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How to Get Your Organization Positioned for the Future

The home is becoming a primary focal point for healthcare. There is a shifting preference to where consumers/patients want to be cared for. Traditional care at home models is innovating care, adding remote technologies, and expanding skilled interdisciplinary care teams. The transformation allows new companies to enter the home care space and signals that traditional models of care are being disrupted.

Expanding continuum-of-care services is an important strategy. The goal is to serve patients as they transition through the various stages of post-acute care. It creates a post-acute network of services which can include in-home personal care services, skilled home health, palliative care, or hospice.

Continuum-of-care services position organizations to gain referrals, participate as a partner in new care at home models, and support future growth.

Three Market Signals to Broaden Continuum-of-Care Services

What we are seeing today in the care at home market is a mixture of hybrid models, providers expanding continuum-of-care services, and payers jumping into the care at home.

The expansion of care at home services is the paradigm shift of the healthcare industry expanding chronic care management into the home setting. The common link to any of these models is developing a business model that expands continuum-of-care services and skilled interdisciplinary teams.

In this article, we explore how providers, payers, and physicians are broadening services to expand partnership referrals, create innovation, and ensure sustainability.

Acute Hospital Care at Home

In November, CMS announced the creation of the Acute Hospital Care at Home program during the COVID public health emergency to help health systems and hospitals increase care capacity during the pandemic.

The waiver is a big step into home-based care that allows Medicare fee-for-service reimbursement of home-based hospital services. The Acute Hospital Care at Home program allows participating hospitals to qualify for Medicare waivers to treat patients at home via telehealth, reducing the strain on EDs and in-patient services.

Brigham Health Home Hospital has taken the Acute Hospital Care at Home program to the next level. Using mobile integrated paramedics, the patient touchpoint increases in the home. The waiver requires that a nurse can see a patient in person or by video at least once a day. Paramedics can provide these visits, administer antibiotics, and can recognize a wide range of clinical, home, social, and environmental factors.

Michigan Medicine’s University Hospital in Ann Arbor was approved for the Acute Hospital Care at Home program. Before the approval, Michigan Medicine has been developing alternatives to hospitalizations for patients with congestive heart failure, cellulitis, chronic pulmonary disease, pneumonia, and urinary tract infections.

A greater focus on triaging patients in the emergency room, once the patient is evaluated, patients can get care at home with remote care management and get scheduled for home health and post-acute visits. These patients are monitored by Michigan Medicine physicians, nurse practitioners, nurses, paramedics, social workers, and other remote monitoring teams.

Mount Sinai at Home program provides hospital services and rehabilitation services to acutely ill patients who would otherwise re quire hospitalization. Mount Sinai has partnered with Contessa Health, a health care company that manages acute-care services at home through prospective bundled payment arrangements to extend Mount Sinai’s existing hospital-level care at home program, known as the Mobile Acute Care Team (MACT) to new markets.

Currently, Mount Sinai’s program is available to Medicare patients with specific acute medical conditions who would otherwise be admitted to a hospital within the Mount Sinai Health System. The partnership with Contessa Health will allow Mount Sinai to scale this program to include patients with different types of health insurance and a broader range of clinical conditions. Additionally, Mount Sinai will work with Contessa to add an option for post-surgical care at home. This will permit eligible patients to recover from surgeries that would normally require an inpatient hospital stay (such as total joint replacements) in the comfort of their own homes.

The program provides patients with a suite of integrated services that include daily visits from nurses, doctors, and social workers; IV support; oxygen; X-rays; and physical therapy through a combination of in-person visits, video visits, and remote monitoring. Patients who receive hospital-at-home care have fewer complications, fewer 30-day ED visits, lower 30-day hospital readmission rates, and decreased length of stay. Mount Sinai also reported increased patient satisfaction and lower cost of care.

The recovery at home models can be scalable for Medicare Advantage Plans, insurers, and decrease the costs for hospitals and ACOs.

Strategic Questions for Leadership

  • How is your organization strategically planning to expand continuum-of-care services?
  • What other provider partners should you include in the continuum?
  • What technology investments should be considered?
  • Is your organization ready to expand chronic care management with skilled interdisciplinary teams?
  • What is your growth management plan?

Payers Hospital at Home Care Models

Payers benefit from a lower total cost of care in the home than in other settings.

Humana recently announced its partnerships with DispatchHealth to offer in home emergency and acute care to its 8.4 million Medicare members. The agreement will provide members living with multiple chronic conditions – such as cellulitis, kidney, and urinary tract infections, chronic obstructive pulmonary disease, heart failure, and many others an opportunity to be treated safely at home and thereby avoid hospital visits. DispatchHealth’s unique model and technology empower clinical care and coordination of other critical services, such as pharmacy and meal deliveries, physical and respiratory therapy, durable medical equipment (DME) access, and imaging services.

In a randomized controlled trial published a year ago in the Annals of Internal Medicine, the adjusted mean cost of Home Hospital acute care episodes was 38% lower for home patients compared to control patients receiving traditional hospital care.

