Abstract
Issue: Homebound and functionally limited individuals are often unable to access office-based primary care, leading to unmet needs and increased health care spending.
Goal: Show how home-based primary care affects outcomes and costs for Medicare and Medicaid beneficiaries with complex care needs.
Methods: Qualitative synthesis of expert perspectives and the experiences of six case-study sites.
Findings and Conclusions: Successful home-based primary care practices optimize care by: fielding interdisciplinary teams, incorporating behavioral care and social supports into primary care, responding rapidly to urgent and acute care needs, offering palliative care, and supporting family members and caregivers. Practices participating in Medicare’s Independence at Home Demonstration saved $3,070 per beneficiary on average in the first year, primarily by reducing hospital use under this shared-savings program. The experience of a risk-based medical group that contracts with health plans and health systems to provide home-based care suggests similar potential to reduce health care spending under capitated or value-based payment arrangements. Making effective home-based primary care more widely available would require a better-prepared workforce, appropriate financial incentives to encourage more clinicians to provide house calls to their home-limited patients, and relevant quality measures to ensure that value-based payment is calibrated to meet the needs of patients and their families.
Background
In the United States, some 2 million older adults are so sick, frail, or functionally limited they are effectively homebound; another 5 million have difficulty leaving home without help.1 Many suffer from multiple chronic health conditions such as heart failure, emphysema, and stroke, which may be compounded by psychiatric or cognitive disorders, including depression or dementia.2 These figures don’t include the millions of younger Americans suffering from catastrophic or disabling conditions like quadriplegia or ALS.3 “These are the people you don’t see in grocery stores and restaurants. Because they also don’t get to the doctor, they often end up in the emergency department and the hospital in crisis,” says Terri Hobbs, executive director of Housecall Providers, a Portland, Oregon–based nonprofit that brings primary, palliative, and hospice services to people at home.
Fewer than 12 percent of people who are completely homebound report they receive any primary care services at home.4 For these very sick individuals, missing regular care can trigger a cascade of problems, many preventable. Tom Cornwell, M.D., medical director of Wheaton, Illinois–based HomeCare Physicians, recalls one patient who visited the emergency department more than 120 times and spent 210 days in the hospital in the seven years before he began seeing her at home. During the first two years under his care, she had just six emergency department visits and two hospitalizations. “It is amazing to see the difference that comes from preventing repeated hospitalizations,” he says. “She was eventually able to leave her home and even take computer classes.”
Both Hobbs and Cornwell have been running home-based primary care practices for 20 years, relying on philanthropy to supplement fee-for-service payments, which generally don’t provide enough to cover the time and resources it takes to care for very complex patients.5 These practices, like other home-based primary care practices around the country, share common features: frequent visits, often by interdisciplinary teams, to manage multiple chronic conditions; help finding social supports for patients and caregivers; and urgent visits to avert hospitalizations.
Interest in home-based primary care has increased in recent years as health care payment shifts from volume to value and evidence emerges that helping frail and elderly patients avoid hospitals, emergency departments, and nursing home placements yields substantial savings.6 One demonstration project created by the Affordable Care Act, Independence at Home, is testing whether providing home-based primary care to frail elderly patients with multiple chronic conditions or advanced illnesses improves outcomes and lowers fee-for-service Medicare spending. Practices that do lower expenses are rewarded with a portion of the savings.7 On average, participating practices saved 7.7 percent or $3,070 per beneficiary in the first year.8 This is many times greater than the savings achieved by accountable care organizations (ACOs) in Medicare’s Pioneer program.9 Reductions in hospitalizations appeared to drive most of the savings.10
Independence at Home is creating access as well as quality systems.
There’s also evidence that home-based primary care improves quality of care as well as patient and family member satisfaction.11 Patients receiving care at home tend to receive less aggressive end-of-life care and die at home, rather than in the hospital, the preference of the vast majority of Americans.12 Cornwell reports that 80 percent of patients in his practice who died in 2015 did so at home.
Experienced house-call providers say their effectiveness is rooted in the trusting relationships they form with their patients, which give them leverage to encourage behavior change. Building trust with patients also means they’re able to uncover issues—like unsafe housing, inadequate nutrition, or poorly managed medication—that can impede good health. In hospitals and office settings, elderly patients often conceal problems for fear of losing their independence, says Joan Valentine, R.N., senior vice president of medical management for Troy, Michigan–based U.S. Medical Management (USMM). USMM provides administrative and clinical support to the Visiting Physicians Association, which is the largest house-call practice in the United States. “They’re wise enough to know they may end up in a nursing home if they admit their vulnerability,” she says. “That’s the beauty of being in the house. We develop a rapport and we find out things like the daughter who they said cooks three times a week actually lives in Florida, and they’re really depending on a neighbor who brings in bulk frozen food.”
