Primary Care at Home

The Independence at Home Demonstration Project

Editor’s note: Demographics are changing. Venues of care are changing. Reps’ call points and the products in their bags are changing too. With this issue, The Journal of Healthcare Contracting begins a series of articles on chronic care management. Chronic diseases and conditions – such as heart disease, stroke, cancer, type 2 diabetes, chronic obstructive pulmonary disease, obesity and arthritis – are among the most common, costly, and preventable of all health problems. As of 2012, about half of all adults – 117 million people – had one or more chronic health conditions. One in four adults had two or more chronic health conditions. Seven of the top 10 causes of death in 2014 were chronic diseases.

In the next 20 years, the number of Americans who are 65 years old or older will nearly double to more than 72 million – one in five Americans, reports the National Association for Home Care & Hospice, or NAHC. Many will live with disability and multiple chronic illnesses.

Authorized by the Affordable Care Act, the Independence at Home Demonstration is designed to provide chronically ill patients with a complete range of primary care services at home. Medical practices led by physicians or nurse practitioners provide primary care home visits tailored to the needs of beneficiaries with multiple chronic conditions and functional limitations

The Demonstration also tests whether home-based care can reduce the need for hospitalization, improve patient and caregiver satisfaction, and lead to better health for beneficiaries and lower costs to Medicare. Primary care team

“I do think we are a nice option for office-based providers to know that there is a team of primary care providers who will see patients in the home,” says Ina Li, M.D., program director for Christiana Care Health System’s Independence at Home Demonstration Program and director of clinical geriatrics for Christiana Care in Wilmington, Delaware.

A typical referral is a patient who has had a stroke, chronic obstructive pulmonary disease and severe arthritis, she says. “This patient is no longer able to walk down her front steps and can no longer make it in to see her primary doctor. The doctor who sees the patient may not have seen them in a year. Due to this situation, the doctor makes a referral to my practice for our team to see the patient and take over their care. We are then able to provide timely care to the patient and, hopefully, maintain and improve their quality of life and reduce their burden of illness and symptoms.”

Karen Abrashkin MD

“The individuals we’re really looking for are the sickest of the sick, homebound patients, who are at risk of goinginto the hospital or suffering a poor outcome because they don’t want to go to the hospital, or because going to the hospital may present its own risks,” says Karen Abrashkin, M.D., medical director of Northwell Health House Calls, an Independence at Home participating practice.

CMS program
The demonstration project began in 2012 and was originally authorized for three years. It was subsequently extended for two additional years through September 30, 2017, by the Medicare Independence at Home Medical Practice Demonstration Improvement Act of 2015. The Bipartisan Budget Act of 2018, enacted Feb. 9, 2018, extended the demonstration for an additional two years through Sept. 30, 2019.

To qualify for an incentive payment, participating practices must meet the performance thresholds for at least three of six quality measures:

  • Follow-up contact within 48 hours of a hospital admission, hospital discharge, and emergency department visit.
  • Medication reconciliation in the home within 48 hours of a hospital discharge and emergency department visit.
  • Annual documentation of patient preferences.
  • All-cause hospital readmissions within 30 days.
  • Hospital admissions for ambulatory care sensitive conditions.
  • Emergency department visits for ambulatory care sensitive conditions.

In the second performance year of the demonstration – the most recent year for which data was available at press time – 10,484 beneficiaries were enrolled in 15 participating practices. The data shows that all 15 practices improved performance from the first performance year in at least two of the six quality measures. Four practices met the performance thresholds for all six quality measures. All together, the 15 practices saved $10.6 million, and seven participating practices earned incentive payments of $5.7 million.

Northwell Health
Northwell Health’s demonstration program is directed by physicians and nurse practitioners, with the aid of an entire team, including technicians, social workers and others, says Abrashkin.

“By providing home-based primary care and a reliable alternative to receiving care through the emergency room and hospital (which many of our patients do not want), we were able to show savings in the total cost of care while honoring our patients’ wishes for where and how they receive medical interventions. “Our home visits are just like office visits, but with a lot more behind them, including more frequent regular checkups as well as sick/urgent visits when necessary,” she says.

