Table 1.

Key Program Elements

Goal: To provide medical care at home to frail elderly people who have great difficulty in accessing medical care because of physical or psychiatric disabilities

Criteria: Aged 65 and older, live in health system catchment area, accept the House Calls providers as their primary care providers, defined as homebound

Capacity: Average daily census of 170 patients, admit ~ 80 new patients per year

Clinical FTE: 0.3 geriatrician, 0.9 nurse practitioner, 1.3 social worker, 0.5 LPN

Administrative FTE: 1.3 secretary, 0.1 staff manager, 0.05 practice manager, 0.05 medical directorship, 0.1 NP case management, 0.1 MD team time/fellows teaching

Physician and social worker each perform an initial standardized assessment

Patients are seen on average every 4 to 6 weeks

Capacity exists to perform phlebotomy, electrocardiograms, mobile X-rays, vaccinations in the home

Multiple community resources such as home care agency and hospice services, in-home psychiatric and podiatric services are used

Care plans are reviewed in weekly care management meetings