Berg started a house-call practice in 1988, but his visit to Glover was among his first in a new role. He and his partner, Alfred Stillman, are now salaried employees of the Visiting Nurse Association of Greater Philadelphia (VNA).
Adding house-call doctors to the visiting nurses does two things, according to Walter Borginis, the VNA's chief financial officer. It will give Berg and Stillman a more predictable income, while better positioning the VNA for the changes likely to occur as health reform moves forward.
The Affordable Care Act encourages greater coordination among hospitals and primary-care providers, mainly by bundling payments and penalizing readmissions. Borginis said the 750 homebound patients in Berg and Stillman's practice in North Philadelphia are exactly the kinds of people the government wants to keep out of nursing homes and hospitals.
Berg and Stillman expect to work closely with VNA nurses because their patients often need specialized nursing care. (Some patients will continue to use other home nursing agencies.) The doctors also will supervise two physician assistants and two nurse-practitioners.
Borginis hopes that creating this network of caregivers will make the VNA a more attractive partner for area hospitals.
"It seems like the next big wave of reform could be these new combinations," Borginis said. The VNA, he said, will do fund-raising to support the new service.
Leaving the office behind
Berg's first career was in biochemistry. He switched to medicine after teaching at Woman's Medical College, a predecessor of Drexel University College of Medicine. After a few years working at a community clinic, he noticed that some of his patients could no longer make it into the office. He started seeing them at home and, before long, he'd chucked the office.
"Number one, this was an unmet need, and number two, I liked doing it," he said as he drove from his new office in East Falls to Glover's house.
Stillman, a gastroenterologist turned geriatrician, joined the practice in 1998.
Berg had thought the retro approach would appeal to middle- and upper-class patients who wanted the convenience of care at home. Instead, he found the real demand came from poorer patients who couldn't handle public transportation while sick or disabled. The doctors now limit their practice to people who are housebound.
He and Stillman are in their mid-70s and have no immediate plans to retire. "We love it," Stillman said. They have encouraged young and retired doctors to follow their lead.
Despite the obvious emotional rewards of helping frail people in their homes and the intellectual challenge of diagnosing without easy access to high-tech tests, the financial obstacle is obvious. The doctors are paid about as much for a home visit as they would get to see a patient in an office. Berg saw four patients the afternoon he evaluated Blanche Glover, about as many as most primary care doctors see in an hour.
Still, the business is growing and Berg thinks it will soon be able to support another doctor.
Berg said he can learn more in a home visit than many doctors would ever know about their patients. He can see what's in the refrigerator, meet a patient's family and caregivers, see whether the medicines are organized or whether the home is in disarray.
He has visited patients who didn't have enough food to eat, who were so afraid of their neighbors that they would rather swelter than open a window, who had little or no electricity and broken plumbing. Some were being abused.
He estimates that his work can delay nursing-home entry by a year or two for most patients.
At Glover's address, Berg found a nicely kept stone house. He walked to the door carrying his tools in a battered black bag he found in a hotel gift shop. Inside, Brockington and Glover's friend and loving caregiver, Rosemary McKie, gave him a detailed rundown of Glover's medical history and recent deterioration. Glover lay silent, swallowed by the covers on her bed.
Finished with the history, Berg leaned over to greet his patient. She spoke for the first time. "I'm not feeling well," she said quietly.
"Tell me more," he said. "Are you sick to your stomach?"
"I don't feel good," she said irritably. Her voice rose and she looked miserable. "I'm sick, I tell you."
Her vital signs were good. But the reflexes on her right side were different from those on the left. Berg would order some blood tests and a home X-ray to rule out pneumonia, uncontrolled diabetes, and other problems. He may suggest a CT scan to see whether there is evidence of a stroke, but that would mean a trip to the hospital.
Some might argue that Glover is weak enough for a nursing home, but Berg bristled at the idea of it. She is comfortable in the house she's lived in for 40 years. She has good caregivers. She needs people like him to let her stay where she is.
Contact Stacey Burling at 215-854-4944 or firstname.lastname@example.org.