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Home-Based Primary Care Models Are Shaping Up

2012; Elsevier BV; Volume: 13; Issue: 11 Linguagem: Inglês

10.1016/j.carage.2012.11.019

2377-066X

Bill Kubat,

Healthcare Policy and Management

When Yogi Berra said, “It's déjà vu all over again,” he was talking about when Mickey Mantle and Roger Maris would hit back-to-back home runs back in the 1960s. There's a certain déjà vu occurring in medicine, as it sees house calls reemerge for the first time since Mantle and Maris were sluggers.Home-based primary care models – utilizing interdisciplinary teams led by physicians and nurse practitioners – enable providers to spend more time with patients and give those providers greater accountability for all aspects of a patient's care. The focus is on timely and appropriate care that improves overall quality of life while lowering health care costs – by forestalling or preventing the need for care in institutional settings.The federal government, through its Center for Medicare & Medicaid Innovation, has launched a demonstration project called Independence at Home to test home-based primary care as both a service-delivery and a payment-incentive model (http://innovation.cms.gov/initiatives/independence-at-home/). Overall, participants will provide services to as many as 10,000 chronically ill Medicare beneficiaries for 3 years.In early 2012, the innovation center selected 16 primary care practices that are led by physicians or nurse practitioners, have experience providing home-based primary care to patients with multiple chronic conditions, and serve at least 200 eligible beneficiaries. Results of another round of applications, in which primary care practices may apply as consortiums, will be announced soon.Medicare beneficiaries eligible for care in the program must have two or more chronic conditions, be currently covered by fee-for-service Medicare, have two or more functional dependencies, have had a nonelective hospital admission in the past 12 months, and have received acute or subacute rehabilitation services in the past 12 months.Practices will be eligible for financial rewards if total Medicare expenditures for people given home care are lower than what Medicare calculates it would have spent on the beneficiaries otherwise and if stringent quality standards are met.Equally exciting work is reported by Dr. George Taler, CMD, who is codirector of the Medical House Call Program, as part of his duties as director of long-term care for MedStar Washington Hospital Center in Washington, D.C. MedStar includes nine hospitals and two skilled nursing facilities plus physician clinics and home health services. The Medical House Call Program serves about 600 patients with teams of physicians, nurse practitioners, social workers, and support staff. Dr. Taler wryly described MedStar's program as based on an unusual premise for a service-delivery model: patient need.MedStar was challenged with the management of high-cost patients, those with comorbidities that demand the most and often most-expensive services. Unattractive to primary care practitioners, these patients generally experience fragmented and poor health care. Instead of leading MedStar to a service model emphasizing physician productivity and income, the decision to focus on patient need pointed toward home-based primary care. In their natural environment, Dr. Taler asserted, complex patients would get better comprehensive plans of care that would keep them out of hospitals and nursing homes.The other benefits of the model were numerous. First, staff physicians in the Medical House Call Program do not maintain office practices. (MedStar does have conventional clinics, but they serve other populations.) No office means reduced overhead costs.Second, seeing patients in their natural environment provides a better perspective for creating comprehensive plans of care that consider patient-support networks. Third, a provider can support patient independence once he or she has assessed firsthand the person's environment and abilities. For example, inherent challenges of daily living may become clear once it's known that the bathroom is on the second floor and the kitchen is downstairs.Point-of-care technologies have been significant tools in home-based primary care. Increasingly, telemedicine can approximate the diagnostic tools available in a provider's office or a hospital emergency room, short of devices such as computed tomography scanners. Thus, response time to patient problems at home can actually be shorter than in an emergency room.Medical House Call Program patients must live within a 20-minute drive of a team member. Patient visits are scheduled by quadrant and occur, on average, 16 times per year.The program has also led Dr. Taler and others to connect some of the dots between various emerging strategies to improve health care delivery systems, such as medical homes. He said that home-based primary care can address a major roadblock within the medical home model: that patients with multiple morbidities can quickly use up the case-management capabilities provided in that model. Home-based case management can be more comprehensive for these patients, Dr. Taler contended.I would add the same caution about accountable care organizations (ACOs). Noble in their intent, ACOs integrate the work of collaborating providers. Viability depends on an infusion of cash for an ACO's startup, and success depends on that integration generating savings. High-cost users of care remain as much a challenge for ACOs as they do for medical homes. These models work fine for two thirds of the population, but less so for patients with multiple morbidities.Look for more home-based primary care models to emerge in the spring of 2013 and beyond. Surely, viability is a function of population density and other variables that CMS's Independence at Home Demonstration Project will test.As CMS continues to test and tweak the model, consider the potential role that an innovative skilled nursing facility (SNF) or continuing care retirement community could play as the developer of or partner in a home-based primary care model. With as many as 70% of SNF admissions being patients who return to the community, there