or less felt obliged to adhere to these regulations. Because of the high density of alternative emergency services, urban GPs seem to be more secure with respect to the consequences of not making home visits. None of the interviewed GPs though referred explicitly to potential liabilities associated with failure to make routine or urgent home visits. GPs may however hesitate to admit that such considerations would affect their decisions.

Although home visiting in the German health care system can be troublesome and may sometimes be a low medical priority, good reasons to perform home visits do exist. Those motives are more personal, accruing from daily work and experience with patients, and are based on a micro, rather than a macro level of health care. First of all, many of our interviewed GPs, similar to other studies [ 12 ], regarded home visits as an opportunity to gain additional information about a patient's living conditions, family dynamics and lifestyle. Moreover they additionally obtained a detailed insight into the patient's abilities and their compliance, especially with regard to taking their medication and/or safety issues. Undoubtedly, the direct exploration of a patient's environment yields valuable information, which may improve the quality of care. Some of our respondents concurred with several studies that indicate the potential of home visits to reduce, or at least better inform the suitability of hospitalisation [ 19 , 20 ]. Caplan et al demonstrated that elderly patients with different acute conditions treated at home rather than in hospital were less likely to develop geriatric complications as confusion, bowel or urinary problems. While the overall number of deaths did not differ significantly between the two environments, the patients' and care givers' satisfaction was significantly higher in the "at-home-group" [ 21 ]. A recent study from Brazil has also demonstrated the cost effectiveness of home visits in the treatment of alcohol dependent patients [ 22 ]. These scientific observations would seem to suggest that home visits deliver an enhanced quality of care and can be cost effective for people suffering from chronic conditions. However, reports describing the effectiveness of home visits by family physicians for a range of conditions encountered in General Practice are still lacking.

Both in our study and in others, the interviewed GPs frequently recognised the positive marketing effect of house calls. One of our interviewees stated that home visits "make patients happy" and there is some research evidence indicating that patients are more dissatisfied with their GP if they undertake fewer home visits [ 10 ]. GPs therefore have good reasons for home visiting, even if a strong medical reason does not exist. Boerma et al. showed that in countries where GPs are mainly salaried, the estimated average number of visits per week was much lower than that in countries, such as Germany, where GPs are usually self-employed. This finding suggests that the decision to undertake a home visit can be made more critically in a non-competitive health care system, and that many self-employed GPs will tend to yield to the concrete or assumed wish of their patients - be it for marketing purposes or for liability concerns. Court et al. commented on out of hours requests for GP visits as eliciting an "inappropriate fear of complaint, which is likely to potentiate inappropriate demand for visits" [ 16 ]. He concluded that further research should explore how this defensive medical practice could be modified to benefit both patient and practitioner. Nearly 15 years later in Germany, GPs admit to feeling obliged to carry out home visits because they "sell well".

Interestingly, the reason most frequently cited against visiting patients at home is also an economic one: GPs complained about the insufficient remuneration for conducting house calls. In the current German health care system, home visits receive minimal financial compensation and their suggested economic advantages through prevention of hospital admission or psychiatric crises do not have any direct financial impact on the service provided by GPs. Therefore GPs feel that satisfactory financial recompense is one of the most important changes needed with regard to the maintenance of this special form of patient care [ 17 ].

In Germany, nursing and residential homes for the elderly do not have their own on-site doctors. Thus as a rule, the GP who has provided care to the elderly patient up to this point will continue to do so after they move into the care home. Home visits to nursing homes differ notably from the "usual" house calls in that they rather resemble ward rounds in hospitals. GPs normally talk much more to the nurses than to their patients. The GPs interviewed in this study commented on the very high emotional burden associated with this sort of home visit. A variety of reasons attracted them to make house calls in nursing homes. These ranged from the relative ease and cost-effectiveness of making visits to multiple patients in one retirement home, to it being professionally ethical to continue to provide care to a long-term patient moving to such an environment; but never has it seemed a real vocation. None of the GPs in our interview group could imagine going to a nursing home themselves in later life. GPs are not specifically trained to work in a care home environment and it is challenging both professionally and psychologically. Therefore, it is not difficult to understand Katz et al. who postulated in 2009 on the creation of a nursing home medicine speciality in the United States [ 23 ]. He quotes that the marginal involvement of physicians impedes communication and their integration in nursing home culture, which has a detrimental impact on patient outcomes. Most acute illnesses are managed by telephone, which in the light of the medical complexity of the residents, may not be in their best interests [ 24 ]. These observations from the United States are applicable to the German situation given the claims of an interview partner in our study; one GP sought to be involved in the staff management of care homes in order to enhance quality of care of the elderly patients. Consequently we feel that a discussion about specialised nursing home physicians, similar to positions already established in the Netherlands [ 25 ], should be conducted more intensely and more open-mindedly than it is currently in Germany.

