How health systems can support underserved patients through in-home care

Hospitals and health systems are looking outside the walls of their acute care facilities to raise the overlap level of care they are delivering to their patient populations.

Finding a way to deliver high-touch care to vulnerable and underserved patients using the patient’s home as the primary point of care has become a strategic priority for both payers and providers.

The strategic shift to a focus on in-home care for these populations — whether it be in traditional homes, group homes, retirement communities or assisted living — is occurring primarily as result of increasing pressure on health systems to lower the cost of care for populations they serve, coupled with the need to solve for the challenges presented by social determinants of health (SDoH). But many other factors have coalesced to cause payers and providers to look to in-home patient care as a viable solution for addressing the needs of their most frail, vulnerable and underserved patients. (For a further discussion of the nature of this challenge, see the sidebar “Factors driving the industry’s new strategic focus on in-home care,” at the end of this article.)

House calls are nothing new, but until recently, they have been a niche for mission-driven providers focusing on strictly homebound patients, based in part on the perception that it is more expensive to deliver care this way. Added to this fact, drive time and other demands of in-home care translate into smaller patient panels.

Yet it also is becoming clear that patients prefer to stay at home rather than in a hospital. The COVID-19 pandemic dramatically added clinical relevance to this stated preference. Patients who are most appropriate for in-home care are avoiding risky and overburdened facilities while finding a way to access proper care for their chronic conditions. It is becoming more obvious that the best way to care for this population is to bring the care to them.

To successfully pursue such an approach, however, hospitals must first understand the key capabilities required to operate an in-home care program and establish clear expectations on how the program will be funded.

Critical capabilities required

A health system requires two foundational capabilities to be able to execute in-home care delivery, whether they are built internally or accessed through a third-party partner.

1 Predictive modeling. Such modeling is required to accurately pinpoint consistently high-cost patients who can benefit from home-based care and treatment. Qualifying patients include, for example, those who meet the following criteria:

• Drive 50% of acute hospital admissions while accounting for 40% of total cost
• Suffer from multiple chronic conditions and are on six or more medications
• Cost the health system a minimum of $38,000 a year in medical expenses.

2 An integrated, multidisciplinary in-home care team. This team must be able to apply appropriate interventions and referrals based on a patient’s social, behavioral and physical needs. Team responsibilities range from reinforcing care plans from the primary care team to managing care transitions and closing quality gaps to referral services for palliative care and behavioral health.

Again, options for acquiring these capabilities include developing them internally versus collaborating with a third-party in-home care provider. In some cases, health systems might discover that their health plan partners have already contracted with a home-based primary care provider, and it is simply a matter of coordinating effectively with that organization to deliver the best care. In other cases, a health system might be able to convince health plan partners to jointly fund in-home primary care.

Funding model expectations

Investment related to in-home care can take many forms. Models can be designed around a fee-for-service payment structure or a value-based approach that rewards quality outcomes. In some cases, a health system might finance an in-home program on its own, or it collaborate with a health plan partner for funding. Whatever payment mechanism is used, in-home care provides significant ROI opportunities for sponsoring organizations. For a typical in-home care model, organizations can expect to see a 20%  reduction in cost of care while also securing Net Promoter Scores for these efforts of 85 and better — significantly higher than traditional healthcare scores. 

Regardless of the funding model, when evaluating in-home care solutions, health systems should insist that the program meet the following basic performance requirements:

• Delivers medical, behavioral, social care and treatment to patients wherever they live 24/7 year-round
• Provides a compelling risk arrangement, with a willingness to place fees fully at risk in support of existing value-based contracts
• Reflects a care model that delivers high frequency contact while ensuring tightly attuned treatment plans and closure of gaps in care while promoting a higher quality of life
• Can demonstrate specific expertise in patient acquisition, engagement and satisfaction
• Has or will have a strong presence in the health system’s key markets, with the capability and readiness to quickly establish a local network
• Provides a flexible approach, with diverse approaches for identifying and selecting patients, delivering care and measuring performance

Regarding the last point, for example, the preferred solution could identify patients for the program using a partner’s proven algorithm, or it could leverage the health system’s desired selection criteria. There also should be flexibility around determining which specific key performance indicators should be measured, based on what’s most important to the health system.

Finally, a clear prerequisite for any in-home care partner, of course, is a proven track record and evidence of success in delivering home-based medical care.

In-home care’s value proposition

Effectively leveraging in-home care services can generate value for health systems in five important ways.

