American Academy of Home Care Physicians
Promoting the art, science and practice of medicine in the home.
2000 Vol. 12 No. 1
Issn# 1049-0028

An Interview With Alan P. Abrams, MD, MPH
By: C. Gresham Bayne, MD

A member of the Board of Directors of the AAHCP, Dr. Abrams is remembered by many members as the presenter of one of the first longitudinal outcomes/impact studies to be compiled from a comprehensive geriatric management program including house calls at the AAHCP Annual Meeting in 1998. Dr. Abrams will be taking a leave of absence to serve in the Health Care Financing Administration beginning in January, 2000. I was interested in having Dr. Abrams share some of the details about his program with you as you think about developing your own practice. GB.

AAHCP: What was your actual title?
Dr. Abrams: Medical Director of Geriatrics for the Cambridge Health Alliance.

AAHCP: Could you please describe your practice?
Dr. Abrams: I have multiple sites of service where my patients are followed through the continuum of healthcare, from ambulatory geriatrics in a primary care center to the rest homes, subacute units, skilled nursing facilities. I have responsibilities as medical director of nursing homes. I teach at Harvard Medical School from students to fellows in geriatrics. I make house calls. My administrative responsibilities include the budget for the geriatric service line for the Cambridge Health Alliance, including PACE, transitional care, geriatric rehabilitation, home care, and nursing homes.

AAHCP: To what extent are house calls a part of your practice?
Dr. Abrams: I spend about a third of my clinical time, about 10% of my total time in house calls. I make house calls more than once weekly, but my schedule changes daily. I often work in the house calls on my way between rounds at a nursing home. I will drop everything and go make acute house calls on occasion; maybe twice monthly.

We have two other part time MDs and 3 part time NPs. As a system, we are probably interrupted for unscheduled calls several times a week. The density of our population is such that travel time is not great. In addition, we geographically distribute our patients among doctor/nurse practitioner teams so we are more commonly in the area of our patients. The flexibility comes from multi-tasking and multiple sites of practice responsibilities rather than from scheduled free time.

AAHCP: Can you describe your division for us and what your prime mission is?
Dr. Abrams: Cambridge Health Alliance provides quality healthcare to all residents in Cambridge with particular concern for the disenfranchised and those unable to access the system easily; e.g. homebound elderly, illegal aliens, people in lower socio-economic levels. It was originally supported by city funds, but is now almost independent with funding from clinical revenues comprising only the majority of support. We work closely with State Medicaid authorities through a managed Medicaid program. Cambridge has its own three hospitals, neighborhood health clinics in Cambridge and Somerville, and one nursing home. It provides comprehensive care except for major tertiary surgical procedures, such as transplants and open hearts. I collaborate with the Administrator of the Alliance, but there is not a real hierarchy in the system.

AAHCP: What trends in the past two years have affected your practice in the home negatively?
Dr. Abrams: It's about money. The reduction in reimbursement for services such as home health, SNF payments, subacute payments, etc. This creates a lot of stress for providers trying to care for the patients. There is not an infrastructure available to provide efficiencies and the current support doesn't allow time personnel to find creative solutions or new technologies to make things better. There is sense of the need of providing care on terms that are good for business, as opposed to good for people. Too much competition makes it difficult to keep the mission of caring for people in focus. Patients are becoming less trustful of the healthcare system than they used to be. They then require more communication about everything, and that takes time, which is not usually reimbursable.

AAHCP: Positively?
Dr. Abrams: There has been a concerted effort to establish a CQI Program which has helped us to improve quality for all patients and kept us thinking about how we provide care. It helps us to keep objective in our self-evaluation and resulted in changes such as development of a CHF management program with the VNA, improved procedures for advanced directives and informed consent. There is a more businesslike attitude in our system providing care to our patients. This leads to utilization ideas that are not necessarily bad, and allows us to balance the need versus the reality. We are becoming more efficient. For example, I have a 90yo women in my house call program who used to be the receptionist for the Cambridge Council on Aging. She volunteered to take our list of house call patients and call them to assess how well we are doing. We could never have afforded this or thought of it two years ago.

AAHCP: Where do you see the limitations of your care delivery system in the home?
Dr. Abrams: The most impressive limitation is the change in home health, which has made it enormously difficult to maintain patients with waxing and waning chronic illnesses in the community. In our area, the reduced payments to HHAs has led to poor staff retention, so we have lost the intimacy that is part of the magic of maintaining people in their homes. The fewer visits has led to a significant increase in hospital admissions. The number of admissions has tripled over three years with a slight decrease in census, from 300admissions/1000 patients/yr to almost 900/1000/yr. The slight decrease in census is due to an internal competition with PACE, which takes patients out of the home care programs. In 1999, we will have some recovery of the lower rate because we took steps to react to the change in home health.

Such steps are requiring personal contact by the nurse before discharging the patient, which allows us to debate the discharge, plan for personal care from other funding sources such as AAA, or even send our own nurse practitioner out as a replacement. In short, we have become highly motivated to make sure the patient is really stable before allowing the discharge.

We are looking at the DRG data to put some teeth in the economic backlash caused by the home-health cutbacks.

AAHCP: What would you like to see next in the development of your practice?
Dr. Abrams: My wish list includes more diagnostic tools in the home. We used to have the visiting nurses get labs and tests done. We would like some of the new point-of-care instrumentation. We would like better technology for communications. With less personal relationships with the nurses, we need better documentation.

