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National Association of ACOs Virtual 2020 Spring Conference

Is Home Care Going Mainstream in the United States?

Laura Joszt
Technology has made it easier to deliver health care in the home in recent years, but the financing models have not caught up just yet.
In recent years, technology has allowed people to deliver more health care in the home with mobile diagnostics, remote monitoring, and telehealth capabilities, but the financing model has not quite caught up, explained Rob Mechanic, MBA, senior fellow at the Heller School of Social Policy Management at Brandeis University and executive director of the Institute for Accountable Care (IAC), during a panel he moderated on care in the home at the spring virtual meeting of the National Association of Accountable Care Organizations (NAACOS).

“Care in the home has been around for a long time, but recently, it’s having a resurgence,” noted Mechanic.

With IAC, NAACOS conducted a survey among its accountable care organization (ACO) members on home visits and its home delivery program. Of the 163 respondents, 26% have a home visit program, while 25% conduct home visits but don’t have a formal program. Another 17% are developing a home visit program, while 32% said they have no plans to start one.

The number 1 reason the respondents have a home visit program is for primary care (26%), followed by care coordination (23%), transition from inpatient to home (16%), addressing social needs (14%), and hospital at home (11%).

The business case remains a challenge for home care visit programs. Billing for services is the big way respondents said they are funding these programs, but often, the fees for the services don’t cover the full cost of care. Many groups who responded to the survey are funded by shared savings from the ACO or through grants.

“We have some work to do with CMS and payers [regarding a financing model], but where the economics work best are in ACO models with global capitation,” Mechanic said.

Traditionally, the field of home care has been in informal services, explained Bruce Leff, MD, professor of medicine at Johns Hopkins University School of Medicine. There are 10 million to 15 million informal caregivers, usually daughters and daughters-in-law. These informal caregivers do things like assist with baths, provide food, and prepare medications.

“You all know that the best long-term care insurance policy in the United States is daughters, not sons,” Leff said.

However, the field is expanding and being disrupted with the addition of services like home-based palliative care, transitional/postacute care, and urgent care at home. The reason it is important to think about these models of care is because there are probably 7 million or more older adults who are completely, mostly, or semi–home bound. These patients cost more and they need care provided where they are, he said.

Going into a person’s home to deliver care really allows providers to see the full context of the patient’s social environment, Leff explained. This peek into the person’s life can also make it easier to develop care plans that match the needs and the abilities of the patient. According to Leff, home-based care is going to grow.

“I strongly believe home-based medical care will be mainstreamed into the US health care delivery system,” he said.

Some data from a systematic review of home-based care programs have shown that they bring down emergency department (ED) visits by about 15%, admissions by 30%, long-term care admissions by 88%, and costs by 24%, according to Leff. Meanwhile, satisfaction and caregiver quality of life are both increased with these programs.

In a meta-analysis of randomized controlled trials of hospital at home programs, there was a 21% reduction in mortality with a number needed to treat of 50.

“If hospital at home were a drug, I guarantee I would not be on the call with you today, I would be sitting on a beach in the Caymans counting my money, because this would be a blockbuster drug,” Leff said. “There are very few interventions that give you a number needed to treat of 50 for mortality. That is a remarkable number.”

However, before adopting a home-based care model, organizations need to consider the problem they are trying to solve, he said. It might be hospital capacity issues, high costs of care for at-risk populations, a change in business model needed because of the pandemic, or the desire to provide better care.

At Scripps Health Care System, the purpose of the home-based care service was to provide care for vulnerable patients with high costs and high utilization who are not well established with their primary care provider or who need short-term primary care in the home. The goal of the Scripps Home Based Care program was to improve care, lower costs, enhance patient experience, and then transition from home-based care to the appropriate care environment, explained Susan Erickson, BSN, MPH, associate vice president of care management at Scripps Health Care System.

“We did not want to have these patients with us in perpetuity,” she said. “Our goal was to shore them up and get them to the most appropriate care.”

They started with phase 1 of the program in September 2019. The pilot was small by design and included Medicare Advantage members. The model used physicians and registered nurses (RNs) as care managers to deliver services. The cost of the pilot program was paid by the health plan. The original target of the program was to enroll 30 members, but they blew past the target and have enrolled 120 since the start of the program with 79 patients currently enrolled.

Scripps learned from the model that RN care was not reimbursable and that even though it was a small pilot, there was a lot of infrastructure cost upfront that was spread against a small number of patients, which made it look like the program was “monstrously expensive.” As a result, they knew had to scale to get efficiencies.

Currently, they are in phase 2 and contracted to help 200 Medicare Shared Savings Program ACO and 200 Medicare Advantage members. The model has also switched from RNs to nurse practitioners based on the learning from the pilot because they can use revenue codes and get a revenue offset.

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