What Brought a Resident Back to House Calls

Date: 4|25|2024

Dr. Paul Chiang

Dr. Dillon Karst

Increasingly recognized for the significant role it plays in providing quality, patient-centered care for homebound or home-limited patients, home-based primary care (HBPC) offers providers a unique opportunity to deliver medical care to patients where they live. The approach is especially beneficial for patients with high-cost, complex medical needs because it helps curtail unnecessary emergency room trips and repeat hospitalizations.

When HCCInsights learned that second-year resident Dr. Dillon Karst at Northwestern Medicine Delnor Hospital had elected to complete another house call rotation with Northwestern Medicine HomeCare Physicians, the practice headed up by Dr. Paul Chiang, HCCI’s Senior Medical and Practice Advisor, we interviewed him — along with Dr. Chiang — to find out what brought him back, and more.

HCCInsights: What about the rotation process made an impression on you?

Karst: What initially made an impression was when Dr. Chiang came to talk to our resident group about how home care works. He used some specific patient examples that resonated with me.

For example, one of Dr. Chiang’s patient examples demonstrated how home-based care makes it possible to reconcile a patient’s medications because they’re physically present in the patient’s home. In the example Dr. Chiang cited, the patient didn’t know how to open his medication, so Dr. Chiang was able to show him how to do that and, by extension, help the patient avoid readmission to the hospital.

HCCInsights: What was a typical day like during your rotation?

Karst: A typical day started with prepping the patients, the usual pre-charting that starts by reconciling everything you can from the chart, such as the patient history and problem list, prior to talking to the patient.

While we were traveling, we reviewed patients’ medical histories. The actual time spent traveling almost seemed like a family drive. We played music, told jokes, it’s fun — there’s not quite that same interaction when you’re in the clinic because you’re physically separated from your colleagues. So that’s another cool thing about being a home-based care provider.

HCCInsights: What were your impressions of being inside the patient’s home?

Karst: It was very humbling, especially when people invite you into their space and you might be a stranger. Dr. Chiang is already established and almost like a friend or a neighbor, but I was new. There’s a vulnerability for both the provider and patient, that humility of them allowing you into their space as a fellow human or neighbor and seeing all the personal things about their lives. You don’t get that in an office appointment.

HCCInsights: How does physically being in the patient’s home help you as a provider?

Karst: It allows you to establish rapport easily because you can ask the patient questions about things in their environment, like, who’s in this photo? It’s much easier to just chat with people about their space. You have more time to spend with the patient, to ask questions. Also, you always have the patient’s medications right there, which is huge. You can try to reconcile their medications in the office space, but you don’t always know for sure what they’re taking.

You see the patient in the home as more of a person because you see all their belongings and the things that they identify with. There’s an instant connection with the person, which is a very visceral, primitive human experience.

Providing care in the home offers insights that you don’t get as often in a clinical setting that can help prevent errors and hospital readmissions. You can only ask so many questions and gather so much information when you’re admitting someone back into the hospital — there’s always this mystery. But home care eliminates that.

HCCInsights:What would happen to patients who can’t physically get to a clinic or office if they weren’t receiving home-based care?

Karst: In that case, they’re likely to come into the hospital and be continually readmitted, which is a shame, and it illustrates the importance of continuity of care. It makes me think of a big circle. There’s the office, there’s the hospital, there’s home, there’s the ED, and then there’s the people in that loop. If there’s one broken point along that loop, it can all fall apart. That’s the importance of home care.

HCCInsights: In addition to the hands-on experience gained during your house call rotation, what other resources have helped develop your approach to providing home-based care?

Karst: The Home Centered Care Institute’s online program modules are really critical to developing the proper way to engage with the home care space because as simple as going into someone’s home sounds, it needs a lot of prep work, almost like choreography. There are distinct rules and parts of the visit, and you need to commit those to memory and work them into your rapport system to provide good care to the patient.

HCCInsights: Did you review HCCI’s program modules before or after completing your rotation, and how did they compare to your actual in-home experiences?