The House Calls team makes visits Monday through Friday, and a primary care provider is on call 24/7 to answer questions and get patients the care they need, says Abrashkin. “We are able to take care of many diagnostics in the home, such as X-ray, lab work, EKG, ultrasound, sleep studies and occupational and speech therapy. We deliver care in the home through primary care, nurse and social work care-manager visits, and interventions, such as IV medications.” Specially trained emergency triage nurses are available telephonically 24/7.

The House Calls team includes community paramedics, that is, specially trained paramedics who can, under the orders of a physician, evaluate and provide treatment in the home around the clock. The average response time is 21 minutes, and they can perform EKGs, blood glucose monitoring and CO2 tests; administer more than 20 medications (either through an IV, inhalation or orally), and more.

“There are very few things in life that physicians and patients love, and that also save money,” says Abrashkin. “But the patient satisfaction rating for our community paramedicine program is through the roof, and we’re offering a new career option to paramedics. By building this team and this program, we are able to give patients safe and reliable ways to receive care at home, where most of our patients prefer to remain.”

During the second year of the Independence at Home demonstration project, Northwell’s House Calls practice provided care to 357 patients in Nassau and Suffolk counties as well as Queens in New York City. In addition to improving health outcomes, Northwell’s clinicians reduced costs that year by $6,816 per patient per year, for total savings to Medicare of $1,641,825. This was the second highest savings performance among the demonstration sites. After accounting for Medicare withholds, Northwell earned $874,151 in incentive payments.

Christiana Care Health System
Christiana Care began participating in the Independence at Home Demonstration Project in 2012. “The Independence at Home program is a delivery model where we are the primary care providers for home-bound patients,” explains Li. “We provide primary care in the patient’s home. Primary care providers who work in offices refer their homebound patients to our program for us to take care of in a longitudinal fashion. The office-based primary care providers relinquish control of their patients once they enter our program.

“We work closely with Christiana Care’s Visiting Nurse Association, as they are another referral source for us,” adds Li. “As many of our home-bound patients require in-home skilled nursing and physical, occupational and speech therapies, we often refer to our Visiting Nurse Association for assistance.

“In terms of outcomes, we have worked hard to reduce our inpatient hospital and skilled nursing facility admissions,” she says. “By focusing on these two specific measures, we have reduced the average Medicare payment per beneficiary per month by 22 percent in the last five years. We are in the process of designing a tool for patient experience to better understand how we can most effectively serve the needs of our patients.” Implementing Independence at Home has been a learning experience, says Li.

“We have found that high utilization of skilled nursing facilities and care for dialysis patients were big factors in [our] expenditures,” she says. “Compared to other Independence at Home programs, we had higher proportions of both. We are now modifying our program to better control these costs.”

That said, Li is convinced that the team-based approach of Independence at Home is a sound one.

“To manage homebound patients who have a high disease burden, including medical, psychological, and socio-economic issues, a team-based model of care is essential,” she says. “Since these patients have complex issues, [they need] the support of many disciplines to ensure that they can receive their care at home and avoid having to be admitted to the hospital.”

Lessons learned
Independence at Home has given Northwell Health House Calls a chance to transform its approach to home-based primary care by adopting some best practices, says Abrashkin, who served as a hospitalist before getting involved in House Calls six years ago.

“Independence at Home has provided financial support and a platform to support our care model,” she says. “There are many expenses in our program – such as care manager visits and community paramedics – that are not reimbursed by Medicare but that are important to providing high-quality care at home. Independence at Home has helped provide funding for these services and also has allowed us to create a network across the country of other practices involved in IAH to share best practices.

“We have applied the quality markers of Independence at Home across our whole patient population – things like advanced care planning to really understand what our patients want for their care, having a provider on call by phone 24/7 to give a meaningful alternative to calling 911, and making an in-person visit within 48 hours of hospital discharge to check on the patient and reconcile medications if they do go into the hospital for treatment. We know that these are important to the outcomes of our patients, and have applied them to all patients, whether they are enrolled in Independence at Home or not.

