Particularly for patients who are older and frail, home-based medical care is often a viable alternative to urgent care centers, emergency rooms, and hospitalization.
This article appears in the September/October 2020 edition of HealthLeaders magazine.
The coronavirus pandemic has increased demand for home-based medical care, according to Michael Le, MD, chief medical officer at Landmark Health.
During the coronavirus disease 2019 (COVID-19) pandemic, patients have been reluctant to visit healthcare facilities due to concerns over coronavirus infection. In April, a Medical Group Management Association survey found that physician practices had experienced a 60% average decrease in patient volume.
Huntington Beach, California–based Landmark Health specializes in providing home-based medical care such as medical interventions and behavioral healthcare to older patients with multiple chronic conditions. The COVID-19 pandemic has been driving demand for this type of in-home care, says Le.
"There has been a dramatic increase in the interest for our services—about a 33% increase in demand for our type of in-home services since the pandemic began. We think that is only going to grow as the year continues, especially as we get back into the flu season in the fall," he says.
The increased demand for in-home services has boosted Landmark's finances, Le says. "From a financial standpoint, the pandemic has grown revenue. We forecast revenue will increase about 230% for this year."
Landmark focuses on risk-based and value-based contracts, mainly with Medicare Advantage health plans. The organization employs about 450 healthcare professionals such as doctors, nurse practitioners, physician assistants, dietitians, and social workers. Landmark operates in 14 states, including 46 metropolitan service areas.
Focusing on frail seniors
There is untapped potential to provide home-based medical care to homebound seniors, a recent article published in Health Affairs says.
According to estimates in a 2015 JAMA Internal Medicine article, there are about two million homebound seniors in the United States and about five million seniors who can only leave home with assistance or significant difficulty.
The Health Affairs article is based on survey data collected from more than 7,500 community-dwelling, fee-for-service Medicare beneficiaries. The study includes three key data points.
- Almost 5% of the Medicare beneficiaries had received home-based medical care during the study period from 2011 to 2017
- Among the Medicare beneficiaries who received home-based medical care services, 75% were homebound
- Compared to non-homebound Medicare beneficiaries who did not receive home-based medical care, non-homebound beneficiaries who did receive this kind of care had more chronic illnesses, more functional impairment, and higher healthcare utilization
For healthcare providers, there is a golden opportunity to provide home-based medical care to homebound seniors and medically complex non-homebound seniors, the Health Affairs article's co-authors wrote. "The significant unmet needs of this high-need, high-cost population, and the known health and cost benefits of home-based medical care should spur stakeholders to expand the availability of this care."
Frail seniors are good candidates for home-based medical care, says Nancy Guinn, MD, medical director of Healthcare at Home, a division of Albuquerque, New Mexico–based Presbyterian Healthcare Services.
"This population is well served by being seen at home for many reasons. Even traveling to a clinic can be difficult or impossible. Patients with cognitive decline or mobility issues may be especially challenged by a clinic visit. In terms of hospital at home, patients avoid exposure to any potential hospital-based infections and are less likely to fall in a familiar setting. Seeing a patient in the home offers significant insight into their environment," she says.
Landmark's mobile care model
The average age of a Landmark patient is 79, and the average patient has eight chronic conditions, Le says.
"For the frail population, they need someone laying hands on them and looking around at the home environment, especially in this time when family members are afraid of visiting and getting their loved ones sick with the coronavirus. Our patients are even more isolated and lonely than they were before the pandemic, and having someone come to examine them and bring treatment to them helps keep them out of emergency rooms, urgent care centers, or hospitals that are full of COVID-19 patients."
Landmark's mobile geriatric care model has four primary elements, he says.
1. "Complexivist" care features a multidisciplinary team. "Complexivist care includes our doctors, nurse practitioners, physician assistants, psychiatrists, pharmacists, dietitians, and social workers. It is a full care team wrapped around the patient. It takes a village to manage the frailties of these patients," Le says.
Complexivist care is provided 24/7 in the patient's home, and caregivers spend a significant amount of time with patients, he says. "As opposed to a 10- or 15-minute office visit, our initial visits are an hour long and our follow-up visits are 50 minutes long."
