New Home-Care Model for Medicare Patients

A few months ago, family physician and geriatrician Ina I. Li, director of the home visiting program at Christiana Care Health System in Wilmington, Del., received a call from an emergency department physician about a frail, elderly man with diabetes and chronic heart failure who was coming to the ED repeatedly for erratic blood sugar and uncontrolled hypertension. The man received new prescriptions and instructions at every discharge but inevitably returned two weeks later. Would Li's team investigate?

Once in the patient's home, it wasn't hard to pinpoint the problem, says Li, who is also director of geriatrics at Christiana Care's Department of Family and Community Medicine. The man's son and daughter-in-law were able and willing to care for him but were uncertain about how to manage his chronic illnesses and, as a result, often missed signs of problems until it was too late.

"We spent a lot of time educating them - for example, we told them to call us if he gained weight because it could mean excessive fluid that we could manage by increasing his diuretic medication," says Li. "That was six months ago and he has not been back in the hospital since."

It's the kind of success story that laid the foundation for CMS' Independence at Home Demonstration project (IAH), authorized by the Affordable Care Act and now in its third and final year. Li's team at Christiana Care is one of 17 participants in the project, which is testing whether home-based care for frail seniors improves quality while lowering costs through fewer ED visits and hospitalizations. Practices that meet certain quality and cost targets become eligible for incentive payments.

If successful, the home care model could be extended nationwide to all physicians that provide primary care for frail patients covered under Medicare. Here's more on how the program works, and how it could affect your practice in the future.

HOW IT WORKS

A typical visit to a patient enrolled in IAH starts with a complete evaluation by a nurse practitioner or primary-care physician, who is equipped with portable diagnostic equipment and wireless access to the patient's electronic health records. Care extends for the life of the patient, with regularly scheduled physician and nurse visits; acute care as needed; and patient access to 24/7 telephone consultations. Social workers are an integral part of the team, managing psychosocial and supportive services.

"We get so much more information from a home visit than we ever would in the office," says Li. "Simple things like getting meals or taking a shower become monumental tasks when you're homebound. We connect patients to the services they need in order to stay in their home."

The home-care team also helps families keep track of multiple medications and implement instructions given at discharge from the hospital, says geriatrician Mary Ann Forciea, director of the University of Pennsylvania's Schnabel In-Home Primary Care Program, an IAH participant.

"Patients and families are often overwhelmed when the leave the hospital," she says. "Being able to adjust the plan they were given to the realities of their day-to-day living is very important."

Recently, Forciea's team visited a 90-year-old patient with a history of hospitalizations for bowel obstructions after he suffered an acute episode of abdominal pain. By adjusting his medications and working with his live-in caregivers, the team avoided hospitalization completely.

"Sometimes it's our technical skills, such as putting in a Foley catheter or removing a feeding tube, that prevent a hospital admission," says Forciea. "But more often it's that we are a source for the patient and family to get support to utilize the medications or care plans they already have in place."

PAYMENT MODEL IS KEY

Despite signs of promise when it comes to patient care and outcomes, IAH participants are still uncertain whether the shared-savings incentives will cover or exceed their costs to set up and maintain the program.

"We've had to invest some upfront staff and resources to qualify for the demonstration and meet the performance requirements," says internal medicine physician and geriatrician Eric De Jonge, co-founder of the Medical House Call Program at MedStar Washington Hospital Center in Washington, D.C., which is participating in IAH. "Those changes have enhanced care and we hope the shared savings will create a more financially viable service."

Data gathered by the University of Pennsylvania's home care program before the start of IAH suggest that those savings can be significant. Between 2004 and 2009, providing home care for a group of frail seniors similar to IAH patients led to 50 percent fewer hospitalizations and 70 percent fewer skilled nursing facility placements, says Forciea. In addition, 43 percent of house call patients were still living at home at the end of the study versus 28 percent of the control group.

Practices participating in IAH were told to expect their first incentive payments after 18 months if they exceeded Medicare's minimum savings requirement (MSR) and met certain quality targets. According to a CMS spokesperson, the agency is delaying payments until it refines the formula for determining the MSR, which is risk adjusted to reflect each practice's patient population.

POTENTIAL FOR SMALL PRACTICES

Given a workable payment model, home-care programs have great potential to help physicians connect with their frail elderly patients, says Forciea. And startup costs can be mitigated through partnerships between physicians and other health and social service providers in the same community.

"Practicing physicians have more resources around them to create home-care teams than they may realize," she says. For example, you can partner with your local agency on aging or visiting nurse service to build a home-care team rather than employing nurses or caseworkers directly.

Those partnerships have the potential to make a home-care program viable for smaller individual practices that do not meet the 200-patient requirement of IAH, she adds.

"Using community resources can help a practice build up a population of 50 to 60 home-care patients," says Forciea. "Then it becomes an inter-professional activity in the truest sense."

Janet Colwell is a Brooklyn, N.Y.-based freelance writer specializing in healthcare. With more than 20 years experience as a journalist, she writes frequently about clinical and practice management issues for several national health industry publications. She can be reached at editor@physicianspractice.com.

This article originally appeared in the January 2015 issue of Physicians Practice.