Theresa Soriano, MD, MPH, Kristofer Smith, MD, MPP at Northwell Health and Karen Abrashkin, MD, FACP
As a myriad of services and activities that were previously only available at hospitals, are now easily accessible at home, it should come as no surprise that patients and caregivers are embracing medical care at home with open arms. In addition to convenience and comfort, medical care at home allows clinicians to comprehensively evaluate the contributors to a patient’s health status─ insights difficult to glean in an office-based visit. Especially in the last decade, home-based medical care (HBMC) has also been shown, through independent studies as well as a multiyear CMS demonstration called Independence at Home, to improve quality and total cost of care. These improvements are accomplished through several mechanisms: hiring and incentivizing clinicians to be risk tolerant instead of risk averse, 24/7 availability to detect and intervene upon issues before they escalate, closely following patients after hospitalization to prevent readmissions, and developing longitudinal relationships that allow for meaningful advanced care planning.
Those who benefit the most from HBMC are those who are of older age and have multiple chronic conditions. Older adults with multiple chronic conditions tend to utilize the emergency room and inpatient care at high rates as they are unable to access traditional outpatient services when they feel unwell or have a change in condition. Furthermore, many of those practices are not designed for the responsiveness and risk tolerance necessary to help realize patient goals of remaining out of the hospital. Finally, many of these complex patients live with behavioral and/or social challenges that require team-based approaches and staffing.
Recognizing the benefits of this care delivery model, leading Medicare Advantage (MA) plans and non-medical organizations have been starting or acquiring home-based medical care practices, turning a field that was once a sleepy corner of healthcare into a highly competitive growth arena. With major health care companies displaying increased interest in acquiring home-based care companies, and several other venture-backed and private organizations moving into the space, the message is clear: medical care in the home is growing in volume and may soon be available at scale for millions of MA and dual-eligible beneficiaries.
As care in the home scales, the importance of developing industry-wide quality standard only increases. First, in guiding the industry growth, quality metrics specific to HBMC move practices in the same direction: towards valuing patient-important outcomes and meeting accepted standards. Those who benefit most from HBMC often prioritize elements of care that are different from younger, healthier individuals, such as medication deprescribing, falls prevention, symptom relief, caregiver support, and advance directives completion. Second, quality metrics are important for patients and caregivers who will increasingly be faced with multiple options for care delivered in the home and require a way to make an informed decision on the practice with whom they will entrust their care. In periods of rapid growth where organizations are fiercely competing for market share and growth can include multiple years of doubling in size of patients serviced, building reliable systems, and finding enough qualified clinicians challenges the field and intensifies the need for quality standards and an oversight process.
Fortunately, the timing for accelerating national quality standards in HBMC is optimal given growth in the MA space combined with new Centers for Medicare and Medicaid Services (CMS) offerings. The recently-relaunched CMS program, ACO Realizing Equity, Access and Community Health (ACO REACH) Model has the potential to open the option for care in the home to millions of Medicare beneficiaries, a population that has previously had few options for HBMC. Combined with the growth in the MA space, the industry is at an inflection point of size and national interest to gain tremendous ground in accelerating accepted standards that will benefit the design and development of all practices delivering care in the home.
There is no question that for the frail older adult population, many of whom live with multiple health conditions and with caregivers who need support and reassurance, home is where patients and caregivers want to receive care. The task, however, of building HBMC practices that consistently deliver on the value equation of decreased cost and/or improved quality requires careful attention, particularly in this period of booming growth and limited provider workforce. As we see practice growth and practice acquisition accelerating, the question now is how we strive to define, measure, and reward quality in HBMC to ensure we provide best-in-class care that this population deserves.