AAHCP: To what extent has technology affected your practice the past 2 years?
Dr. Abrams: The availability of finger stick labs and portable EKG reduces ER visits for particular patients. I believe the improved technology reduces cost by increasing early diagnosis and intervention before hospitalization is necessary. If someone were to give me a machine, I would like to have an iSTAT for chemistries and ABGs. A portable MRI would be nice.

AAHCP: Do you use an electronic medical record; if not, how do you create the chart?
Dr. Abrams: No. We are moving slowly toward an EMR. We now identify house call patients in the hospital setting to segregate data. We can print a list of patients and medication lists on standard databases now. This helps in checking out to the on call physician.

AAHCP: What percentage of your practice involves managed care?
Dr. Abrams: I am the Medical Director of Evercare, a SNF managed care program, and the Medical Director of PACE. These positions require about 20 % of my time if you include the time taking care of a few (between 20-50) primary care patients. I have one HMO homebound patient. She was such a cost outlier, the doctor taking care of her bailed out and said "you do it, and I'll authorize everything." She has terrible osteoarthritis, ITP, terrible bipolar disorder, narcotics addiction, and communicating hydrocephalus, not to mention other things like plantar fasciitis, morbid obesity, poly pharmacy problems, recurrent bowel obstructions and a chronic wound dehiscence.

AAHCP: How is care of this patient different?
Dr. Abrams: There are burdens in getting approval. She has to take Celebrex because of the ITP preventing other arthritic medications, and getting this high-cost medicine approved took time. When I met her, she had been in bed for a year and couldn't stop crying long enough to give a medical history. So I got a book on spiritual sayings about life and read it to her until she could calm down enough to give a history. After a week, I was able to get a history, and she is now downstairs, ambulating on the first floor, dressing herself, and smelling the flowers outside again.

AAHCP: Has the prudent layperson's rule required payment by HMOs for urgent medical care affected your practice?
Dr. Abrams: No.

AAHCP: Could you please describe your relationships with home health agencies?
Dr. Abrams: We have a relationship with a home health agency. There is no contract, no financial concerns, just a common mission in the community. We cross refer with this agency and they give us a specific nurse for each of our care teams. To the extent that they can do it, that nurse makes all the visits for that care team in that geographical area. There are three nurses that are relatively specific to our three care teams. That helps in fostering good team relationships despite the communications problems.

I don't think that this would fly in a general for-profit setting, since the agency I am talking about is not the home health agency that is part of our health alliance. We stayed with the agency we had been working with for years when the Cambridge Health Alliance was formed and they let us do it.

AAHCP: DME equipment suppliers?
Dr. Abrams: Generally, the visiting nurses make the selections. If there is no current home health enrollment, our office rotates referrals randomly.

AAHCP: How do you promote efficiency in your offices when you go out on house calls?
Dr. Abrams: There is usually cross coverage at the clinics for me, so I can leave, but I almost always send the NP out for urgent or unscheduled house calls. It would be extraordinarily rare for me to have to leave a backed up clinic to see a patient in the home. There is always a circulating NP that can be dispatched "hot" in the field. We can always ask the VNA nurse to make a quick visit, usually within an hour.

AAHCP: How do you coordinate the care of your homebound patients?
Dr. Abrams: Weekly small group meetings with teams, and large group meetings with all providers involved.

AAHCP: How do you triage patients that call with an urgent medical problem?
Dr. Abrams: A single number is called and the secretary interviews the patient and codes the pages to the clinician. She is a college student majoring in English that we have trained.

AAHCP: How do you handle urgent lab needs, routine specimens?
Dr. Abrams: VNA will still make the visits for us if it is urgent. We draw and transport the routines.

AAHCP: How do you get xrays, ultrasound and other tests done in the home?
Dr. Abrams: Portable Xray, EKG, Holter are available. We don't use mobile U/S, but I think it is available.

AAHCP: Have you noticed any changes in the transportation payment policies by insurers affecting your practice?
Dr. Abrams: Not in the house calls practice.

AAHCP: What is the critical needed factor to improve, expand your system in the home?
Dr. Abrams: It boils down to more home health services.

AAHCP: How are house calls different to you than office visits?
Dr. Abrams: Being able to see the patient's illness within the context of their life is the key to understanding how to care for them.

AAHCP: Are the patients different?
Dr. Abrams: Yes. They are functionally much more disabled.

AAHCP: What other specialists do you use in your practice?
Dr. Abrams: Psychiatry, Ophthalmology, Neurology, Podiatry are common. They like the NP to meet them at the home to facilitate the visit.

AAHCP: How do you arrange for their consultations?
Dr. Abrams: Personally.

AAHCP: Can you compare the office visit with the house call in the following ways: Personal gratification?
Dr. Abrams: Much more gratifying

AAHCP: Professional Challenge?
Dr. Abrams: Much more challenging

AAHCP: Economic return?
Equal, because I am salaried

Value to society?
More important

AAHCP: Value to your institution?
Tremendous value: it helped my institution win the Foster-McGaw Award for Community Hospital Excellence.

AAHCP: What do you see as the future of the physician's role in home care?
I think there is an opportunity for physicians to take a lead role in creating a paradigm shift in the locus of care to the home, for everyone, and not just for the chronically ill. I have an intuitive sense that there is a therapeutic dimension in the home that will improve outcomes in and of itself.