limited-quality patient-oriented evidence C Consensus, usual practice, opinion, disease-oriented evidence, case series PRACTICE RECOMMENDATIONS ❯ Consider incorporating home visits into the primary care of select vulnerable patients because doing so improves clinical outcomes, including mortality rates in neonates and elders. A ❯ Employ team-based home care and include community health workers, nurses, pharmacists, social workers, chaplains, and others. B 508 THE JOURNAL OF FAMILY PRACTICE | DECEMBER 2020 | VOL 69, NO 10 house calls on Medicare recipients, but interestingly, the total number of home visits was increasing.3 This resurgence of interest in home health care is due in part to the increasing number of homebound patients in America, which exceeds the number of those in nursing homes.4 Further, a growing body of evidence indicates that home visits improve patient outcomes. And finally, many family physicians whose work lives have been centered around a busy office or hospital practice have found satisfaction in once again seeing patients in their own homes. The COVID-19 pandemic has of course presented unique challenges—and opportunities, too—for home visits, which we discuss at the end of the article. Why aren’t more of us making home visits? For most of us, the decision not to make home visits is simply a matter of time and money. Although Medicare reimbursement for a home visit is typically about 150% that of a comparable office visit,5 it’s difficult, if not impossible, to make 2 home visits in the time you could see 3 patients in the office. So, economically it’s a net loss. Furthermore, we tend to feel less comfortable in our patients’ homes than in our offices. We have less control outside our own environment, and what happens away from our office is often less predictable—sometimes to the point that we may be concerned for our safety. So why make home visits at all? First and foremost, home visits improve patient outcomes. This is most evident in our more vulnerable patients: newborns and the elderly, those who have been recently hospitalized, and those at risk because of their particular home situation. Multiple studies have shown that, for elders, home visits reduce functional decline, nursing home admissions, and mortality by around 25% to 33%.6-8 For those at risk of abuse, a recent systematic review showed that home visits reduce intimate partner violence and child abuse.9 Another systematic review demonstrated that patients with diabetes who received home visits vs usual care were more likely to show improvements in quality of life.10 These patients were also more likely to have lower HbA1c levels and lower systolic blood pressure readings.10 A few caveats apply to these studies: • all of them targeted “vulnerable” patients • most studies enlisted interdisciplinary teams and had regular team meetings • most findings reached significance only after multiple home visits. A further reason for choosing to become involved in home care is that it builds relationships, understanding, and empathy with our patients. “There is deep symbolism in the home visit.... It says, ‘I care enough about you to leave my power base … to come and see you on your own ground.’”11 And this benefit is 2-way; we also grow to understand and appreciate our patients better, especially if they are different from us culturally or socioeconomically. Home visits allow the medical team to see challenges the patient has grown accustomed to, and perhaps ones that the patient has deemed too insignificant to mention. For the patient, home visits foster a strong sense of trust with the individual doctor and our health delivery network, and they decrease the need to seek emergency services. Finally, it has been demonstrated that provider satisfaction improves when home visits are incorporated into the work week.12 What is the role of community health workers in home-based care? Community health workers (CHWs), defined as “frontline public health workers who are trusted members of and/or have an unusually close understanding of the community they serve,”13 can be an integral part of the home-based care team. Although CHWs have variable amounts of formal training, they have a unique perspective on local health beliefs and practices, which can assist the home-care team in providing culturally competent health care services and reduce health care costs. In a study of children with asthma in Seattle, Washington, patients were randomIn the elderly, home visits have reduced functional decline, nursing home admissions, and mortality by 25% to 33%. MDEDGE.COM/FAMILYMEDICINE VOL 69, NO 10 | DECEMBER 2020 | THE JOURNAL OF FAMILY PRACTICE 509 HOME VISITS ized to a group that had 4 home visits by CHWs and a group that received usual care. The group that received home visits demonstrated more asthma symptom–free days, improved quality-of-life scores, and fewer urgent care visits.14 Furthermore, the intervention was estimated to save approximately $1300 per patient, resulting in a return on investment of 190%. Similarly, in a study comparing inappropriate emergency department (ED) visits between children who received CHW visits and those who did not, patients in the intervention group were significantly less likely to visit