However, when asked to consider the future of home visits in general, the participants of our study failed to propose any significant ideas. Very few among them had considered reorganising home visits or even home care in the German health care system. The most frequently considered alternative was for home visits to be performed by practice nurses linked to their practice. In fact, the German primary care system is currently offering courses to specially train such nurses (e.g. Versorgungsassistentin in der Hausarztpraxis (VERAH ® , or Care Assistant in Family Practice) but such supporting personnel are not widely established and reimbursement has limited attractiveness. In this regard Germany is lagging behind other countries, where nurses are medically trained and actively involved in ambulant patient care, even sometimes acting as "substitutes" for doctors. Far less conceivable for the GPs of our interview group, was the engagement of an independent nurse to conduct home visits for multiple, but not necessarily linked general practices. This is despite finding that an initial project to establish whether such an arrangement would be attractive or even essential for undersupplied rural areas in Germany had good acceptance from both patients and the participating GPs [ 26 ]. A study from the United Kingdom showed that nurse practitioners could substitute for GPs in out-of-hours-calls without any deterioration in patient satisfaction or clinical management outcomes [ 27 ]. One of our respondents could see an abolition of home visits in favour of primary care centres, which patients attend and hospital ambulances would provide transport to if necessary. This is exactly what GPs from an English investigation rated as a possible alternative to out-of-hours visits [ 17 ]. Surprisingly, our interview partners did not suggest making more use of technology (e.g. telecommunication, computer guides to diagnosis and treatment) although it is likely to both be used in future home care and change the culture of home visits [ 28 ].

The results of our study indicate that a conscious discussion is needed on the pros and cons of home visits in their current form in Germany. GPs willingness to further conduct home visits under the existing conditions is rather small. However there are suggested advantages for primary home care, as economic savings by e.g. avoiding hospital admissions or to ensure health care for housebound elderly. Such presumed advantages must be critically addressed by further health care and economic research. Moreover, patients' perspectives on home visits and those of other stakeholders from the health care system will have to be explored. Another striking point is the GPs' attitude towards nursing home visits. Further research needs to evaluate the current situation in German nursing homes by assessing the attitudes and needs of patients and nurses. Our Institute of General Practice and Family medicine will contribute to this important, under-researched field by conducting a qualitative empirical analysis of interprofessional collaboration and communication in nursing homes. The planned study is funded by the German Federal Ministry of Education and Research. It will include 120 interviews with GPs, nurses, residents and their relatives, and additional direct observations and focus groups involving another 100 individuals from the various stakeholders. In this way we hope to achieve a broad insight into medical care in nursing homes.

What ever change future will bring to the home visit system as it now stands: the quality of primary health care must be maintained while an out-dated system will have to be modernised so that it can deal with the shifting population demographics.

While home visits in Germany seem to represent a primary care tradition and are rated to have clear advantages with regard to patient care they are nevertheless perceived as an obligation by many GPs. A conscious discussion on the pros and cons of home visits in their current form in Germany seems to be indispensable. Visits to nursing homes are perceived as emotionally stressful. Further research is needed to obtain a broad insight into GPs' (negative) attitudes towards nursing homes and to develop improvement strategies concerning primary home care. If home care by GPs is politically desired or recognised by society as the best way to ensure good medical care particularly for the very old and sick, appropriate financial incentives would effectively guarantee a continuation of this "tradition". To quote Leff et al.: Sentiment alone will not be enough.

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Acknowledgements

We thank all the general practitioners who participated in this study.

The study has been funded by the Institute of General Practice and Family Medicine, Hanover Medical School.

The article processing charge has been funded by a programme of the Deutsche Forschungsgemeinschaft (DFG): "Open access publication".

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Institute of General Practice and Family Medicine, Hanover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany

Gudrun Theile, Carsten Kruschinski, Marlene Buck, Christiane A Müller & Eva Hummers-Pradier

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GT conceived of the study, was involved in analyzing and interpreting the data and wrote the manuscript. MB was involved in study design, conducted the interviews, and performed the analysis of the data and interpretation of the data. CK, CM and EHP contributed to the interpretation of the data, the writing, and critical revision of the manuscript. All authors read and approved the final manuscript.