In this brief, we describe the key components of home-based primary care, explore challenges to scaling the model, and make policy recommendations for ensuring homebound patients have access to effective care. It is based on interviews with experts in the field as well as leaders of six home-based primary care practices, selected to represent a range of sizes and payment models. Five of the sites earned shared savings in the Independence at Home Demonstration under fee-for-service Medicare; the sixth—Landmark Health—offers an example of how home-based primary care is being implemented by Medicare Advantage plans (Exhibit 1).
Key Attributes of Home-Based Primary Care Practices
Even if home-limited or homebound people could make it to primary care offices, short visits focused on a single complaint would not serve them well. Delivering holistic, team-based care as needed in patients’ homes—whether private residences, group homes, assisted living facilities, or nursing facilities—is a key competency of the home-based primary care practices profiled.13 (See Appendix for detailed description of each practice.)
Fielding Interdisciplinary Teams
Because homebound and home-limited patients typically suffer from complex health conditions and functional limitations, home-based primary care practices often rely on interdisciplinary teams. In addition to physicians, nurse practitioners, and physician assistants, teams may include behavioral health professionals, care managers, pharmacists, dieticians, and rehabilitation specialists.
Home visits typically last longer—an hour or more—than office visits and vary in frequency (e.g., from every four to six weeks for stable patients to daily for those with acute medical problems). A daily case load of nine patients per provider is typical, although providers with Doctors Making Housecalls, a practice headquartered in Durham, North Carolina, that serves patients mainly in assisted living facilities, may make as many as 15 visits per day.
Teams provide a range of services, including therapies, medication and symptom management, health education, and caregiver support, and focus on managing chronic conditions and averting crises. Procedures may include placing feeding tubes and catheters, changing tracheotomy tubes, performing wound care, giving infusions, and conducting lab work. It’s also common to perform diagnostic tests such as X-rays and EKGs in the home.
Team members meet frequently to coordinate care. At Landmark Health, a medical group based in Huntington Beach, California, that partners with health plans, health systems, and provider groups to deliver in-home primary care to high-risk patients, team members come together for a half day each week to discuss new patients and events that merit increased vigilance or stepped-up services to prevent or mitigate deterioration in a patient’s condition. Landmark Health clinicians often work in partnership with primary care physicians. By contrast, most other house-call providers serve as patients’ primary care providers.
Responding Rapidly to Urgent and Acute Care Needs
Avoiding unnecessary hospitalizations and readmissions is a key benefit of home-based primary care. Not only does this reduce costs, it also avoids the potentially detrimental effects of hospitalizations on very sick and frail patients. Patients and families feel they have a “lifeline” to rely on for help rather than immediately calling 911, practice leaders say.
Practices offer after-hours and urgent care routinely. USMM staffs a central hub where licensed practical nurses and emergency medical technicians have access to patients’ medical records and relay information to providers taking calls after hours.
Home-based primary care providers also manage transitions across care settings and work to improve communication between inpatient and outpatient providers. Housecall Providers sends its staff to advocate for patients admitted to hospitals and emergency departments, in part by sharing their medical histories and advance directives. Penn Medicine, an academic medical center that operates the Truman G. Schnabel In-Home Primary Care Program in Philadelphia, relies on a dedicated geriatric unit and hospital staff who work collaboratively with house-call providers. Health information exchanges (HIEs) that notify providers when their patients are hospitalized can facilitate these efforts. The Visiting Physicians Association leverages them in three markets. Tracking patients in markets with an abundance of hospitals and no HIEs is more challenging. Staff with Doctors Making Housecalls, for example, must call roughly 250 independent and assisted living facilities every day to find out if their patients have been hospitalized.
Incorporating Behavioral Care and Social Supports into Primary Care
As noted, home visits create opportunities to identify and address nonmedical issues affecting health (e.g., unsafe housing or food scarcity), often through referral to community resources. Visiting Physicians Association providers, for instance, discovered that a patient who was cycling in and out of the hospital had a neighbor who was cooking methamphetamine—triggering exacerbations of her COPD. They were able to help her find housing elsewhere.
Because of limited reimbursement for social work staff, some home-based primary care practices partner with Area Agencies on Aging (AAAs) and other community-based organizations to provide social services. For example, Penn Medicine’s house-call teams work closely with social workers from Philadelphia’s AAA to arrange home health aides, day care, and housing modifications as well as Meals on Wheels, transportation, and other services for their patients. An evaluation of this partnership—known as the Elder Partnership for All-Inclusive Care—found it improved survival and reduced Medicare and Medicaid costs.14 Long wait times for long-term services and supports in some communities may hinder house-call practices’ efforts to partner with community organizations that offer such services.
