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THE number of Australian GPs willing to do home and nursing home visits could be boosted if more doctors were exposed to both as registrars, new research suggests.
An Australian study published in Family Practice found that young doctors who participated in home visiting during registrar training were five times more likely to be doing them up to 5 years post-graduation compared with those who did not get the training opportunity.
Similarly, those who did nursing home visits as registrars were 11 times more likely to be doing them 5 years post-graduation.
The study was a cross-sectional questionnaire-based survey of recent (within 5 years) graduates of three of Australia’s 17 regional GP training programs. Of the 230 responding graduates, only 48.1% performed home visits and 40.6% performed nursing home visits in their current clinical GP role. Study co-author, Professor Parker Magin of the School of Medicine and Public Health at the University of Newcastle, said the results suggested that it was possible to stem the decline in home and nursing home visiting.
In Australia, the rate of home visits decreased from 15.8 per 100 persons in 1997 to 7.7 in 2007.
“If we improve opportunities and incentives for doing home and nursing home visits during training, it may increase the rate of new graduates doing them,” Professor Magin told MJA InSight.
“Aside from the health system benefits, home visits and nursing home visits are a wonderful opportunity for registrars to get experience in continuity of care, care of older patients and dealing with multimorbid disease,” Professor Magin said. “These experiences will make the registrar a better doctor and help them pass their exams.”
The study found that 48% of recently graduated GPs performed any home visits and 41% performed any nursing home visits, based on survey responses from 230 metropolitan and regional GPs who had graduated 6 months to 5 years earlier.
The authors noted that this was substantially less than European established GPs, 90% of whom did home visits, according to one study. However, it was more than Canadian GP recent graduates, whose home and nursing home visiting rates were shown to be below 5% and 10%, respectively.
In Australia, concerns have been raised about the increasing reliance on older male GPs to provide nursing home care.
Consistent with this, the latest study found that visiting rates were lowest among part-time GPs – often younger female GPs – and international medical graduates.
“If you accept that home visits are an important part of general practice and essential to continuity of care, it’s not unreasonable to want more GPs to be doing them or expecting a bigger proportion to be involved,” Professor Magin said.
“I don’t think it’s something you could make compulsory or impose top down and enforce, because it’s a complex issue with a whole range of barriers to it.
“The time home visits take is not reflected in the Medicare Benefits Schedule, and the patients requiring home visits are often not those able to afford private fees.”
Sydney GP supervisor, Dr Linda Mann, said remuneration was perhaps the biggest barrier to visiting.
“The pay is terrible,” she said. “We are all reduced to being Medicare item number experts.”
“Only one doctor visit can be claimed, even if two doctors go, so one is at the practice’s cost,” she said.
Still, she argued that all practices that trained registrars should be doing visiting, and it appeared some were not.
“Many newly accredited bulk-billing high throughput clinics have begun to take registrars,” she said. “These do not offer home visiting as a characteristic of the practice, although individuals may not be denied the chance to do so.
“I would support mandatory evidence in teaching practices of a practice-wide, implemented policy indicating the presence of home visiting, nursing home visiting, disability group home support and similar.”
Dr Melanie Smith, president of General Practice Registrars Australia, said that practices appeared to have a range of very different attitudes to visiting.
“Some clinics appear to be reliant on registrars taking up their nursing home workload,” she said. “Other practices are taking on aged care and visiting as a kind of subspecialty.
“Registrars would appreciate the opportunity for supported education to train in nursing homes,” she said. “It’s a really important part of training that hasn’t been explicitly supported by the requirements of training programs as yet.”
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The lack of good doctors with geriatric training attending Nursing Homes is abhorrent. Many do not either bother attending when they are required& some rort the health system& fail in their duty of care by changing patients medications by what the Nursing Home RN’s notes are only! This is taking advantage of the elderly patients when they don’t attend the Nursing Home and consult face to face with the patient. This is surely an offence re billing!
Unfortunately, the government treat doctors like plumbers, your work is not appreciated, not to mention the possibility of danger in the process of home visits,
The healthcare management treat doctors like part of their business, the Medicare has been frozen for a while now , we don’t charge like a plumber, because they charge what ever the market price was, we don’t.
Sitting in the high ground doesn’t help the system and it only make yourself feel good for a short while.
“accept nothing if they can’t afford it” – I thought your contributors were supposed to be medical doctors, not financiers. Could some honest university not teach medical students how to quickly assess patients’ poverty state by asking them and looking around the home when they visit? Doctors who vote conservative should be able to detect quacks, oops, I mean tricksters, because they vote for a political party which continues to make the poor poorer and the rich richer.
