Physicians speak up about home care
Need for improved communication cited
A recently conducted landmark survey of physicians’ perceptions about home care services found that 67% believe their patients sometimes do not receive enough home care. Nearly half also indicated that patients sometimes stay in the hospital longer than necessary because of inadequate insurance coverage for home health services.
The survey of Massachusetts Medical Society (MMS) members was conducted in July 1998 by Stackpole & Partners, a Boston-based research firm. The four-page survey was mailed to 6,462 MMS members representing 21 medical specialties considered likely to have home care involvement. A total of 1,306 MMS members responded, for a 20% response rate.
MMS commissioned the study in response to member requests. "A group of physicians said home care is becoming a bigger issue in health care and they asked to find out more about it. We convened an expert panel and found we didn’t have solid information about Massachusetts physicians in home care," explains Dale MaGee, MD. MaGee is chair of the MMS Committee on the Quality of Medical Practice, which oversaw the survey. He also has a gynecology practice in Shrewsbury, MA.
The survey had 29 questions covering physicians’ knowledge, awareness, and use of home care, home care utilization and practice patterns, physicians’ relationships with providers, and their knowledge of home care payments and regulations.
Nearly 90% of physician respondents indicated that within the past year, their patients had received home care services ranging from Meals on Wheels to private duty nursing. (See chart of types of home care used, p. 66.) About 40% reported making home visits themselves. Those most likely to have made home visits include oncologists, general and family practitioners, geriatricians, internists, and physiatrists. Not surprisingly, the survey found that "home visiting is a central variable in physicians’ attitudes toward, and perceptions of, home care."1
Physicians’ Reported Use of Home Care Services Within Prior 12 Months |
|
| Type of Home Care |
|
| Home Health Aides
Durable Medical Equipment Nursing Services Rehabilitation/Physical Therapy Respiratory Therapy/Oxygen Infusion Therapy Services Wound Care Hospice Homemakers Meals on Wheels Social Worker Services Personal Care Attendants Enteral/Parenteral Nutrition Private Duty Nursing |
84.2
75.9 75.3 75.3 60.7 59.7 58.1 54.6 50.4 48.2 46.6 42.3 40.1 24.3 |
|
*Percentages do not equal 100 due to multiple responses per physician Source: ©1998 Massachusetts Medical Society, Waltham, MA. Used with permission. _____________________________________________________________________ |
|
Survey respondents each work with an average of 4.5 home care providers, although the number varies significantly based on specialty. Obstetricians reported only one to two; orthopedic surgeons up to 40. Affiliation with a hospital was the most common method used for selecting home care providers, followed by insurance case manager recommendation, availability of home care liaisons, and nurse recommendations.
Most physicians found the quality of home care services good (3.63 average on a 5-point scale). Frequent suggestions for improving clinical quality included:
• providing more staff training and education;
• improving communication between providers and physicians;
• giving physicians more control over services;
• changing employees’ compensation and staffing patterns;
• better coordinating services.
Practically anyone involved in home care — providers, physicians, and patients alike — detests the paperwork it entails. It’s no surprise, then, that MMS survey respondents cited paperwork as the No. 1 thing they dislike about home care. Communication with providers, the level of physician control over services, lengthy and/or unnecessary services, and staffing issues were also common complaints.
On the plus side, doctors like the level of service and care administered along with providers’ skills and attitudes. Interestingly, although many reported a need for improved communication, about 21% said the level of communication with providers was one of the things they like most about home care.
Most respondents said that changing the method and frequency of communication is the best way to improve the quality of communication. Others indicated that more standardized forms and/or procedures and less paperwork would help physician-provider interactions. Still others cited meetings, rounds, or conferences, contact with nurse practitioners or case managers, and training and educating providers as opportunities.
With so many different responses, home care providers may wonder how they can effectively communicate with physicians. It all comes down to flexibility, according to MaGee. "There’s not one solution — for communications, education, or whatever. To do something well, there have to be menus. Tailoring communications and care plans for physicians will produce a higher degree of satisfaction," he says. (See related article on improving relationships with physicians, Private Duty Homecare, April 1999, p. 43.)
Responses about preferred methods of receiving more information about and increasing knowledge of home care were equally varied. Newsletters, continuing medical education, conferences, home care liaisons, rounds, the Internet, and journals were the most frequently cited methods.
"I’m surprised that so many mentioned newsletters," says MaGee. "We get so much information that reading is difficult."
Most physician respondents said they were only moderately involved in home care oversight, and more than 58% indicated they want no more extensive involvement. However, physiatrists, general practitioners, and cardiologists generally reported the need for more oversight. Ways cited to accomplish this included improved communication with providers, paperwork changes, more physician control over services, and compensation/reimbursement changes.
Apparently only a few survey respondents even attempt to bill for Medicare care plan oversight. Nearly 90% indicated that they do not submit charges; most (57.6%) because they were unaware they could do so. Others said the time involved is not worth the compensation, they aren’t paid when they do submit the charges, or they don’t spend enough time each month overseeing patients’ care.
"Most physicians view it as too much of a hassle. It takes too long to complete; it’s too hard to document; and physicians fear it will trigger an investigation, or that Medicare never pays anyway, so it’s simply not worth it," MaGee explains.
Lack of payment, however, does not influence the decision to use home care, says MaGee. "I don’t think money is an enormous issue. They’re more worried about fraud and abuse and complying with regulations," he says.
Still, 67% of respondents indicated that their patients sometimes do not receive enough home care. The top reasons cited include:
• clinical care issues (36%);
• insurance issues (28%);
• income or other circumstances mitigate receiving proper care (11%);
• socio-demographic issues such as age and language interfere (9%);
• availability of services (6%).
Physician specialists who more frequently reported patients not receiving enough home care include internists, family practitioners, physiatrists, pulmonologists, oncologists, hematologists, and infectious disease experts.
On a related note, about half of the physician-respondents reported that their patients’ hospitalizations have been lengthened due to inadequate insurance coverage.
With some baseline information under its belt, the MMS plans several pilot projects to enhance physicians’ understanding of and information about home care. It will post a directory of Massachusetts-based home health agencies on its Web site, enter roundtable discussions about improving communication and quality with the Home and Health Care Association of Massachusetts, test ways to improve communication and set up grand round-type case reviews, according to MaGee.
"There’s a need for education about home care on the part of physicians. Other than family practitioners, they’re not taught about it as residents," he says.
[Editor’s note: If you would like a copy of the Massachusetts Medical Society’s survey, call Vicki Ritterband. Telephone: (781) 893-4610, Ext. 1318.]
Reference
1. Physicians’ Practice Patterns, Attitudes Toward, and Perceptions of Home Health Care: A Research Report Prepared for the Massachusetts Medical Society. Waltham, MA; 1998.
Source
• Dale MaGee, MD, 604 Main St., Shrewsbury, MA 01545. Telephone: (508) 842-2010.
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