could be an opportunity for LTC professionals to shape the model – and the future – rather than just react to it. When Yogi Berra said, “It's déjà vu all over again,” he was talking about when Mickey Mantle and Roger Maris would hit back-to-back home runs back in the 1960s. There's a certain déjà vu occurring in medicine, as it sees house calls reemerge for the first time since Mantle and Maris were sluggers. Home-based primary care models – utilizing interdisciplinary teams led by physicians and nurse practitioners – enable providers to spend more time with patients and give those providers greater accountability for all aspects of a patient's care. The focus is on timely and appropriate care that improves overall quality of life while lowering health care costs – by forestalling or preventing the need for care in institutional settings. The federal government, through its Center for Medicare & Medicaid Innovation, has launched a demonstration project called Independence at Home to test home-based primary care as both a service-delivery and a payment-incentive model (http://innovation.cms.gov/initiatives/independence-at-home/). Overall, participants will provide services to as many as 10,000 chronically ill Medicare beneficiaries for 3 years. In early 2012, the innovation center selected 16 primary care practices that are led by physicians or nurse practitioners, have experience providing home-based primary care to patients with multiple chronic conditions, and serve at least 200 eligible beneficiaries. Results of another round of applications, in which primary care practices may apply as consortiums, will be announced soon. Medicare beneficiaries eligible for care in the program must have two or more chronic conditions, be currently covered by fee-for-service Medicare, have two or more functional dependencies, have had a nonelective hospital admission in the past 12 months, and have received acute or subacute rehabilitation services in the past 12 months. Practices will be eligible for financial rewards if total Medicare expenditures for people given home care are lower than what Medicare calculates it would have spent on the beneficiaries otherwise and if stringent quality standards are met. Equally exciting work is reported by Dr. George Taler, CMD, who is codirector of the Medical House Call Program, as part of his duties as director of long-term care for MedStar Washington Hospital Center in Washington, D.C. MedStar includes nine hospitals and two skilled nursing facilities plus physician clinics and home health services. The Medical House Call Program serves about 600 patients with teams of physicians, nurse practitioners, social workers, and support staff. Dr. Taler wryly described MedStar's program as based on an unusual premise for a service-delivery model: patient need. MedStar was challenged with the management of high-cost patients, those with comorbidities that demand the most and often most-expensive services. Unattractive to primary care practitioners, these patients generally experience fragmented and poor health care. Instead of leading MedStar to a service model emphasizing physician productivity and income, the decision to focus on patient need pointed toward home-based primary care. In their natural environment, Dr. Taler asserted, complex patients would get better comprehensive plans of care that would keep them out of hospitals and nursing homes. The other benefits of the model were numerous. First, staff physicians in the Medical House Call Program do not maintain office practices. (MedStar does have conventional clinics, but they serve other populations.) No office means reduced overhead costs. Second, seeing patients in their natural environment provides a better perspective for creating comprehensive plans of care that consider patient-support networks. Third, a provider can support patient independence once he or she has assessed firsthand the person's environment and abilities. For example, inherent challenges of daily living may become clear once it's known that the bathroom is on the second floor and the kitchen is downstairs. Point-of-care technologies have been significant tools in home-based primary care. Increasingly, telemedicine can approximate the diagnostic tools available in a provider's office or a hospital emergency room, short of devices such as computed tomography scanners. Thus, response time to patient problems at home can actually be shorter than in an emergency room. Medical House Call Program patients must live within a 20-minute drive of a team member. Patient visits are scheduled by quadrant and occur, on average, 16 times per year. The program has also led Dr. Taler and others to connect some of the dots between various emerging strategies to improve health care delivery systems, such as medical homes. He said that home-based primary care can address a major roadblock within the medical home model: that patients with multiple morbidities can quickly use up the case-management capabilities provided in that model. Home-based case management can be more comprehensive for these patients, Dr. Taler contended. I would add the same caution about accountable care organizations (ACOs). Noble in their intent, ACOs integrate the work of collaborating providers. Viability depends on an infusion of cash for an ACO's startup, and success depends on that integration generating savings. High-cost users of care remain as much a challenge for ACOs as they do for medical homes. These models work fine for two thirds of the population, but less so for patients with multiple morbidities. Look for more home-based primary care models to emerge in the spring of 2013 and beyond. Surely, viability is a function of population density and other variables that CMS's Independence at Home Demonstration Project will test. As CMS continues to test and tweak the model, consider the potential role that an innovative skilled nursing facility (SNF) or continuing care retirement community could play as the developer of or partner in a home-based primary care model. With as many as 70% of SNF admissions being patients who return to the community, there could be an opportunity for LTC professionals to shape the model – and the future – rather than just react to it.