2. Urgent care services are provided to patients. "We do not just lay hands on the patient and take vital signs. If we find a health problem, we can make an intervention immediately—we are like a global urgent care or emergency room. We can draw blood and check labs. We can administer medications such as Lasix, IV antibiotics, and steroids to treat and stabilize patients. We can insert catheters, perform suturing, and check X-rays or ultrasound imaging," Le says.
3. Behavioral health services are provided to patients because about 50% of Landmark's patients have behavioral health comorbidities that negatively impact their quality of life and healthcare outcomes. "We have our own behavioral health team to help address behavioral health needs and social determinants of health," he says.
4. Palliative care and advanced care planning are provided to patients because they are statistically approaching their last years of life, Le says.
"We train our providers to have end-of-life conversations with patients. As a former hospitalist, I can say there is no worse place to have those kinds of conversations than in an emergency room or an ICU. There is no better place to have those kinds of conversations than in a patient's living room while they are surrounded by their family. That way, the whole family can have discussions about goals and values."
Geared for the pandemic
Landmark's in-home service model is well-suited to rising to coronavirus pandemic challenges, Le says.
"Whether it is a direct impact from the pandemic or an inability to get out and get medications, we have seen worsening behavioral health severity among patients. Our behavioral health team—our psychiatrists, nurse practitioners, and social workers—has seen about a 180% increase in visits during the pandemic."
Landmark caregivers are serving as a "pre-frontline" during the pandemic, he says.
"We are able to go into homes and treat our patients so they do not have to go into a hospital and be around symptomatic patients who could be spreading the coronavirus. We can alleviate some of the frontline stress in the emergency rooms, so they are not overwhelmed."
Treating frail, elderly patients in their homes limits their exposure to possible infection with coronavirus, Le says.
"Many of our patients have diabetes, heart failure, and cancer, which puts them at higher risk if they contract COVID-19 at a healthcare facility. If they catch coronavirus, these patients will likely have a bad outcome. Our patients have another option to receive care other than just dialing 911 and being transported to an emergency room."
Landmark focuses on the sickest and frailest patients now, but healthcare is moving in the direction of the home, he says. "Whether it is for convenience, safety, or good outcomes, more and more healthcare will be shifting toward the home. We believe there is a gap in this area."
As a care delivery method, home-based medical care is likely to follow a similar trajectory as telemedicine, Le says. "Just like telemedicine has surged and will be part of the healthcare landscape for years to come, the shift to more home-based medical care has been accelerated and will continue to grow long after the pandemic."
Guinn is equally bullish on the future of home-based medical care.
"We can't keep assuming that hospital-based care is the best choice for all of the patients that we currently hospitalize. That is not to say patients should receive lesser care—they should receive care that is appropriate for their needs. As our population ages, home-based medical care is going to be more important rather than less important," she says.
Guinn says home-based medical care is an attractive care model for frail seniors and other high-risk patients. "What a better way to get care. You stay home. The doctor comes to you. The care team spends an hour or an hour and half with you. We do flu vaccines in the home. We do Pneumovax in the home and other shots. We even have a podiatry nurse who comes in and does foot care for our diabetic patients. Who wouldn't prefer that as a way of getting care?"
Healthcare at Home model
At Presbyterian Healthcare Services, Healthcare at Home programs offer a range of care in the home from primary care, to urgent care, to Hospital at Home. The health system built its home-based medical services unconventionally, Guinn says.
"We did not follow what most people would call a normal progression. Normally, you would set up a house calls practice, then branch out. We became interested in Hospital at Home when it was being created and thought it was a good idea for us. Then we discovered that we needed broader-based services for our patients than Hospital at Home could provide. Hospital at Home really is hospitalization. We have criteria for admission just like a hospital would have criteria. But often patients do not need that level of care, so we had to broaden what we were doing. That is how we ended up backing our way to house calls," she says.
For other health systems that are considering adoption of home-based medical care services, Guinn says organizations should conduct an in-depth needs assessment first. "Whatever progression you take in launching home-based medical care services, you need to understand what the needs are. You also need to understand the stakeholders, whether they are your patients, your board of directors, your insurer source, or your hospital system. You have got to understand their needs, then construct programs that are appropriate."
