Willie Moore's red manicured nails were the only visible sign of the vibrant woman she once was. 

The former nurse and beautician has a litany of health problems, can hardly walk and may have some memory loss. 

"Ms. Moore, you are quite a challenge," Dr. Peter DeGolia said after he had spent an hour with her in her Woodland Avenue apartment. "We need to make sure you receive skilled nursing. I am extremely concerned about the clutter in the house. It is the source of potential falls. You have already fallen once, you don't want it to happen again." 

Moore, 76, who spent two months in a hospital and nursing home after she fell in her apartment and was not discovered for two days, nodded in agreement. 
As he walked out of the building, DeGolia told three medical students who accompanied him on the house call that if Moore had come to his office he would have never seen her living conditions or discovered she had combined some prescription pills in one bottle. 

"The future of geriatric medicine is in the home and community," said DeGolia, director of the center for geriatric medicine at University Hospitals. "The elderly are not able to visit a doctor's office because of mobility or cognitive problems." 
Although Moore's niece and brothers visit with food and provide some care, they can't meet all her needs. 

Student Jason Toy said he was appalled that Moore, who only takes sponge baths because she is afraid of falling, could live in such a manner. 

"I can't imagine one of my parents living like that," Toy said. "I would not allow it." 

"It's not that easy," DeGolia said. "They have opinions." 

An aging population, an increase in Medicare reimbursement for home visits and technology that allows diagnostic tests and health monitoring at home led to the resurgence of house calls in the past 10 years, DeGolia said. 

Most patients are like Moore - they have numerous health problems, including heart disease, diabetes and high blood pressure. 

"The need is huge," said Constance Row, executive director of the American Academy of Home Care Physicians "These are the people that are not getting any care at all until they get so sick they end up in the emergency room or in a hospital." 

But as the elderly population grows, stagnating Medicare reimbursement rates over the past two years have dissuaded all but the most dedicated doctors from house calls, said Row. 

An increase in Medicare reimbursement in 1998 led doctors to meet the increasing need for house calls for the elderly, she said. But since 2005, rates have declined and it became impractical for doctors to provide the service since they could only see seven or eight patients a day, far fewer than in an office. 
Row said many doctors work for hospitals or agencies that subsidize the cost of house calls. 

Without fund-raising benefits and foundation grants to supplement federal reimbursements, the Visiting Nurse Association of Cleveland would not be able to offer house calls, said Roberta Laurie, executive vice president of VNA House Calls. 

VNA, which has provided home care for more than 100 years, added a house call program with doctors in 2003 after nurses and health aides realized about 25 percent of people sent home from the hospital didn't know how they would get medical follow-up care, Laurie said. 

The Summa Health System began its house call program three months ago after an evaluation of its SummaCare Health insurance plan showed many elderly were only being seen in emergency rooms and hospitals, said Dr. Teresa Koenig, senior vice president of the Akron health plan. 

Officials determined if they could not get to a doctor, a doctor would come to them, Koenig said. The program is financially viable because the health plan, the doctors and supporting services are all in the Summa system. 

Doctors from the system's Center for Senior Health visit patients monthly and the number enrolled is expected to grow to about 400 by the end of the year, she said. 

The VNA currently has about 475 people in Cuyahoga County and part of Lorain County in its program and many are visited seven to eight times a year, Laurie said. She said the program could handle up to 800 people. 
"Our patients have many multiple conditions that they are coping with and take eight to 12 medicines," she said. "There are a lot of complicating issues." 

Those issues are better addressed in the home instead of an office, said Dr. DeGolia, whose affiliation with the hospital allows him to go on house calls three half-days a week. He limits his practice to a seven-mile radius. 

On each outing he sees four or five patients. Many are regulars but some, like Moore, are new. She was referred by a nursing home after she was released following rehabilitation for a fall. 

"The doctor/patient relationship is significantly different in the home," he said. "You are their guest." 

He sits and chats in a bedroom instead of standing over the patient in an examining room. He also questions caregivers to make sure they are not under stress. 

"About half of them would be in an institution without their caregiver," he told the medical students. 

Louis Farmer doesn't consider caring for his wife, Mary, a burden. 
Mary Farmer, 86, has been ill since 1992 and is bedridden. She has vascular dementia. The cause was a stroke caused by diabetes and high blood pressure, DeGolia said. 

Health care aides visit daily, but Farmer, 72, provides most care, including charting his wife's blood sugar levels. Her hospital bed and reclining chair have replaced a dining room table and chairs in his immaculate Cleveland home. 

DeGolia, who has visited for two years, gave Mary a flu shot. Farmer, who calls DeGolia his partner, held his wife's hand. They have been married 54 years and have no children. 

"The gift you are giving her is priceless," DeGolia said. "You are able to keep her in the home." 

"That's where I want her," Farmer said. "Right here with me."