” accept nothing if they can’t afford it”….
how ridiculous. why should doctors work for free ?
The problem with home visits boils down to as stated above opportunities & incentives. In an ideal setting , GP should be able to visit their patients at home as this will give the doctor a much better picture of how things are as things in the in the consulting room are very much different.
Also, home visits specially for after hours should be justified.
Health assessments should ideally be made with a home visit as well.
But unless doctors are given better opportunities & incentives , home visit is not going to continue for long.
Maybe it can be made mandatory part of the training for general practice.
I have to disagree, home visits belong to a past age. The current pay is way too inadequate and daily hours too long. No-one should have to do home visits anymore. we need to move on.
The adage of ‘You don’t know your patients until you have visited them at home’ rings true.Has taken a long time for GP land to reawaken to this one. Charge a Fee like the plumber or accept nothing if they can’t afford it.Go bush registrars,youngsters and women and toughen up!
Home visits to the frail elderly or disabled should be an integral part of medical student and GP registrar training. It gives the GP an insight to a patient’s life, their living conditions in the kitchen , bathroom, and backyard.
Doing this annually at health assessments or acute illness , should be well funded to be encouraged at least once a year so a quick inspection of food, hygiene, medication stores, including complimentary ones, steps and other risks for falls. Complex patients need an assessment of their psycho-social aspects of their health.
Not just symptomatic treatment of another pill for another compliant in the consulting room . We are not making a profit of selling more drugs . Unless we want more side – effects and the patient to return for some more quick fix care!
I’ve been a GP for 38 years , mostly solo practice ,and in those years Home Visits were a matter of course as were Nursing Home Visits (not to forget having patients in two hospitals that required daily visitation ).Life was preety demanding in those days compared ,I feel to the current workplace situation (excluding, of course, over worked solo GP’s and Rural Practitioners). On a typical day i would leave home at 0615 , visit my 2 hospitals and start consulting at 0800 .Lunch time was taken up with home and or Nursing Home Visits , then arvo consults till 1800 and often a Home or Nursing home Visit on the way home .(Never forget one wet and stormy tropical night when I finished Consults at 1900 and had 5 Home Visits to do – can be very stressful ) What a “breeze “these days to work in Clinic with essentially no visitation whatsoever ; however I feel these up and coming GP’s miss out on a lot of experience that comes from assessing patients in their home situation – amazing what one sees and learns .
I’ve been a GP for 38 years , mostly solo practice ,and in those years Home Visits were a matter of course as were Nursing Home Visits (not to forget having patients in two hospitals that required daily visitation ).Life was preety demanding in those days compared ,I feel to the current workplace situation (excluding, of course, over worked solo GP’s and Rural Practitioners). On a typical day i would leave home at 0615 , visit my 2 hospitals and start consulting at 0800 .Lunch time was taken up with home and or Nursing Home Visits , then arvo consults till 1800 and often a Home or Nursing home Visit on the way home .(Never forget one wet and stormy tropical night when I finished Consults at 1900 and had 5 Home Visits to do – can be very stressful ) What a “breeze “these days to work in Clinic with essentially no visitation whatsoever ; however I feel these up and coming GP’s miss out on a lot of experience that comes from assessing patients in their home situation – amazing what one sees and learns .
The remuneration for all home visits is poor. I have been a GP for nearly 40 years and did lots of home visits in the early days, fewer now. However I still see a few elderly patients at home, sometimes after hours if urgent.
Most patients are more mobile these days and can usually attend the surgery. Most nursing homes in the area where I work, which is full of retirement homes and age care facilities, seem to have doctors who attend regularly. As the Medicare rebates for these visits are poor, and decrease with the number of patients seen, it is hardly worth doing them. I often think of all the evenings I got home very late after doing visits on the way home, my young son in tow, and arriving home tired, and both of us hungry. In a way it was worth it to see how patients lived, to get to know them and their families and background, which has an impact on their health. I still see some of these families, of 3 to 4 generations, even though I have moved around a lot. I think home visits still have a place in GP, but only for certain patients, not like the patient who called me last winter as they had a cough. I got lost trying to find their unit, due to poor information, was in the dark, threatened by dogs, and finally found it, and was then late for a meeting, when the patient could easily have waited till morning to se a doctor. She had only been to the practice once, but my old fashioned doctor self couldn’t refuse to attend!