House calls offer a valuable service to homebound patients, but their availability is limited. Since nurse practitioners have traditionally worked with underserved populations and at-risk groups, house calls are a perfect business niche.
Patients best served by house calls are the elderly, chronically ill children, people with disabilities and patients with psychiatric conditions. Sources of referrals for a house call practice include home health agencies, senior services, hospital discharge planners, church groups and other regional medical practices.
Nurse practitioners who want to establish a house call practice should have enough venture capital to cover start-up and management expenses until profits start to exceed costs. Anticipate working at least 3 years before a new practice starts to turn a profit. Start-up costs include salaries, office space, furnishings, utilities, office supplies, a small refrigerator for lab supplies, advertising, malpractice and business insurance, medical supplies, durable medical equipment and licenses (city or county business license, CLIA license, professional licenses for practice, a pharmacy dispensing license, and Medicare and Medicaid credentialing).
Consider hiring an accountant who specializes in medical practices to assist with bookkeeping, since this is best handled by a professional. You will also need a professional billing service to handle your accounts. Reimbursement is key to your survival and is well worth the 10% fee most billing services charge.
Every house call practice must have an office manager. While you are on the road seeing patients, the office manager will handle the daily operations: answering phone calls and triaging emergent needs, maintaining medical records, and compiling billing forms and documentation for the billing service. The office manager can make or break a practice, so it is essential to find someone who is competent and personable.
Make sure you have the tools and expertise to provide appropriate assessment, diagnosis and treatment in a patient's home. Medical and diagnostic supplies are vital. A durable, waterproof medical bag can store the items typically necessary for home visits. Essential items include a blood pressure cuff (with cuffs of several sizes), a stethoscope, non-sterile gloves, lubricant, Hemoccult slides, an otoscope, an ophthalmoscope, a digital thermometer, a tape measure, a reflex hammer, a tuning fork, bandage scissors, ear curettes, a feeding tube declogger, a suture and staple removal kit, a disposable speculum, 18 to 20 French straight catheters, urine dipsticks, silver nitrate sticks and alcohol pads.
Phlebotomy services are an important adjunct to a house call practice, so establish a contract with a local lab service for tests that cannot be analyzed in the home. Portable diagnostic equipment is available for glucose, cholesterol and International Normalize Ratio (INR) monitoring, and the i-STAT machine performs basic metabolic panels.
Regulation and Reimbursement
Reimbursement is dependent on thorough documentation. There are CPT codes specifically for house calls, and reimbursement rates are revised yearly and vary slightly from state to state (see box). Nurse practitioners currently receive 85% of the allowed amount. All documentation forms should list the specific components required for each visit: exam, history and medical decision making. Your billing form should list patient demographic information, the date of visit, CPT codes and the diagnosis code supported by your documentation.
If physician collaboration is required in your state, your house call practice will be more traditional, and the MD may need to make house calls as well. In states that require physician supervision, be sure to maintain appropriate documentation of all communication with the physician.
While establishing your house call practice, you may want to consider additional sources of revenue. House calls fill a gap in the health care system and lend themselves to a rewarding and successful practice.
Nanette Lavoie-Vaughan is an adult and geriatric nurse practitioner who provides primary care to residents of long-term care facilities and nursing homes in Raleigh, N.C. She has self-published a manual for NPs who want to start their own house call practice, and has written and presented extensively on entrepreneurial topics. Reach her at firstname.lastname@example.org.