Providers Expanding Continuum-of-Care Services

2020 while challenging, resulted in many examples of how provider organizations such as home health, hospice, palliative care, and in-home providers sought new agreements to expand continuum-of-care services.

Baptist Health in greater Jacksonville announced a joint venture with BAYADA Home Health Care to expand upon the services provided to the community by Baptist Home Health. The combined organization, Baptist Home Health Care by BAYADA, will have the capabilities to serve more patients at home, where they can recover and thrive best. The joint venture comes as part of a growing trend in which health systems and hospitals are partnering with home health care providers that have the expertise and experience to manage care at home for patients who are at high risk of being readmitted to the hospital.

Last August, Amedisys, Inc. (NASDAQ: AMED), an independent home health, hospice, and personal care company, signed a Care Coordination Agreement with BrightStar Care to add its agencies to the Amedisys Personal Care Network, which helps facilitate the coordination of care between Amedisys’ hospice and home health care centers and a network of personal care partners.

BrightStar Care’s 340 personal care locations in 38 states reach approximately 75% of the U.S. population and largely overlap Amedisys’ hospice and home health footprints.

“If COVID-19 has taught us anything, it’s that America’s seniors need quality care in the home more than ever before to stay safe and feel supported,” stated Amedisys CEO Paul Kusserow. “I’m delighted to welcome the incredible BrightStar Care caregivers as care coordination partners in expanding access to a much-needed continuum of care that improves patient outcomes and lowers costs.”

The inability to effectively manage patients with multiple chronic conditions and activities of daily living restrictions is a primary driver of hospital admissions. With both clinical and non-medical teams coordinating care for patients, hospitalizations can be avoided.

Dallas-based AccentCare and Rosemont, Illinois-based Seasons Hospice & Palliative Care (Seasons), agreed to combine their organizations. AccentCare’s expertise in home health, personal care services (PCS), and hospice is complemented by Seasons’ leadership within the hospice and palliative care spaces. These strengths, along with an expanded geographic footprint, will enable the new combined organization to expand offerings in current and additional markets.

Chapters Health System’s Andrew Molosky, President and CEO, is reinventing the future of community-based care. Under his strategic leadership, the organization has combined innovation and creative disruption to dynamically shift its position as the nation’s largest not-for-profit, end-of-life care organization into that of the leading community-based population health organization.

Using a matrixed approach incorporating home health, advanced illness management, telemedicine, social determinants of health, and primary care they have been able to move chronic illness care further upstream delivering the low-cost, high-quality experience that has for so long been the provenance of hospice to patients, families, and communities.

Home-Based Primary Care (HBPC)

Home-based medical care models are shaking-up the $260 billion primary care market. Primary care practices are getting hit hard by the loss of revenue during the COVID-19 pandemic and the impact of the health crisis is forcing organizations to rethink how they operate.

HBPC programs provide appropriate care (primary, urgent, or palliative) to high-risk, medically vulnerable patients, often suffering multiple chronic conditions, when and where they need it.

This patient-centric, continuous care mod el delivers clinical, economic, and human benefits such as:

  • facilitating timely interventions when chronic conditions worsen and preempting avoidable emergency department visits and hospitalizations,
  • alleviating social stressors that contribute to poor health, and
  • comforting patients by giving them loving care and letting them know they’re not alone.

The aging population and the shift to value-based payment models are arguably the two most disruptive forces in healthcare. Yet, payers and providers too often fail to see, monitor, and manage those individuals who will disproportionally affect the impact of this gathering storm.

They are the “invisible homebound,” an estimated 2 million frail, functionally impaired, and vulnerable adults who:

  • are unable to visit their primary physician’s office,
  • have severe functional impairments, disabilities, and/or multiple chronic conditions,
  • may require palliative or end-of-life care,
  • often are not cared for by disease-specific management programs, and
  • account for approximately half of the costliest 5% of patients.


  • Landmark Health: The model focuses on managing multiple chronic care patients in the home. Partnering with health plans in shared savings arrangements, Landmark’s 24/7 in-home medical care brings medical, behavioral health, and palliative care, along with social services to patients in 46 communities across the U.S.
  • Iora Health: Iora Health is a clinic-based, interdisciplinary team model that offers medical care to a broader population of clinically complex patients.
  • MedStar: MedStar’s medical house call program in Washington, D.C., offers team-based primary care to patients in their homes.
  • ChenMed: A physician-led primary care company, ChenMed is focused on providing services to moderate-to-low-income seniors with complex chronic conditions.
  • Oak Street Health: Operates 54 primary care centers in 9 states targeting seniors who are Medicare Advantage members.
  • VillageMD: VillageMD, through its subsidiary Village Medical, is a leading, national provider of value-based primary care services.

Home-based care delivery or home-based primary care will become even more important going forward for Medicare Advantage (MA) health plans and risk-bearing providers to close care gaps.

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