The number of house calls in the United States has been rising steadily since 2000, but it's not doctors who are leading the charge. An analysis of Medicare data by the American Academy of Home Care Physicians shows that the number of doctors' visits made to the homes of the elderly surged from 1.5 million in 2000 to two million in all of last year. But even as there was a modest rise in the number of physicians willing to see a patient at home, it's been nurse practitioners who have been signing on to satisfy at least a portion of the enormous need to see the elderly where they live. About half of all home visits are made by general care practitioners, says the association's Constance Row. And that share has remained fairly steady over the years. "But the increase has been in the steady growth of visits by nurse practitioners and physician assistants." Only a handful of home visits by nurse practitioners were recorded in 1996, adds Row. And then Medicare began to change its reimbursement policy, encouraging more home visits. By 2000, the number of nurse practitioner visits grew to 66,194. Four years later, they accounted for 223,355 of the total. The total number of home medical visits would soar, says Row, if physicians and other medical professionals around the country were willing to meet the full need for house calls. Adds Row: "If anybody is willing to provide the service, we will nearly guarantee them the need is there." In fact, she says, the number of house calls would jump from two million to anywhere from 10 million to 12 million house calls. But for a host of primary care doctors, house calls have become a thing of the past. Strict payment schedules by managed care organizations as well as state and federal healthcare agencies — along with steadily rising practice costs — have essentially mandated that doctors stay on a tight schedule, seeing a lineup of patients every day. But there have been concerns that the office system may be particularly hard on homebound seniors who can't make the trip to see their doctors. Those patients with complex cases are often neglected and may often see their medical conditions fester into enormously expensive healthcare crises. By some counts, 3.5 percent of Medicare patients account for 43 percent of the program's costs. As a result, Medicare is beginning a pilot program in a variety of neighborhoods around the country to see if paying for more home visits can actually pay a dividend to the program. The program plans to begin enlisting beneficiaries for the program in the fall. "Fragmented care leads to avoidable complications and unnecessary costs despite the best efforts of healthcare providers in caring for Medicare beneficiaries with complex illnesses," says CMS chief Mark McClellan. "This is another effort to support promising approaches to help our beneficiaries get the most innovative, effective care possible as well as reward organizations who provide better quality care at lower costs." CMS has enlisted six different groups to handle the work, including outfits like ACCENT, a consortium of physician clinics in Oregon and Washington; a home monitoring technology company Health Hero Network and the American Medical Group Association that will care for patients using a technology platform that includes home-based appliances for electronic health coaching and patient monitoring and decision-support tools for providers; Care Level Management — an around the clock physician home visiting program whose services will be provided in select counties in California, Texas and Florida; and Massachusetts General Hospital and Massachusetts General Physicians Organization — a collaborative effort between the hospital and the physicians that will provide care to beneficiaries associated with their programs in counties in the Boston metropolitan area. According to CMS, the awardees will deploy a variety of models including support programs for healthcare coordination, physician and nurse home visits, use of in-home monitoring devices, provider office electronic medical records, self-care and caregiver support, education and outreach, tracking and reminders of individuals' preventive care needs, 24-hour nurse telephone lines, behavioral healthcare management and transportation services. In addition, awardees will stratify targeted beneficiaries according to risk and need and to customize interventions to meet individual needs.