Meet Norman Vinn, DO. A board-certified osteopathic physician, Dr. Vinn, 57, has an office without walls, but with wheels instead. As chief medical officer of Housecall Doctors Medical Group Inc. in Laguna Hills, he coordinates medical care on the phone from the black leather seat of his car. And when he sees patients, the walls of the exam room aren't his, but theirs. Dr. Vinn makes house calls, delivering examinations, diagnoses and treatments in the living rooms and bedrooms of Orange County's homebound.

His patient population of about 500 includes the frail elderly, permanently disabled, bedbound and morbidly obese as well as those at the end of life. Compassionate and coordinated care for the "hidden underserved," as he calls them, is his mission. The home environment intensifies his medical interventions, first, because of the amount of time he spends and, second, because he can truly see how his patients are living--and dying.

Nothing could be farther from Dr. Vinn's heady days as an executive at Mullikin Medical Centers and MedPartners Inc., building IPAs and negotiating managed care deals worth millions. The distance he has now put between his administrative practice of medicine and his service as a residentialist is purposeful. He exited the managed care arena in 1998 in search of something more meaningful, more personal.

Southern California Physician joins him Friday, Oct. 27, 2006:

Before work: I wake up early to get organized before getting on the road to see patients. I check e-mail on my laptop, review my schedule of home visits, read faxes and countersign medication orders for almost an hour. After completing that work, I head north from my home in San Clemente on Interstate 5, my satellite radio tuned to the traffic report. All's clear.

8:35 a.m.--My first patient is a new one. Inside a quiet Lake Forest home, I start my day by talking about the end of another man's days. My 54-year-old hospice patient is surrounded by family as I examine him and discuss pain management. There are tears.

9:23 a.m.--I leave, reminded that there's a certain poignancy to treating patients in their homes. Being a residentialist carries its own challenges and joys. I use that term purposefully to communicate to the professional community that this type of practice requires specific skills and competencies. Ten years ago, the term "hospitalist" was little known, but today, it reflects an accepted component in the continuum of care.

House calls are the oldest form of practice known. However, because of changes in medicine, in the standard of care and in reimbursement, house calls fell out of favor. But Medicare created house call codes in 1998 and raised the reimbursement in January this year, so there are better opportunities now. We are closing a gap in the continuum of care and creating a new resource. We believe the residentialist model will achieve in the future the same acceptance within the medical community as the hospitalist model.

Toward this goal, I work with two part-time physicians, five nurse practitioners, and six case management and billing staffers, including my wife, Marsha Vinn. Together, we focus on clinical case management and communication with all members of a patient's healthcare team, from home health aides to specialists.

9:40 a.m.--I swing by our group's administrative office and meet up with Maria Koziol, one of our nurse practitioners. We discuss the problems a patient is having with a PIC line and set a course of treatment designed to keep him out of the hospital.

10:15 a.m.--After driving across town, I arrive at The Wellington, an assisted living facility. From my trunk, I fish out my black bag, which contains basic diagnostic tools and minor procedure equipment. In my right arm, I tuck my clipboard that contains the two-part carbon copy sheets I use for notes. The original goes in an office chart and the copy goes in a folder I leave with the patient--it's my peripheral medical record.

10:20 a.m.--Robert and Merna Fitzpatrick are a wonderful couple I've been taking care of for two years. Merna has had falls and fractures and Bob has an indwelling catheter for prostatic hypertrophy. Merna always exudes appreciation for my services. Bob does, too, but in a nonverbal way. His speech and mobility are severely impaired by Parkinson's. Julie, their part-time caregiver, is also there.

"We think a lot of you," Merna says. "Thanks for coming."

Among other things, I'm here to check out a pain on Bob's left side. I listen to Merna and Julie explain. But I start all home visits by taking vitals and asking about the basics.

"Has he had any fevers or night sweats?" No.

"Any trouble with his ears, nose or throat?" No.

"Has his weight been stable?" Yes.

"How about any trouble with swallowing? We have to watch for that as part of the Parkinson's." His swallowing is OK, but Merna admits that they haven't been doing his tongue exercises.

"How's his mood?"

"His disposition is wonderful," Merna volunteers. "Better than it used to be. He's just the best patient." Everyone chuckles.

After a few more questions and a review of his medications, I ask, "Bob, is there anything else that you need to tell me about?"

Bob comes back with a question about the waves at the beach. He knows I surf and he used to enjoy kayaking on Doheny State Beach. Having this personal exchange lightens the mood for a minute.

I get to his recent complaint of pain. "Can you point with one finger where you hurt? If I do this, does it hurt?" I rule out kidney stones and decide the pain is muscular, from physical therapy.

11:05 a.m.--Merna's exam starts with all the vitals and basics, too. She raises no red flags on any question I ask. "I'm in great shape," she insists.

She's an "Unsinkable Molly Brown." Despite a recent broken shoulder from a fall and compression fractures in her back, she's resolute about walking on her own.

"Watch me," she says, as she demonstrates by taking 10 steps across the room and 10 back. Gently, I remind her not to be overconfident and to have Julie help. She can't take another fall.

11:25 a.m.--It's been almost an hour. I close the visit by talking about coordination of care issues. We discuss the quality of the nursing staff that comes to change Bob's catheter and about the visiting physical therapists. As a main priority, I work to ensure that all the components of medical care at home are in place.

11:35 a.m.--On the opposite side of the building lives Dorothy Chase, 93. Her attitude is quite the opposite of Merna's as well.

I knock and go in. "So what's new?" I start.

"Nothing," she deadpans.

"Are you getting downstairs for any social activities?"

"No."

"I hate to see you sitting by yourself. We've talked about that before."

"I'm not alone."

Addressing psychosocial issues is a big part of taking care of homebound patients. So is nutrition and cognitive status. I try to assess the whole person, and my osteopathic training plays into that philosophy.

I find my chart on a tray table and refresh my memory about her condition and medications. After I ask her all the basics, she says: "Look at my beautiful chair. It's a Harvard chair."

"That's pretty classy, Dorothy," I say. "How about I examine you while you sit in it?"

Stethoscope in hand, I request, "Take a deep breath." After further examination, I conclude her condition is stable. "All right young lady, good seeing you," I say.

11:59 a.m.--As I walk to my car, I think about how Bob, Merna and Dorothy are all doing pretty well. Many of my house calls aren't nearly as smooth. I see a lot of fragile people in their homes. They are fighters trying to remain independent, but desperate because things are failing. Sometimes I'm just humbled by the stoic way they meet challenges every day.