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Tuesday, November 19, 2002

By Virginia Linn, Post-Gazette Staff Writer

Amid phone calls and visits from the plumber and a neighbor, Kenneth Cater got a full medical checkup from Dr. Stephen Liederbach as he sat in his wheelchair off the kitchen of his Beaver Falls home.

	Dr. Stephen Liederbach and medical assistant Wendy Abraham, during a house call to Ken Cater in Beaver Falls. Liederbach went over Cater's medicines, including those he takes for diabetes, as part of the exam. (Robin Rombach, Post-Gazette)

The doctor asked about his medical history, examined some sores on his left leg, checked his heart and breathing and looked through a shoe box filled with Cater's bottles of medication. And he made sure Cater got pneumonia and flu shots right on the spot.

Instead of a little black bag, Liederbach and his medical assistant, Wendy Abraham, carried a huge canvas satchel stuffed with medical equipment, a portable EKG machine and briefcase full of paperwork.

Call it the old-fashioned house call with a modern twist.

The Visiting Physicians Association, one of the largest doctor house call businesses in the country, opened up shop in Pittsburgh last week, signaling a revival of a medical service that virtually disappeared decades ago.

National statistics show that doctors made about 1.6 million house calls in 2001, an increase of 100,000 over the previous year. And that trend is being reflected in Pittsburgh, particularly among the region's aging population.

The Western Pennsylvania Hospital, for example, has seen a dramatic increase in demand for a home visit service it set up 10 years ago. Doctors in this program often bring residents along as part of their training.

Regular primary care physicians do make house calls on occasion to their frail elderly patients, but it's difficult for them to get out of the office, where they're seeing 20 to 30 patients a day.

"For routine visits, or checking things on an ongoing basis, I think home visits have a really important place," said Dr. Cynthia Napier Rosenberg, executive director of Senior Health Services at West Penn.

The Visiting Physicians Association, one of several private companies that have cropped up across the country, was founded in Michigan in 1993 by Mark Mitchell. He came up with the idea after taking care of his aging grandmother, who could not travel to the doctor's office.

After steady growth in Michigan and Ohio, the company's expansion has taken off this fall, with new locations opening here and in Atlanta, Milwaukee and Chicago.

"We're not a service of convenience, we're a service of necessity," said Julie Dean, vice president of operations in Michigan.

Patients must be homebound to qualify, whether they're frail elderly, are recovering from an accident or have some disability that makes it difficult to leave their home.

No insurance referral is needed. Ninety percent of the patients generally are covered by Medicare, although most private insurers also cover the visits.

Doctors with the service become the patient's primary care physician and work closely with a patient's former physician to ensure continuity of care.

"Certainly, if a patient's condition improves, we refer them back to the previously attending physician," Dean said. "Most attending physicians realize there's a certain number of patients who have difficulty getting to the office. We don't see healthy, walking, talking people. They're the sickest people out there."

		More info Visiting Physicians Association opened last week in Green Tree. You can reach the service at 1-877-HOUSECALL, or check its Web site at www.visitingphysicians.com

Most patients receive a house call within 24 to 72 hours of requesting a visit, and doctors see an average of 10 to 12 patients a day. Initial visits usually last an hour or more. Many diagnostic tests and services -- such as electrocardiograms, X-rays, injections and vaccinations and tests for bone mineral density, pulse oximetry (which measures the oxygen in the blood) and pulmonary function -- can be done in the home. The association operates its own lab in Michigan where most test samples are analyzed. Time-sensitive ones are sent to local labs.

Patients who have an emergency in the middle of the night are instructed to call 911 for immediate help, although the service does have a doctor on call.

Liederbach, who did his residency in internal medicine at Allegheny General Hospital in the mid 1980s, had worked recently with nursing home patients at Mariner Health Care of West Hills in Moon.

"I used to see people admitted into the nursing home who hadn't seen a physician in years," he said. "They had a catastrophic event that could have been prevented had they gotten care."

Many serious conditions are easily prevented by simply monitoring blood pressure, catching a urine infection early, or just making sure the patient gets a vaccination for pneumonia or the flu, he said.

Cater, 78, called for an appointment last week as soon as he heard about the service because getting to the doctor had been difficult. Diagnosed with diabetes eight years ago, the retired custodian recently lost most use of his legs "because they just stopped working" and uses an electric wheelchair.

Without family nearby, he relied on a medical van service with a wheelchair lift that cost him $48 out of pocket for the three-mile trip to the doctor. After all that effort, his doctor for 20 years had little time to do a thorough exam.

"He hasn't been doing much good. He just checks my heart and lungs. And he won't come out to see me."

After the home exam, Liederbach told Cater he'd arrange for an immediate visit by home health nurses to properly treat his leg ulcers. The doctor planned to return within the week to begin treating some progressive conditions that hadn't been addressed. He also planned to adjust his medications.

A medical director for Comprehensive Occupational Health Service in Washington, Pa., Liederbach, 44, said he was attracted to the concept of house calls to those who don't get regular care. "I have a special interest in the elderly population. I feel they're somewhat neglected."

Once the service gets off the ground here, it's likely that more doctors will be involved. The company's largest office in Southfield, Mich., has 15 full-time physicians.

West Penn's Rosenberg wasn't familiar with this company, but noted that, as with any medical service, patients should make sure the doctor is reliable, that he does good follow-up care, that test results come back in a timely manner and that the service can be reached in an emergency. Patients also should review their insurance to make sure the service is covered.

"I think home visits are a great idea, particularly when you're feeling sick, if you're old and the weather is bad."