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Theile, G., Kruschinski, C., Buck, M. et al. Home visits - central to primary care, tradition or an obligation? A qualitative study. BMC Fam Pract 12 , 24 (2011). https://doi.org/10.1186/1471-2296-12-24

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DOI : https://doi.org/10.1186/1471-2296-12-24

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GP mythbuster 71: Prioritising home visits

It is good practice for GP practices to have systems in place to triage and prioritise home visits.

Since the coronavirus (COVID-19) pandemic, the need for a home visit should be continue to be carefully assessed. The British Medical Association (BMA) and Royal College of General Practitioners have published COVID-19 Workload Prioritisation Unified Guidance  which explains response levels. The guidance outlines types of work that should be undertaken in primary care, depending on:

• COVID-19 prevalence
• other workload
• workforce factors

The British Medical Association (BMA) has produced a COVID-19 toolkit for GPs and GP practices .

NHS England issued a patient safety alert to raise awareness of the need to have a system in place to assess:

• whether a home visit is clinically necessary , and
• the urgency of need for medical attention.

The alert states that:

"This can be undertaken, for example, by telephoning the patient or carer in advance to gather information to allow for an informed decision to be made on prioritisation according to clinical need. In some cases, the urgency of need will be so great that it will be inappropriate for the patient to wait for a GP home visit and alternative emergency care arrangements will be necessary."

"Many practices will already have systems in place to manage home visits. Where this is the case, consideration should be given to whether a review is required in light of this alert. The review should also consider whether all clinical and non-clinical staff involved in the process are aware of their responsibilities when managing requests for home visits, and if any outstanding training needs exist.”

GPs should also consider whether alternate ways of assessing the patient are appropriate. For example, video call, telephone calls or the use of virtual wards in care homes.

When delegating home visits, the provider must ensure that the Health Care Professional (HCP) has the necessary:

• competence and
• training to deliver the home visit.

The HCP should also receive appropriate supervision and support from the clinical team. Practices should ensure that the person allocated is competent to carry out home visits.

When we inspect

We will expect to see evidence of how the provider has assured themselves of the capability of non-medical HCPs, to whom they delegate home visits. This should include a process of assurance: both on initial delegation of the role and how the HCP’s capability is maintained on an ongoing basis. It should include audit of:

• their clinical decision-making
• prescribing decisions when relevant and
• a system for escalation to a senior clinician when necessary.

We use these regulations when we review if the practice is safe, effective, responsive, caring and well led. This mythbuster relates to:

• Regulation 9 (Person centred care)
• Regulation 12 (Safe care and treatment)

It is part of our key lines of enquiry (KLOEs). One of our key questions is whether services are organised so that they meet people’s needs. In particular, KLOEs:

• S2 Managing Risk
• S3 Safe care and treatment
• E3 Staff skills and knowledge
• E4 How staff, teams and services work together
• R1 Person centred care
• R3 Timely access to care and treatment
• WL8 Learning, improvement and innovation .

We may look at how the practice:

• manages and prioritises home visits
• recognises a deteriorating patient
• works with other professionals
• manages care planning, referrals and investigations.

We may also look at:

• the practice’s processes and systems to monitor patient safety through reporting patient safety incidents
• how they learn from these incidents and significant events.

This patient safety alert shows how important it is for GP practice staff to report all patient safety incidents to the National Reporting and Learning System (NRLS). Lessons can be learned across general practice.

Further information

• GP mythbuster 24: Reporting patient safety incidents to the National Reporting and Learning System (NRLS) for GP practices
• GP mythbuster 66: Advanced nurse practitioners and primary care
• GP mythbuster 100: Online and video consultations and receiving, storing and handling intimate images
• GP mythbuster 102: Pulse oximetry and monitoring vital signs outside the GP practice
• Patient Safety eForm (nrls.nhs.uk)

GP mythbusters

Snippet gp mythbusters rh.

Clearing up some common myths about our inspections of GP and out-of-hours services and sharing agreed guidance to best practice.

See all issues:

• GP mythbusters: listed by key question
• GP mythbusters: full list
• GP mythbusters: recently updated

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The paramedic will see you now: home visits by ambulance staff lighten GPs’ load

Patients – many of them housebound – have responded positively to an initiative that relieves pressure on family doctors

Ambulance services are helping to relieve GPs’ huge workloads by using some of their paramedics to carry out home visits to sick patients, a service traditionally undertaken by family doctors.