Karst: I took them after. The HCCI courses corresponded pretty much to how the actual visit went because the provider goes over the exact same things every single time. And because it’s an organized module, you’ll see the exact same thing at the visit, too, because it must be the same in order to provide that good care. Of course, there are nuances to daily things that happen, so that’s not going to be captured exactly, so you’ll have to actually provide the care to experience those things.

HCCInsights: After seeing Dr. Chiang in action — and knowing he’s made more than 38,000 house calls during his career — is there anything you’d like to ask him right now?

Karst: Yes, the one thing I would ask Dr. Chiang is, “What do you think the most important part of a home visit is?”

Chiang: To me, the most important part of a home visit is being in the home. There is no other space in medicine that offers the richness, the personal connection, the information you can obtain, and the transformational process that happens not only with the patient but also with the provider. In my eyes, no other place in medicine offers the opportunity to make the kind of dramatic impact you can make in the lives of these patients who desperately need healthcare on an ongoing basis. Otherwise, they will have to use what can often be fragmented care, in terms of continuity.

HCCInsights: If you could summarize your experience of making a house call in a couple of words, what would they be?

Karst: I would summarize the home call experience as being “effective” and “sacred.”

HCCInsights then asked Dr. Chiang several questions.

HCCInsights: Dr. Chiang, do you feel a house call rotation has practical value for residents who don’t plan to go into house calls long-term?

Chiang: I do think it’s important for residents to have the house call experience, even if they never do house calls on a routine basis, for a couple of reasons. One, it is enriching. It brings the patient back to the center of your care. Medicine can be very reductionistic, reducing a patient to a set of diseases. But being in the home forces you to open up and engage, to see what the patient’s interests are, what they eat, how they live, and how patients are far more than just a collection of medical problems.

The other benefit of house calls is the opportunity to gather more information, whether it’s medication-related issues, a mobility-related issue, or a caregiver-related problem, such as caregiving distress. You get a much deeper understanding of your patients when you visit them in their homes versus seeing them in the office, emergency room, or hospital.

We also want to educate residents on how to address patients who are elderly and complex and, at the same time, give residents the skills they need to competently handle these situations. We often talk about the 4Ms in geriatrics care, which are what matters most, mentation, mobility, and medications. The 4Ms provide a structure for the residents to develop a care plan that addresses the medical issues and honors the patient’s goals of care. Even if residents do not pursue a career in home care medicine, they will be confident in the care of complex patients and likely be better able to appreciate the personal side of the individual they’re caring for.

HCCInsights: Approximately how many residency programs in the U.S. would you estimate offer a house call rotation, Dr. Chiang?

Chiang: From what I know, maybe only a handful of residency programs offer residents the opportunity to go into a patient’s home on a consistent basis to learn the process of taking care of elderly, complex patients, and understand the importance of the Social Determinants of Health in the overall health and well-being of the patients.

It’s unfortunate that few residency programs offer a house call experience, because house calls can demonstrate to the residents the importance of understanding and caring for the entire patient, especially for those people who lack access to ongoing primary care services. In addition, as the landscape of medicine pivots from a fee-for-service to a value-based model, house call medicine allows a deeper appreciation and understanding of improving the quality and managing cost of medical care.”

HCCInsights: What is it like for you, Dr. Chiang, to share your passion for house calls with another clinician like Dr. Karst, who is also obviously passionate about providing this type of care?

Chiang: I am thrilled whenever I can share my passion for house calls with providers in training. I want to share the joy of caring for patients at home, to help providers better appreciate patients’ challenges, and to equip these providers well so that they can better care for complex, elderly patients in the future.

HCCInsights: What advice would you give people just starting their career that you wish someone had given you when you were getting started?

Chiang: One piece of advice that I would have loved to have heard would be to guard your mind against cynicism — to remind myself why I went to medical school and why I became a doctor. Being at the patient’s home is a constant reminder to treat patients with respect and courtesy. Never forget the sacred relationship that exists between the patient and the provider. I can get derailed in my thinking when my mind is clouded by cynicism. Taking the time to engage with my patients and reminding myself to do my best for my patients are ways to keep the joy in the practice of medicine.