1. Promoting better managed, healthier patient panels. By providing in-home support for vulnerable and underserved patients, health systems can achieve dramatically improved outcomes clinically, financially and experientially for these patients.
2. Closing gaps in access. This approach allows health systems to address gaps in access, whether they be driven by SDoH concerns or staffing shortages. Not only do the patients get the care they need, but also the health system’s clinical staff experience less burnout as home-based care gives them the satisfaction of being able to extend care to hard-to-reach patients, improving treatment and medication adherence and reducing unnecessary readmissions and ER utilization.
3. Improving performance in value-based care contracts. Providing in-home care allows health systems to more effectively extend care to patients in value-based care panels who are high risk and high cost but who are not adhering to care plans and are struggling with access to care in general — in other words, the patients who they have the hardest time reaching but who also are among the most important patients to reach. They account for 40% to 50%of all claims.
4. Providing a competitive advantage when working with health plans. Approaching health plans with a solution that better serves their most vulnerable and underserved members will immediately cast a provider organization in a more positive light.
5. Enhancing patient satisfaction and retention. One regional health plan in the Northeast measured patient satisfaction with a collaborative model where their primary care physicians were coordinating with in-home care providers to meet their needs. Surveyed patients reported a Net Promoter Score of 87, which is highly competitive for any industry and an exceedingly superior score for the healthcare sector.

Case example: Adventist Health

In response to new opportunities through the California Advancing and Innovating MediCal (CalAIM) program, Adventist Health in Roseville, California, is leveraging in-home care delivery to close gaps for patients with the most complex care needs by addressing social barriers, such as homelessness, which influence a patient’s health.

“This innovative care delivery model reflects our deep commitment to improving the physical, mental and spiritual well-being of our community,” said Shelly Trumbo, vice president of Well-Being at Adventist Health.

Adventist Health is deploying field-based care teams, consisting primarily of community health workers (CHWs), to meet patients on their terms, whether it’s at home, in a homeless encampment or in the emergency department. Once engaged, CHWs conduct a SDoH assessment to understand the social impediments that may be impacting the patient’s health, such as access to food, stress, transportation and more.

Remote nurses and social workers connect and coordinate preventive care and clinical treatment through Adventist Health’s clinics, while also providing wraparound support, including transitions of care, member and family assistance and coordination/referral of patients to community and social support services.

This program aligns with the health system’s broader goals related to health equity.

“Our vision is to see a time when well-being is accessible to everyone, everywhere,” Trumbo said. “We know that the future we envision requires strategic investments outside the walls of our hospitals and clinics, meeting community members where they are.”

A transformation recognizing a growing imperative

The U.S. population is aging, the prevalence of chronic disease continues increasing and behavioral health needs are exploding. The care delivery system is buckling under the stress.

At the same time, providing the right care at the right time for the most vulnerable and underserved patients is difficult. The answer is also to deliver care in the right place, which for many patients is in the home.

Hospitals and health systems committed to delivering only the highest quality of care should demonstrate that commitment by making in-home care delivery for vulnerable and underserved patients a strategic priority. By doing so, they not only stand to benefit clinically, operationally and financially but also will be able to keep pace with an important aspect of the industry’s value transformation. Ultimately, those that miss this opportunity today are likely to find it increasingly difficult to compete and survive in the future.

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Why the industry requires a new strategic focus on in-home care

The proliferation of in-home care in the United States reflects a necessary response to growing challenges facing the nation’s healthcare system.

For one, it offers a way to meet the needs of high-cost patients whose utilization of the healthcare systems is being fueled by a combination of medical complexity – including chronic conditions and polypharmacy issues  –  and unmet socioeconomic needs.

Meanwhile, even as clinician shortages and staff burnout force them  to do more with less,  health systems find themselves trying to operate amid two conflicting payment scenarios. First, many continue to rely to a large extent on  fee-for-service payment, which doesn’t afford them the ability to effectively manage their patient panels proactively between visits. And second,  most are engaged to various extents in value-based contracts, where success hinges on their ability to consistently engage with high-risk, hard-to-reach patients.

Despite these patients’ being an obvious priority, health systems are challenged to deploy the right tools and resources to find them, engage them and support them longitudinally to guide them to better health.  The clinic-only care model is proving ineffective, because it requires high member density to rationalize the cost, while the members who have the greatest need are often unable to make the trip to a clinic for their care due to mobility issues and/or access to transportation.

All of these factors  strongly point to the need for hospitals and health systems to offer a better solution for their most vulnerable patients in the form of in-home care. And they need to make this solution a strategic priority if the nation is to achieve the essential goals of value-based care and cost effectiveness of health.