Home-based primary care is more than a portable version of office-based care. But is it sustainable in a fee-for-service world?
Clinics were built to optimize the productivity of clinicians in a fee-for-service healthcare world, says Patina CEO Jack Stoddard in a recent article in Forbes. But the model doesn’t always hold up, particularly for people who are unable to go to a doctor’s office due to age or disability. And there are a lot of them. According to the American Academy of Home Care Medicine (AAHCM), an estimated 2 million frail, seriously ill and vulnerable adults – many with two or more chronic conditions – are unable to visit physicians’ offices.
Launched in October 2021, Patina specializes in providing home-based care to people 65 years and older. “We decided to bypass the ‘drive-park-wait’ clinic model and use technology and people to bring care to them, on their terms,” says Stoddard.
Home-based primary care represents a different approach to care than traditional office-based visits, say proponents. By staying in close touch with patients, home-based primary-care professionals can monitor and manage many chronic conditions, such as heart and lung disease.
“We learn a great deal about people when we visit them in their homes,” says Stoddard. “Does the patient have enough social support? How do they manage their medicines? Their meals? Are they lonely? Often these factors determine outcomes even more than clinical interventions.”
But is home-based primary care sustainable in a fee-for-service environment? After all, the systems and logistics requirements are demanding. Proponents believe it might work only if value-based reimbursement takes hold.
“Home-based medicine, broadly speaking, which includes home-based primary care, is witnessing a cameo moment right now,” says Rebecca Ramsay, MPH, BSN, CEO of Housecall Providers, which has been providing home-based care in northwest Oregon since 1995. “There are still significant barriers to making this type of care accessible to all who need it, primarily around sustainable payment models and workforce education and capacity building,” she says. “It will take action at many levels to reach our access goals.” Ramsay is a board member of the Home Centered Care Institute (a national education and research organization) and a governing board member of Advanced Illness Partners, a nationwide accountable care organization, or ACO.
It’s not home care
Home-based primary care differs from care typically provided by home health agencies, e.g., part-time or intermittent skilled nursing care or care from home health aides (such as wound care or IVs), physical/occupational therapy, speech-language pathology or medical social services, according to AAHCM. Rather, it provides comprehensive primary, urgent and in some cases, palliative care. For some patients, that can include the services of home health agencies.
Home-based primary care tends to focus on older, homebound or home-limited people with multiple chronic conditions, says Julie Sacks, president and COO of the Home Centered Care Institute. “Often, they have stopped seeing their primary care provider because it’s too difficult to get to the office. Home-based primary care steps in when there’s disconnection with primary care.”
In home-based primary care, physicians and advanced-practice providers (e.g., nurse practitioners) become the patient’s primary care providers, usually for life, says Jay Holdren, senior director of VCU Health at Home in Richmond, Virginia. VCU Health has been providing home-based primary care for adults since 1984. Clinical staff members make home visits every weekday during daylight hours to provide ongoing primary care as well as urgent care. Criteria for enrollment include living within 15 miles from the hospital and being unable to leave home to be seen in clinic without great effort.
Skilled home health agency nurses are a vital component of the program, helping monitor serious illness and/or unstable health status, says Holdren. “Home health nurses carry out critical functions, such as wound care for pressure sores or surgical wounds, intravenous or nutrition therapy, lab draws, and patient and caregiver education. Skilled home health providers also offer physical therapy, occupational therapy and speech therapy for our homebound patients. We believe in this model to such a degree that we founded a new joint venture home health agency in 2021 to meet the needs of patients of VCU Health System and beyond.”
Independence at Home project
As part of the Affordable Care Act, the Centers for Medicare & Medicaid Services enacted the Independence at Home (IAH) demonstration project in 2010 to test a payment and service delivery model for providing home-based primary care to chronically ill and functionally limited Medicare beneficiaries. In a January 2023 update, CMS reported that even though “no compelling evidence” exists that primary care delivered in the home reduces Medicare spending or hospital use, evidence suggests it may lead to better – or at least different – care.
In Year 7 of the project, IAH beneficiaries received twice as many primary care visits from primary care physicians and non-physician clinicians than comparison beneficiaries – and somewhat fewer specialty care visits. IAH beneficiaries had 10.9 primary care visits while comparison beneficiaries had 5.5 visits on average, translating to approximately one primary care visit every five weeks for IAH beneficiaries and one every nine weeks for comparison beneficiaries. On the other hand, IAH beneficiaries averaged one specialty care visit every 17 weeks, while comparison beneficiaries had one every 10 weeks. In Year 7, specialty care accounted for about 50% of total visits for comparison beneficiaries, compared to about 22% for IAH beneficiaries.
