Homedical Associates brings care to those who can't go out to get it

Albany Times Union
By WILLIAM BRANTLEY, Staff writer
First published: Tuesday, December 21, 2004

As Dr. Roberta Miller drives through seemingly calm suburban Schenectady in the darkening afternoon, she looks at the modest houses she's passing by and sees potential disaster: More and more people need home health care, and the resources aren't there to give it to them.

"You're out driving and you wonder which house hides someone who's homebound," Miller says, steering her office -- a white minivan, whose back seat serves as a trash can, filing cabinet, coat rack and supply closet -- through traffic.

Miller, formerly the director of the Stratton Veterans Affairs Medical Center Hospital home health care program, is now a partner in Homedical Associates. Started by Miller's husband, Dr. David Hornick, Homedical, which has administrative offices in Niskayuna, is the only private primary and consultative medical care practice in the Capital Region that's dedicated entirely to the homebound.

In other words, they make house calls to the homebound.

According to a recent issue of the New England Journal of Medicine, house calls are on the rise for the first time in decades. By the mid-1990s, less than 1 percent of all doctor-patient visits in the United States were home visits. Then, in 1998, Medicare reimbursements went up. By 2002, 15 percent more house calls were made than in 1999.

Still, Homedical struggles to survive. It does house calls full time, its four physicians on call 24/7; its patients spread over four counties.

Homebound clientele

Homedical sees around 500 patients. They range in age from 30 to over 100, but most are elderly. A few weeks ago, they had to declare a moratorium on new patients. Hornick has started a waiting list. He got a call last week about a 107-year-old woman.

"You don't have to go very far from anywhere to find someone who's homebound; the population is there right below the surface," she says, pulling up to the Niskayuna home of Margaret and Frank DeBiase.

"Going into someone's home totally changes the doctor-patient dynamic. The whole balance of power shifts," she says. "When you're in a patient's home, you're a guest."

Gone are the days of the doctor's black bag. Although she has a stethoscope slung around the back of her neck, Miller's most important instrument is her laptop, which stays juiced in the front passenger leg space of the minivan.

Homedical's staff of eight -- four doctors, one nurse practitioner and three administrators -- maintain and update patient charts using secure medical records software. Lab work is outsourced to local hospitals.

On a call

Miller parks in the DeBiases' driveway. A warm light glows inside what used to be the garage but is now Frank DeBiase's living space.

Inside the room, the DeBiases have guests. Introductions are made, coffee is poured, pizzelle cookies and fruit are offered. Miller hugs Margaret then settles in next to Frank.

Last February, the 76-year-old man was watching television after supper.

"I heard a loud noise and ran into the kitchen," says Margaret. "Frank was on the floor." A CAT scan at Ellis Hospital revealed that a severe stroke had hit the left side of Frank's brain, permanently robbing him of speech and paralyzing the right side of his body.

After Frank's hospital and rehab periods ended, Margaret prepared to set him up in a nursing home.

Just before, "I just decided I couldn't do it," she says. "I just knew in my heart that he would prefer to be at home."

When Margaret wondered aloud at the possibility of finding a doctor who would make house calls, one of the nurses at the rehabilitation center mentioned Homedical.

"It's been very surprising to have all these things available in the home," she says.

Noninstitutional care

David Smingler, an executive assistant to state Sen. Hugh Farley of Niskayuna, says that a growing number of people want to receive health care in their homes instead of going into institutionalized care.

"The senator has been interested in noninstitutional care for a long time," says Smingler. "He's always felt that it's more humane to have people stay in their homes as long as long as possible. The more people can stay in their homes, the better off we are as a society."

"The concept has been that you grow old, you get sick and then you go into a nursing home," says Miller. "The consumer has become a good advocate for senior care. People don't want to be marginalized. A lot of people don't want to end up in nursing homes. They want to stay in their neighborhoods.

Growing numbers

Though Medicare has very specific (but complicated) parameters for what constitutes "homebound," the term generally applies to someone who has difficulty leaving the house without, as Hornick explains, "substantial assistance." Their numbers can only be estimated. Homedical believes there are at least 5,000 in the region. According to the Journal of Medicine, 2 million Americans are homebound.

According to the Journal, the number of people over the age of 85 will double by 2040. The number of people 65 and older is expected to grow by 10 million by 2015.

The changing attitudes about senior care combined with the growing number of seniors must be met with a change in the way home health care is valued, says Thomas Buckley, of the Visiting Nurse Association of Albany.

"There's no doubt there's a great need," he says. "It's a pressing, pressing issue."

An obvious example: Homedical sees only a few dozen patients covered by Medicaid. But for each of those visits, the practice is reimbursed only $8. No matter what they do, how long they stay: $8.

After six years, several mortgages and a dip into Hornick's retirement fund, Homedical has gone into crisis mode.

"The ability for us to meet our payroll is in jeopardy," says Miller. "It's because we shoulder the responsibility for patients that can't get anyone else."

Meeting a niche

Buckley, of Albany VNA, says that losing Homedical would be a great loss for the community.

"There are other physicians who do home visits, but not another who does exclusively home visits. They meet the niche," he says. "If they go away, you're going to have all the patients they're seeing not having access to short-term care."

Recently, Hornick set up a nonprofit called Alliance for the Homebound, the donations to which will directly support Homedical's activities. He hopes to raise $300,000 from private donations in the next few months.

It sounds like a lot, he says. "But it's less than the cost of institutionalizing one person in a nursing home for one year in each of the four counties that we serve." The estimated cost of keeping one person on Medicaid in a nursing home for one year is $80,000.

"This is the first time in six years that I have put my pride aside and said, 'Yes, we're hurting, and we need help.' "

William Brantley can be reached at 454-5448 or by e-mail at wbrantley@timesunion.com.

GETTING AT-HOME CARE

* For more information about home health care, visit the Web site of the American Academy of Home Care Physicians at http://www.aahcp.org. For a list of local home care physicians, see http://www.aahcp.org/physicianreferral.shtml#NY.

* For more information about Homedical Associates, visit the Web site at http://www.homedicalassociates.com. To make a donation to the Alliance for the Homebound, click on the 'Donate' button at the top of the page.

* For more information on the Visiting Nurse Association, visit the Web site at http://www.vnaalbany.org/.

* For learn more about issues and laws affecting the health care and quality of life of seniors, visit the Web site of the New York StateWide Senior Action Council at http://www.nysenior.org/.

All Times Union materials copyright 1996-2004, Capital Newspapers Division of The Hearst Corporation, Albany, N.Y.

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