“This work is very meaningful, both to our staff and to our patients and their families, but also very difficult,” she continues. “Going into the home setting, where the typical resources of a hospital or an outpatient facility are not available, pushes our team to think outside the box on a daily basis. Our staff encounters new and different situations and challenges every day. The people working in our program are doing this work because they are truly dedicated to their patients.

“We have also learned that regulations set for traditional office-based settings may hamper growth of programs delivering home-based primary care. For example, the oxygen saturation readings measured by our community paramedics cannot be used to certify a patient for home oxygen; instead, we need to send a physician or nurse into the home to retake the measurement. There is also a role for telemedicine that is not currently reimbursed, which could allow us to increase our footprint and provide more care across our area. But without support for these services, it is very difficult to develop programs that could potentially be helpful.”

The Northwell Health team has also learned that organization and predictable workflows are essential to the success of a program such as Independence at Home.

“With a mobile workforce, communication can be more difficult than in an office or hospital,” says Abrashkin. “What you might discuss over lunch with your colleagues now has to be communicated deliberately to a group who is driving across Queens and Long Island. This also goes for collegial discussions amongst physicians or care managers about difficult cases and how to proceed. These discussions have to be built into the work week or else they won’t happen, and they are very important for holistic team-based care.

“Having a medical record that supports your work is very necessary for day-to-day work and communication as well as reporting. This is a real challenge when working remotely.”

But the payoff makes the effort worthwhile.

“A major lesson learned is just how meaningful this work is,” she says. “Going into someone’s home allows you to get a real insight into their life and allows you to realize that, as a medical provider, your care is only one slice of what is going on in a person’s life and influencing his or her health outcomes.”

NAHC a big supporter

The National Association for Home Care and Hospice is a self-proclaimed strong supporter of the Independence at Home Demonstration project. IAH works because:

  • It is designed to provide appropriate levels of care for a carefully targeted group of the most complex, high-cost beneficiaries.
  • It requires an interdisciplinary team to provide access to care 24 hours a day, seven days a week, and to offer in-home visits within 48 hours of hospital or emergency room discharge, including medication reconciliation.
  • It prevents unnecessary hospitalizations and misuse of medications, and discourages overuse of services.
  • It has rigorous quality standards that assure better patient and family experience, and better clinical outcomes.
  • It is backed by a substantial body of evidence showing that home-based primary care, as applied in the IAH demonstration, enhances quality of care and reduces cost for seriously ill elderly Americans.
  • It saves Medicare money.

“The Independence at Home demonstration project is focused on very high-risk patients, generally, the top 5 percent high-risk Medicare patients, so it is appropriate that medical practice takes a predominant role,” says NAHC President William A. Dombi. “Will that change in the future? It certainly could, but probably not to the point of being driven by a non-medical fo- cus. Home health could certainly become more involved in the future, thanks to technological improvements, but currently home health is more appropriate for the other 95 percent of Medicare patients.”

Health plan waives cost for chronic-care meds

A health plan in Massachusetts has begun offering a program that waives co-pays for 11 common prescription medications that treat chronic conditions, such as high cholesterol, high blood pressure, heart disease and depression. The program will be offered by Neighborhood Health Plan on a selection of commercial plan designs for large employer customers. Neighborhood Health Plan is a member of Partners HealthCare.

“Care Complement” also gives members access to prevention services, such as diabetic education and nutritional counseling, at no additional cost. Cost-sharing is waived for certain pain treatments offered in place of opioid prescriptions, as well as for cardiac rehabilitation services to speed recovery after a heart attack.

“Care Complement improves adherence and management of chronic disease, and offers affordable alternatives to opioids for the treatment of pain,” Dr. Anton B. Dodek, chief medical officer for Neighborhood Health Plan, was quoted as saying. “By eliminating cost sharing, this benefit design encourages members to work with their doctors and optimally manage their conditions, which results in healthier outcomes and improved patient satisfaction.”

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