Paramedics are swapping answering 999 calls for tending people who have asked for a GP to see them at home because they are too ill or frail to come into the surgery.

NHS bosses say paramedics taking on this role is fast emerging as a way of helping GPs , stopping patients ending up in hospital unnecessarily and tackling chronic understaffing.

The North East ambulance service (NEAS) is one of several services that is seconding paramedics to work with GPs because they believe that home visits help the NHS overall, including reducing pressure on A&E, which is experiencing record demand for care.

“It helps GPs , patients like it and paramedics enjoy working like this,” said Paul Younger, who has been with the NEAS since 2002 and is one of its six paramedics who work in primary care.

“It takes about 45 minutes for a GP to go and see a patient for a home visit. But they can see four to five patients in their surgery in that time if a paramedic does the home visit instead.

“Plus, we paramedics can get there quicker, sometimes in as little as 15 minutes, whereas if a GP was going to visit someone at home who’d rung the surgery that morning, they’d have to wait until they’d seen all their patients that morning and then go, so not until lunchtime.”

Three NEAS paramedics work like this every weekday around Berwick, and another three in North Tyneside, including Whitley Bay, North Seaton and Wallsend. They drive unmarked cars rather than NHS ambulances.

“Initially, some local GPs were a bit dubious. GPs have been doing primary care for decades so, with the change, some thought: do the paramedics know what they’re doing? Are patients safe? But over time they’ve learned that they can play an important part of looking after patients in primary care,” added Younger.

Almost all the patients he and his colleagues visit are housebound. Most referrals have come from a GP but sometimes a district nurse, care home or domiciliary care worker makes the request. The NEAS paramedics also cover care homes – they comprise one in seven of their visits.

“The range of clinical cases paramedics deal with is vast,” said Paul Aitken-Fell, NEAS’s lead consultant paramedic, who set up the service in 2019. The most common problem they encounter is trouble breathing, for example because of chronic obstructive pulmonary disease. But they deal with a wide range of conditions including joint pain, skin problems, infections and heart attacks.

“If you are having a heart attack you’d be better off with a paramedic turning up at your house than a GP because, being specialists in urgent and emergency care, we see them more than GPs,” added Younger. Only one in 10 patients ends up going to hospital because paramedics’ experience means they can treat most of them on the spot and draw up a care plan, sometimes with input from a GP.

NEAS is in talks with GPs elsewhere on its patch to start providing the service, including Hartlepool and Easington, said Aitken-Fell. NEAS’s ability to deal with 999 calls is not undermined by the scheme because the six are dedicated home-visit paramedics, and deploying them like this should ultimately cut the number of people needing a blue light ambulance, he added.

“This is a great example of different parts of the NHS coming together and working in new ways to deliver better care for patients,” says Saffron Cordery, deputy chief executive of NHS Providers, which represents England’s NHS trusts, including the 10 specialist ambulance trusts. “It’s a win-win-win: for the organisations involved, for staff and above all for patients, who feel listened to, safe and confident in the care provided.”

NHS Providers has highlighted NEAS’s work with GPs in a report to be published this week on the creative solutions that trusts are adopting, given the health service in England is short of almost 100,000 staff.

Several other ambulance services offer GP-style home visits. London ambulance service paramedics have undertaken home visits and worked in GP surgeries in the boroughs of Redbridge and Merton since last year.

LAS is expanding its efforts to help hard-pressed GP surgeries. Thirty of its paramedics are currently on a training course, in conjunction with Health Education England, to enable them to work in GP surgeries alongside family doctors, practice nurses and their colleagues.

“Arrangements like this are proving to be a virtuous circle where everybody benefits. We must expand these schemes to help keep primary care sustainable,” said one NHS boss.

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Learning from home visits

8 November 2013

Using home visits to learn or teach can be an important part of CPD, writes Dr Neil Metcalfe

The consultation is at the heart of general practice and is where primary care is delivered. This includes home visits.

The RCGP curriculum includes numerous learning outcomes that are underpinned by a commitment to patient-centred medicine. 1 This article will briefly outline these requirements to summarise what can be learnt, and how, on a home visit.

Learning about the patient

When visiting a patient's house, contributing factors towards many conditions can be discovered. The saying 'A picture paints a thousand words' is very apt. Home visits may alert doctors to alcohol bottles, cigarette packets, sweets, damp, pets, loose carpets, unused health appliances, and cohabitants, none of which may be addressed when a patient presents in surgery.