Significant behavioral health needs are common among homebound patients. Doctors Making Housecalls found more than half of its patients suffered from depression and 80 percent had symptoms of dementia. But behavioral health providers serving the homebound are in short supply. Penn Medicine has retained a psychologist to make home visits and Visiting Physicians Association providers partner with a home care agency with behavioral health expertise.
Offering Palliative Care and Supporting Family Members and Caregivers
Mortality rates among homebound patients may be as high as 25 percent in a year, making palliative care and end-of-life planning a key part of home-based primary care. Many practices also actively involve hospice programs to help care for patients in the last six months of life, according to Mindy Fain, M.D., division chief of geriatrics, general medicine, and palliative medicine at the University of Arizona and president of the American Academy of Home Care Medicine.15
Proponents of the model say it is crucial to involve family members and caregivers to ensure respectful care at the end of life and enable people to stay in their homes. “Part of their ability to stay in the community is the support of the family,” says Amy Berman, senior program officer with the John A. Hartford Foundation, which has supported efforts to improve care for frail elders.
Payment Models
One of the biggest barriers to the spread of home-based primary care is that dominant payment models provide insufficient funds to support it. Practices that rely on fee-for-service reimbursement from Medicare have difficulty making a profit because they receive only a modest surcharge for providing care in patients’ homes—$10 to $30 per visit—not enough to compensate for time spent driving between homes. Travel time can add up to two hours a day to providers’ schedules in rural areas, according to USMM, which uses GPS devices to track such metrics. Doctors Making Housecalls is profitable because it focuses on assisted living facilities, where providers can see many patients in one stop, and because it charges a trip fee for patients in private homes, which the insurer that administers claims on behalf of Medicare has authorized.16 While such a fee helps to financially sustain this practice, it could present a hardship for low-income patients. “The great majority of patients we serve have a hard time paying a $3 copay,” says Cornwell.
Supplementing Fee-for-Service Payments
Medicare has recently begun paying providers extra fees for chronic care management (average reimbursement $42) and advanced care planning (between $75 and $86). This has helped, but home-based primary care practice leaders say it is inadequate to compensate for investments that they make to optimize care for complex patients. These costs include hiring care coordinators and behavioral health staff, as well as reserving time for team meetings and longer home visits.
To help cover these costs, Robert Sowislo, government affairs officer for USMM, says the company entered into arrangements with Medicare and commercial plans to supplement fee-for-service payments with a share of the savings that accrue from reducing hospitalizations and emergency department use.17 In 2015, USMM formed the only accountable care organization in the Medicare Shared Savings Program devoted exclusively to home-limited patients. With 16,400 attributed beneficiaries in its first year, USSM saved $15 million, of which it received roughly half.
Some practice leaders have advocated for a payment model that combines shared savings and a monthly care management fee—an approach used in Medicare’s Comprehensive Primary Care Plus demonstration to help practices finance “medical home” infrastructure. “Home-based primary care requires a lot of interdisciplinary collaboration that is not compensated. It’s the ‘cement’ that holds it together,” says Bruce Kinosian, M.D., associate professor of medicine, Division of Geriatrics, Perelman School of Medicine at the University of Pennsylvania. Care management fees might encourage smaller practices to offer home-based primary care. These funds would allow them to invest in staff and gain experience with the model while mitigating the risk of not receiving shared savings, he says.18
Medicaid waivers that offer states flexibility in how they reimburse providers may be another vehicle for compensating house-call practices. MedStar Health Total Elder Care–Medical House Call Program, based in Washington, D.C., has been able to tap funding from the District of Columbia’s Medicaid waiver program to hire social workers to serve patients and their families to address nonmedical needs that are integral to improving health outcomes.
Using Risk-Based Contracting
To fund its home-based care program, Landmark Health relies exclusively on risk-based contracting with health plans and integrated delivery systems. These arrangements offer the company flexibility to staff as it sees fit. It can, for example, hire psychiatrists and psychiatric nurse practitioners to meet behavioral health needs. Risk-based contracts also enable the company to share in the savings that result from lower health care spending, provided it meets quality and patient satisfaction targets. Adam Boehler, Landmark Health’s CEO, reports that the company has reduced the medical loss typically associated with high-cost patients, but the savings can take time to realize. “Succeeding in risk-based contracts takes actuarial and analytics expertise and a lot of investment in care redesign and technology. You can’t just take what you do [in a fee-for-service environment] and shift to risk,” he says.
Combining Medicare and Medicaid Funds
Integrating Medicare and Medicaid funding streams for patients who are eligible for both programs is another alternative. This would give providers control of home health benefits paid for by Medicare as well as Medicaid funding for long-term services and supports essential to achieving good outcomes for patients with functional limitations. It also may create opportunities to streamline benefits and pay for social support services that providers have difficulty finding in the community.
