UO > Feature > The House Call of the 21st Century

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Ellen Gonzalez, MD, a 35-year-old Puerto Rican native, works four days a week and covers five nursing facilities. Arriving at the communities before the patients’ breakfast trays, she usually works a 6 am to noon or 7 am to 1 pm shift, depending on commuting time and the facility staff’s preferences. “I like this practice a lot. I control my schedule and it’s refreshing to see different people every day. It’s so easy to be nice to them because ECP [her


	Who will care for an aging American?

employer] handles all the billing and administrative tasks,” she says.

Gonzalez works for Extended Care Physicians of Asheville, North Carolina, a physician group of 10 internists, one psychiatrist, and an emergency physician who serve more than 20 long-term care facilities in five counties. Before becoming a facility-based doctor, Gonzalez and her husband, a family practice physician, spent two years building a practice in Arden, North Carolina. “It’s hard to have two doctors married to each other in a new practice. Then I got pregnant with our third child and the private practice couldn’t work for us financially,” says Gonzalez. “Plus, we both needed personal and professional space.”

Although Gonzalez has been at ECP less than a year, she acclimated quickly. She commutes with a wheelie suitcase and notebook computer, finds a nook for an office in each facility, talks to the director of nursing about emergent issues, and sees an average of 14 patients each day. ECP has an electronic medical record to capture diagnostic and billing information, which Gonzalez uploads to headquarters via the Internet. The job isn’t perfect: Gonzalez works in isolation, only seeing her colleagues formally at monthly meetings. When another ECP doctor is a facility medical director, they have more contact. She likes that ECP intervenes when there’s a problem: “If, for example, lab results are too slow coming from a hospital, ECP will speak for me, and they’ve got a big voice.”

Rod Baird, ECP’s president, has seen the group grow steadily in the last five years. “Deploying physicians to retirement communities and nursing facilities has created a good niche business. For physicians, we provide a virtual office,” he says.

Physicians come to ECP from different paths, ranging in age from 35 to 59, with the average age being 50. “Nearly all were in office-based practices first, but gave it up for a variety of financial, professional satisfaction, and lifestyle issues,” Baird says.

Other medical groups who employ physicians in long-term care settings include Matrix Medical Network of New York City and Sutter Medical Group, based in Sacramento, California. Matrix hires doctors to work full-time in skilled nursing facilities and SNF hospital units. Sutter Medical Group is a multi-specialty group of 160 physicians who work full time in skilled facilities, says Cheryl Phillips, MD, the group’s regional medical director. She and another physician cover one SNF and one hospital-based SNF unit, with limited contracts in 14 other facilities. Phillips says that health-care needs more facility-based physicians but that it’s hard to generate enough revenues from Medicare billings to be self-sustaining.

Jeffrey Kerr, MD, is a geriatrician who relocated to rural Rolla, Missouri, when a managed care organization bought his multi-specialty group’s big city office practice. He chose a novel career path to an independent practice caring for the elderly. Ditching his office altogether, he and a salaried nurse practitioner cover long-term facilities using beepers and cell phones. Early on, Kerr got swamped with calls from facilities on routine medical matters. When he got 83 such calls in one day, he developed a written protocol for facility staff to follow, which decreased calls to an average of 10. Kerr was so efficient that the state gave him a $100,000 grant to train nursing and personal care staff on when to call a physician. Kerr says that it’s much better practicing geriatrics from home than “working hard for non-medical people so I could earn less and they could earn more.”

They’ve chosen career paths different than most, and the physicians practicing in retirement communities relish their choices. Gonzalez calls it a great job for someone who loves geriatrics, has a family, and still wants to be active professionally. “It’s not the best for someone right out of residency because it’s better to experience either hospital medicine or an office practice before going solo,” she says. Weise calls it ideal for someone who likes basic general medicine, dealing with multiple problems, and values the art of medicine. Narrett swears he’d never achieve the high quality practice if he had to maintain an office without Erickson’s support.

Whatever the reason, geriatricians who practice in retirement settings like their jobs. With baby boomers approaching retirement age, demographics make this field one to watch in the future. g