Laura is the editorial director of The American Journal of Managed Care® (AJMC®) and all its brands, including The American Journal of Accountable Care®, Evidence-Based Oncology™, and The Center for Biosimilars®. She has been working on AJMC® since 2014 and has been with AJMC®'s parent company, MJH Life Sciences, since 2011. She has an MA in business and economic reporting from New York University.
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.
UnityPoint Health set up care at home services with the goal of reducing ED and hospital utilization by delivering improved quality, experience, and economic outcomes through home-based care services. Dianne Schultz, vice president of operations at UnityPoint Health, highlighted the multiple care at home services UnityPoint offers.
The Hospital to Home model is a home-based hospital acuity care model with the goal of averting the need for hospital facility care. This model has a 2-hour response time.
“A lot of patients truly desire to have their care delivered in the home, are most comfortable in the home, and were able to avoid a lot of potential complications by managing their care in the home,” she said.
The Primary Care at Home model has a 4-hour response time and is a provider-level home-based urgent care model that averts the need for ED care. “You can see that we’re building those layers that are necessary to manage unplanned acute events at whatever acuity level and urgency is necessary,” Schultz said.
There are also 30- and 60-Day Ambulatory Care Bundles, which strive to manage acute events through traditional services and innovative services. These bundles are part of an integrated, interdisciplinary home-based model to manage acute events.
UnityPoint analyzed the outcomes of these programs and found a reduction in the 7- and 30-day ED escalation rates, as well as the 7- and 30-day hospital admission escalation rates. They compared the period from September 2018 to September 2019 (the baseline preintervention period) with the period from October 2019 to April 2020 (the postintervention period) to understand the impact of the Hospital to Home model with the 30-day bundle.
UnityPoint served 59 patients in the baseline period compared with 36 patients as part of the intervention. The 7-day ED escalation rate dropped from 8.5% to 0% and the 7-day hospital admission escalation rate dropped from 6.8% to 0%. There were dramatic decreases in the 30-day rates from 27.1% for the 30-day ED escalation rate to 3.0% and from 22.0% for the 30-day hospital admission escalation rate to 3.0%.
“These are performing significantly better than our best-known targets,” Schultz said.
Amina Ahmed, MD, chief medical officer at Summit Health Management, explained how her organization realized after reviewing its high-risk patient list that the top 5% of the patient population accounted for 60% of total cost, which led to its multidisciplinary home care model. The home visits were typically bundled and included the annual wellness visit, advanced care planning, and a routine home visit. The goal of the program was to improve patient experience and quality of life, as well as transitions for the highest risk patients so they are not just cycling through the system.
Ahmed advocated for keeping the home model simple for success. “The more you try to do all at once, it becomes overwhelming,” she said. “So, you have to keep it simple.”
She also noted that having a strong foundation for a home visit program is beneficial for building a more comprehensive hospital at home model.
Schultz and Erickson also provided recommendations based on their own learnings for other ACOs looking to start home care models. Schultz noted that it is critical to have key partners so an organization doesn’t have to recreate the wheel or rebuild a program that is already available.
“Don’t let perfection be your enemy,” Erickson said. “Your model may be a little shaped by what you can cobble together to get started, but you need to get started.” Otherwise, organizations can spend forever trying to build a perfect model without ever implementing, she added.
The panelists also addressed coronavirus disease 2019 (COVID-19)’s impact on the home care model. According to Leff, the pandemic has “created an environment that clearly pushes systems toward thinking about home-based care.”
There has been an attitudinal shift among patients that they no longer view health care facilities as a danger-free zone, and if that mindset sticks among patients, they will want more care in the home, which may drive the system. He added that CMS will be a big factor in the decision of what stays in a postpandemic world; for instance, how much of the telehealth expansion and relaxations will stay permanently?
Erickson noted that in San Diego, COVID-19 cases were surging again and with intensive care units full, there is more momentum toward setting up hospital at home. Schultz noted that the Midwest never experienced such surges in COVID-19 cases, but the health systems prepared for it and part of the strategy to prepare was to develop a rapid deployment of the hospital at home across the system.
“We were excited that this was one of the strategies coming forward in all of this,” Schultz said.