The Future of Independence at Home
Providers who remain dependent on fee-for-service payment are hopeful that the Independence at Home Demonstration will become a permanent benefit. In July 2016, Sen. Edward Markey (D-Mass.) introduced the Independence at Home Act, which would extend the demonstration by establishing a permanent Home Medical Practice Program. Eligible practices would receive incentive payments if they spend less money caring for homebound Medicare beneficiaries than spending targets set by the Centers for Medicare and Medicaid Services (CMS).19 The bill has attracted bipartisan support. Practice leaders also recommend that Medicare drop the copayment required for home-based primary care, as it has done for hospice services, since copays can be an impediment for low-income patients. The Independence at Home Demonstration is due to sunset on September 30, 2017, unless it receives an extension, as practice leaders hope.20
To ensure the adequacy of the shared-savings model, Kinosian says it will be important to refine the methods used to establish savings targets to account for the impact of patient frailty, clinical instability, and untreated behavioral health needs. These factors are typically not captured in historical claims data and can have a large impact on spending and the accuracy of shared-savings payments.
Need for Larger and Better-Trained Workforce
House-call practices also face challenges in recruiting physicians, nurse practitioners, and physician assistants. “The great limiting factor is not demand for these services, but the supply of providers,” Alan Kronhaus, M.D., CEO of Doctors Making Housecalls, says. An estimated 2 million more elderly people could benefit from this model, requiring many thousands of new providers. In 2014, there were only 1,066 individual clinicians who made more than 1,000 house calls to Medicare beneficiaries (Exhibit 2).21
Kinosian argues that the field doesn’t necessarily need more full-time clinicians, but instead better incentives for clinicians to provide house calls to their highest-need patients. “Rather than thinking about pulling more people into a different sector,” he says, “what you need to do is change the relative terms of practice—so that people are incentivized to do more of this.” By his count, there were more than 10,000 providers who billed Medicare for at least one house-call visit in 2014. “A lot of providers do this a little bit,” he says.
Not all primary care clinicians may be willing to travel to patients’ homes and handle very complex patients. “It takes a special person,” says Janet Jones, senior vice president of operations for USMM. Providers must sometimes travel into dangerous neighborhoods and homes in squalid conditions. But Jones says that the close relationships providers establish with patients and their families and the transformation they witness as patients’ needs are met far outweigh the drawbacks. It’s not an easy sell, however, when jobs in medical offices and hospitals pay more. “We had a medical director who almost went home crying when she first started after seeing all the problems just one patient was trying to manage. It seemed impossible. Later she could look back and see how her actions saved this person’s life,” Jones says.
Some argue that higher salaries for home-based primary care physicians are needed to encourage more physicians to pursue this work. “We need to build the field and show young health care providers that this is a viable career path,” says Fain. Experts also point out the need for training, as few clinicians are exposed to the model during medical residency programs.
Some philanthropists have stepped in to help. The John A. Hartford Foundation has funded an initiative led by Cornwell’s Home Centered Care Institute in Schaumburg, Illinois, to develop training curricula and educational programming to build the workforce. The Institute provides training to practicing clinicians and health system leaders in how best to deliver high-quality home-based primary care. “It was standing-room-only for a multiday meeting so it’s getting the receptivity that we would hope for,” says senior program officer Berman. Cornwell also is helping to establish centers of excellence at academic medical centers around the country, including one at Northwestern Medicine, to expose medical students, residents, and medical providers to both clinical and practice management models.
Some experts have suggested that using technology, like video to supplement home visits or remotely monitoring patients’ conditions between visits, might make home-based primary care more scalable, particularly in rural communities with long driving distances. Home-based providers say that while such technology may eventually be part of their work, it could not fully replace face-to-face encounters, given that much of their effectiveness is derived from the personal relationships between providers and patients and the insights providers gain by seeing patients in their homes.
Conclusion
Home-based primary care offers a promising way to optimize care for many of the nation’s sickest and frailest patients—those who are homebound or face functional limitations that prevent them from obtaining routine care in physicians’ offices. The U.S. population age 85 and older is expected to quadruple by 2050; there are likely to be many more frail older adults who could benefit from home-based primary care.22 In addition, many younger adults, including those with disabilities and behavioral health conditions, could benefit from this approach.
The robust cost savings achieved by successful practices in the Independence at Home Demonstration suggest that extending the benefit to more Medicare beneficiaries, including those also eligible for Medicaid, could help reduce federal government spending. The experience of a risk-based medical group suggests another pathway for spreading home-based primary care through capitated Medicare Advantage plans, which are enrolling an increasing share of beneficiaries, or through integrated delivery systems working under value-based payment arrangements.
Ensuring success will require payment models that attract broader participation by medical practices and training opportunities that prepare primary care clinicians to work effectively in patients’ homes. As the nation moves toward value-based purchasing of health care, policymakers and payers should consider the role home-based primary care can play alongside other effective models of interdisciplinary primary care in advancing a higher-performing health system.