• Urgent Care Moves to Homes, Offices, Hotels

    By Lola Butcher Nov 13, 2017

    Offering house calls for urgent care and primary care will pay off in the long run through lower total costs, more efficient care delivery, and improved patient satisfaction, say two provider organizations that are taking the lead in implementing such programs.

    Some forward-thinking health systems believe that house calls for patients seeking urgent care or primary care will become recognized as an important component of high-value care delivery systems.

    Providence St. Joseph Health, an affiliate of Providence Health & Services, introduced house calls in two markets—Seattle and the South Bay region of Los Angeles—in 2016 as part of its Express Care at Home product line. That line also includes walk-in clinics and telehealth services for urgent care.

    All three delivery modes are designed to increase convenient access to primary care and urgent care for minor conditions. Without these access points, patients are likely to seek care at urgent care centers or emergency rooms—or postpone treatment until their medical condition becomes more complicated and harder to treat, says Sunita Mishra, MD, MBA, vice president of Express Care at Home and Consumer Innovation for Providence St. Joseph Health. 

    Urgent Care_Sunita MishraLike Vanderbilt University Medical Center (VUMC), another leading provider of urgent care house calls, Providence thinks the program’s ROI will be significant across the industry. “Our belief is that we will be able to lower the total cost of care for payers because we have these alternative access channels,” Mishra (pictured at right) says.

    How It Works

    As part of Providence Express Care at Home, nurse practitioners travel to a patient’s home, office, or hotel to diagnose and treat minor illnesses and the manageable symptoms of chronic conditions. House calls are available from 8 a.m. to 8 p.m., seven days a week, for patients ages 2 and above.

    “For the most part, we see things that may make patients feel miserable but are not really an emergency, such as pink eye, cough, cold, earaches, tummy ache,” Mishra says. 

    Patients or their family caregivers use a phone app to request a house call, and a provider responds with a phone call, generally within two minutes. During that conversation, the provider determines whether a home visit is appropriate or whether the patient should be referred to a medical clinic or emergency department. “That call is really important because it helps us ‘right-size’ care,” Mishra says. 

    If a house call is the right choice, the nurse practitioner notifies the patient of an estimated time of arrival—usually within 90 minutes.

    In the service’s first year, 66 percent of patients were female, and the average age was about 32. However, the house call providers recently started seeing Medicare patients, so Mishra expects the patient mix to change as older patients with more complicated conditions start seeking at-home care.

    About 60 percent of those who used Express Care at Home in the first year were already Providence patients. The nurse practitioners access those patients’ electronic health records and add information about the at-home encounter.

    For the 40 percent of patients who are new to the system, Mishra says, follow-up care is offered if they do not have a primary care provider.

    VUMC, in Nashville, quickly followed Providence’s lead into the house call business. Three nurse practitioners—two of whom are devoted full-time to house calls—staff Vanderbilt Health OnCall (VHOC) to provide 8 a.m.-8 p.m. coverage every day. VHOC treats patients 18 and older.

    The nurse practitioners travel with many common medications so they can administer the first dose, saving patients an immediate trip to the pharmacy.

    In addition to home visits, Vanderbilt sees significant potential to serve tourists—including members of the entertainment industry who visit Nashville—at their hotels, says April Kapu, DNP, APRN-BC, associate nursing officer for VUMC Advanced Practice and director of the Office of Advanced Practice. Further, she thinks the convenience of VOHC will be attractive to time-strapped workers.

    Urgent Care_April Kapu“There are lots of folks who work here at Vanderbilt and in surrounding businesses and really can’t break away from work for an hour or two hours to go to a walk-in clinic,” Kapu (pictured at right) says. “They would prefer to have someone come and see them in their office.”

    Thinking About ROI

    Offering a digital platform and unprecedented convenience, the Express Care at Home service is part of Providence’s effort to cater to younger healthcare consumers, Mishra says.

    “Those are going to be our patients in the future, so it is important for us to try to reach them in more convenient ways,” she says.

    Sending clinicians to see patients is expensive, but Providence and Vanderbilt leaders take a broad view of the associated ROI. For one thing, the service offers a way to increase market share—or to stave off patient-poaching from national telehealth providers and local concierge medical practices.

    With 90 newcomers moving to Nashville every day, primary care clinics struggle to meet demand. Meanwhile, the house call service can expand as needed given that it requires no physical space.

    Urgent Care_Jennifer Mitchell“Vanderbilt is well-placed within the community and we have a robust referral base, so if somebody needs another level of care or wasn’t already established within a healthcare system, we can make appropriate referrals and help navigate them through the system, if needed,” says Jennifer Mitchell, MSN, APRN-BC (pictured at right), Vanderbilt’s director of advanced practice and the executive in charge of the house calls initiative. “That wouldn’t always be the case for other house call services that are in the community.”

    Kapu and Mitchell consider three factors that make the house call service financially advantageous:

    • Freeing up capacity in Vanderbilt’s clinics. “We are partnering with our own clinics, so they can offer this as an option for a patient that would typically come to a clinic,” Kapu says. “This allows us to serve more patients in a shorter amount of time, which helps to offset the direct cost.”
    • Improving patient experience. Who wants to wait weeks to get an appointment or drive to an urgent care clinic and wait for more than an hour to be seen when a clinician can come to your house in 90 minutes?
    • Lowering costs to patients and healthcare purchasers. VUMC, which provides insurance coverage for 20,000 employees and their dependents, will save money every time a house call replaces an unnecessary ED visit for one of those individuals. 

    How It’s Paid For

    Urgent care and primary care house calls are still new concepts for insurers. Representatives for Cigna and Anthem said they do not have company-wide coverage policies for such house calls. But Providence and Vanderbilt are both finding that many commercial insurers are willing to support the new delivery model.

    For self-pay patients, Providence charges a flat fee of $199 per visit. Vanderbilt charges $99 for the visit, with lab tests, first-dose medications, and certain services priced separately.

    Both organizations file insurance claims for home visits just as they would for any other services.

    “For patients, it’s very similar to what they would experience if they went to see a provider in the doctor’s office,” Mishra says. “They pay the copay, and the remainder of the $199 is billed to the insurance company.” 

    Next Steps

    Both Providence and Vanderbilt expect to expand the geography of their house call programs in the years to come. Providence’s extension of the house call service to Medicare patients could open up an important market for the model.

    Kapu, meanwhile, expects that Vanderbilt’s house calls team will start providing scheduled visits in the foreseeable future. “For example, if a patient goes to the emergency room and the ER contacts our team, we could visit the patient two or three days later to follow up,” she says.

    Both organizations say patients have been slow to try the service because they either are unaware that the service is available or are accustomed to “going to the doctor.”

    “For patients who use the service, our net promoter scores are through the roof,” Mishra says, referring to a measure of how likely a patient is to recommend a service to others. “We are getting a lot of referrals by word of mouth and by our own primary care providers, so we are hopeful that this will continue to grow.”


    Lola Butcher writes about healthcare business and policy topics for several HFMA publications.

    Interviewed for this article: April Kapu, DNP, APRN-BC, associate nursing officer, Office of Advanced Practice, Vanderbilt University Medical Center, Nashville; Sunita Mishra, MD, MBA, vice president of Express Care at Home and Consumer Innovation for Providence St. Joseph Health, Los Angeles; Jennifer Mitchell, MSN, APRN-BC, director of advanced practice, Office of Advanced Practice, Vanderbilt University Medical Center, Nashville. 

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