More than 1,000 patients are receiving medical services through Presbyterian's Healthcare at Home programs, she says. The Hospital at Home program can serve as many as 14 patients daily. About 700 patients are receiving primary care and urgent care services through Healthcare at Home's Complete Care program. And about 300 people are receiving care at a bricks-and-mortar clinic established for Healthcare at Home patients.
"We created a small clinic for people who would prefer to be seen in a clinic setting even though they qualify medically for the home programs. What we have found is that people drift back and forth between the home and clinic settings depending on their need. If they have an urgent issue, we will see them in the home," Guinn says.
Across Healthcare at Home programs, there are 285 employees.
Patients are highly satisfied with Healthcare at Home programs, she says. In patient satisfaction scores for the second quarter of this year, 100% of Hospital at Home patients reported that they would recommend the service for others, and 95% of Complete Care patients reported that they would recommend the service for others.
Hospital at Home
There are three keys to success in operating a Hospital at Home program, Guinn says.
"First of all, it is a really good funding mechanism. Medicare does not pay for this service, which is a shame because it is valuable. So, contracts must be built with other insurers such as Medicare Advantage health plans," she says.
The second crucial Hospital at Home component is recruiting an appropriate clinical care team, Guinn says. "Hospital at Home requires a rapid response team. You have got to have a team that has the proclivity to move quickly when necessary. For example, many of our Hospital at Home nurses used to work in emergency rooms—they have the sense of the urgency of care."
Hospital at Home physicians must be able to work independently, she says. "People naturally assume that a Hospital at Home provider is a former hospitalist, but we are more likely to hire rural primary care physicians. Those clinicians are isolated enough that they are used to coping with whatever comes through the door. Our Hospital at Home clinicians need to be confident enough and have enough breadth to be able to cope with whatever they find in the field."
The third essential element of a successful Hospital at Home program is "prearrangement," Guinn says. "You need to know where you are going to get your medications and where you are going to get your durable medical equipment. You need to arrange infusions in the home and you need to establish partnerships with companies that move rapidly enough to ensure patient safety."
The Hospital at Home program is not appropriate for all patients who are sick enough to require hospitalization, she says. "Basically, it involves the idea of patient safety. There are many conditions that we can treat in the home, but there are some conditions that are advanced enough that we would prefer the patients go into a tertiary facility."
The program treats patients with nine diagnoses, including congestive heart failure exacerbation, COPD exacerbation, community-acquired pneumonia, DVT and simple pulmonary embolism, complicated cellulitis, and complicated UTI. "For all of those diagnoses, there are markers for distress that are beyond what we feel is safe for the home," Guinn says.
Funding home-based medical care services
At-risk contracts such as those set in Medicare Advantage health plans are the best fit for providing home-based medical care services, she says.
"With home-based medical care, you absolutely have to find a funding source that does not focus on payment for services rather than payment for outcomes and results. You need to have at-risk funding. The goal is always to identify how you can fund these services—acknowledging that the funding is based on value and cost savings by offering appropriate care, not on a fee-for-service model."
Healthcare at Home's Complete Care program has generated significant cost savings, Guinn says. "For the four years between January 2015 and December 2019, Complete Care reduced the cost of care by 38% compared to predicted cost for similar patients."
She says the cost savings from Complete Care are generated on several fronts, including medication management, decreased utilization of emergency department and hospitalization services, and fewer specialist visits.
Hospital at Home also drives cost savings, including avoided postacute care services, Guinn says. "If you don't go to the hospital, then you don't go to a skilled nursing facility. Postacute care costs are really significant for this population, and a hospitalization predisposes toward spend in postacute care costs."
A Health Affairs article published in 2012 found that Presbyterian's Hospital at Home program generated cost savings in patient care of 19% compared to similar patients who received care in an inpatient setting.
Photo credit: Illustration by Francesco Ciccolella
Christopher Cheney is the senior clinical care editor at HealthLeaders.
The increased demand for Landmark Health's in-home services is boosting revenue, with the organization projecting revenue will increase about 230% this year.
At-risk contracts such as those set in Medicare Advantage health plans are the best fit for providing home-based medical care services.
At Presbyterian Healthcare Services, Healthcare at Home's Complete Care program reduced the cost of care by 38% compared to predicted cost for similar patients.