The modern-day house call
“We often refer to ‘modern-day house calls’ because they’re so technology-enabled,” says Sacks. In addition to digital technology and remote monitoring, home-based care can offer blood and lab tests in the home, portable X-ray and point-of-care ultrasound. “A smartphone can function as an EKG and a portal to many medical references, such as drug databases. You can look up just about anything.”
Since VCU’s home-based primary care program began, both human capital and technological enhancements have advanced its capabilities, says Holdren. “An electronic medical record allows our providers to see notes from specialists, ER encounters, as well as laboratory results and other details. Portable laptops have replaced heavy, thick paper charts as well. Contracted mobile diagnostic imaging affords safe and timely access to X-rays and ultrasounds.
“We have added social workers to address often complex social dynamics, and we have a dedicated practice operations manager for home and community services, who manages the front- and back-office operations, as well as IT, supplies and equipment,” he says. VCU Health has also implemented a geographic software system called CareLink to help map efficient home-visit routes.
“Currently we don’t utilize remote patient monitoring to a large degree in the program, but we’ve recently established a transitional RPM program that monitors patients who have recently left one of our hospitals,” Holdren says. “By using that technology in tandem with nurse monitoring and telemed visits by an MD/APP [physician/advanced practice provider] team, we’ve shown significant progress in moving the needle on swifter hospital discharges and reduced readmissions for challenging diagnoses, such as sepsis, congestive heart failure and respiratory illness, including COVID.”
But is it affordable?
One of the biggest challenges facing primary care providers is delivering high-quality home-based care that is cost-efficient and sustainable, says Sacks. Small to mid-sized practices looking at providing such care will probably have to prepare themselves for value-based contracting, she says. HCCI can help them learn how to code their services correctly, identify and track quality metrics, and present that information to payers with whom they want to contract.
Some home-based primary care providers have partnered with other provider groups for support and growth. In the fall of 2020, Housecall Providers became a founding partner of the Advanced Illness Partners ACO [Accountable Care Organization], says Rebecca Ramsay. The ACO includes seven advanced illness providers around the country that provide primary care services, care coordination, community services and on-call support to patients and their caregivers.
As a network of practices, Advanced Illness Partners has been able to negotiate group pricing for various services and solutions, including remote patient monitoring, chart auditing, and education on documentation and coding, says Ramsay. “The ACO also provides data and analytics services to the participating providers in a way that is more meaningful and cheaper than what we would be able to purchase on our own.
“But the largest single benefit is the learning community that has evolved because of our joining forces to participate in [a CMS Innovation Center ACO demonstration project]. Our success in the demo hinges on our collective success, which incentivizes us to work together and learn together to improve our performance.”
New skills for in-office teams
No one knows how many practices will ultimately offer home-based primary care, but even those that don’t may benefit from colleagues’ experience in the field, says Sacks. For example, they can reframe questions to maximize the few minutes they have with their patients. “I don’t mean simply asking, ‘How are your kids?’” she says. “I mean digging deeper, so instead of asking, ‘How is your diet?’ they can ask specific questions like, ‘Tell me what’s in your refrigerator right now.’ If the answer is ‘frozen dinners,’ the doctor knows that patient is probably overdoing the sodium.
“It’s a very different way of asking questions. It means treating the whole person rather than the tiny slice of the person the doctor sees for 15 minutes in the office.”
The Home Centered Care Institute has trained approximately 3,000 providers since its founding and hopes to double the home-based workforce in five years, she says. “When we started, we focused on providers who were currently practicing. Now we’re adapting our curriculum for physician and nurse practitioner training programs. We’ll be doing more to build the pipeline.
“One thing we know for sure: When students, media people – anyone – goes on a house call, they suddenly ‘get it.’ When they see and experience the relationship, they fall in love with it.”
Says Rebecca Ramsay, “Things are aligning demographically, epidemiologically, and socially in a way we haven’t seen in a very long time, if ever. This is the time for investment in home-based medicine.”
Sidebar:
Home-based services
Home-based primary care visits can include:
- Routine medical care and management of chronic diseases.
- Annual wellness visits.
- Addressing urgent medical needs.
- Management of cognitive and neurological disorders.
- Advance care planning (e.g., goals of care conversations, end-of-life preferences).
- Vaccinations.
- Wound care and other procedures.
- Coordination of diagnostic testing (e.g., blood tests, EKGs, ultrasounds, X-rays).
- Medical visits at assisted living facilities, group homes, foster care homes and similar settings.
- Care coordination with community services and other healthcare providers, including specialists in psychiatry, podiatry, optometry, dentistry and more.
- Caregiver support and guidance on managing patients’ complex medical and social needs.
Source: Home Centered Care Institute, www.hccinstitute.org/app/uploads/2023/03/HCCI-Home-Based-Primary-Care.pdf