Home visits allow a better understanding of interventions. In terms of medication, for example, a patient may say their analgesics are working when they attend the surgery, but the GP may come to a different conclusion when observing how mobile and pain-free the patient is at home.

Similarly, adherence to taking medication safely can often be better assessed on a home visit, for example, by the presence of numerous unopened, or far too quickly finished, packets of tablets.

Such information also provides details of the patient's beliefs regarding their medication, the likelihood of potential side-effects, and the possible need for investigation of alternative diagnoses or dementia.

Support at home

The social and economic situations of patients and their families can be better understood on a home visit. Knowing who the patient's relatives are and who is involved in their care helps to provide medical care for the whole family, all or some of whom may also be patients.

Questions such as whether the patient has enough basic amenities, including heating and food, whether they have enough appropriate support, and if the support comes from family members who may also need assistance, may prove useful.

This can benefit later consultations at the surgery when seeing family carers who may be presenting with fatigue, depression, anxiety or joint pains, for example, for which the social part of their presentation has previously provided clues.

Learning about yourself

Various professional and life skills can be developed and improved using home visits.

The doctor/patient relationship dynamic has been qualitatively reported to shift on some home visits for patients, compared with consultations at the surgery. 2 This requires varied consultation styles to be employed by the GP.

Similarly, the home visit requires the GP to develop examination methods that greatly differ from conventional methods learnt while at medical school.

This may be because the environment lacks the perfect couch, light, or assistant. It could be because of the presence of certain hazards, which can range from pets to broken glass.

Plans involving access to primary and secondary care for home visit patients may also need to differ from surgery-based patients.

All of this tests the GP's flexibility, their ability to adapt, manage and develop risk identification skills.

Learning about the team

Home visits potentially allow the GP to have greater contact with the primary healthcare team.

This might be by being present on a visit at the same time as another team member.

This can help to further your knowledge of the roles, responsibilities and referral methods for such allied agencies. Meeting these individuals also helps in forming professional relationships with them.

There may be information from such agencies at the patient's home, either in shared care folders or through the presence of supporting aids, leaflets and letters, all of which can help to form or confirm a GP's understanding of who is involved in the patient's care.

Teaching using home visits

Using the home visit to teach and learn can start early in a career. Various learning outcomes for students, 3 in their foundation year or on GP specialty training (GPST) courses, can be acquired on a home visit.

A two-week, home visit based course that required undergraduates to undertake at least five supervised home visits 'helped them in organising their thoughts and planning a follow-up and an intervention programme. All students reported a better understanding of the role of home visits in family practice.' 4

Joint visits should not be forgotten as a potential learning method for GPSTs, but these do not need to be solely with their GP trainer. Using the training period generally to observe and learn from other members of the primary healthcare team on home visits could be useful.

Some qualified GPs may benefit from such an opportunity if it will help in their personal development plan. Cases and significant events from home visits could be a formal subject at peer group and vocational training scheme sessions.

In terms of teaching, methods such as case analysis and video analysis could be specifically performed for home visits, whether the learner is a trainee or a GP.

Home visits should also be a potential source of feedback. Regular patient questionnaires could include those who are housebound.

Clinicians who are involved in medical education could also use joint home visits for feedback to their students or GPSTs on clinical and teaching skills. Feedback can be obtained from team members, for whom home visits may be a better opportunity than surgery meetings to comment on interaction with patients and colleagues.

Home visits are an important part of GPs' work. They can provide various learning opportunities about patients and the community, as well as about GPs themselves.

However, there may be barriers to learning from home visits, and surgery or telephone-based consultations can also be used for learning development.

With these caveats, the learning potential of home visits is important to consider for professional development, just as much as other forms of consultation.

Owing to the role of home visits in primary care, they could potentially be used as a formal method of learning and assessment for medical students and GP trainees, as well as a specific source requirement for GP revalidation.

• Dr Metcalfe is a GP in York

1. RCGP. Royal College of General Practitioners Curriculum 2010. London, RCGP, 2013.

2. Yuen JK, Breckman R, Adelman RD et al. Reflections of medical students on visiting chronically ill older patients in the home. J Amer Geriatr Soc 2006; 54(11): 1778-83.

3. Zabar S, Hanley K, Adams J et al. No place like home: teaching home visits. Medical Education 2009; 43(11): 1102-3.

4. Kannai R. A systematic approach for teaching the home visit. Medical Education 2005; 39(11): 1152.

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