Home visits are being used by accountable care organizations (ACOs) across the nation to improve care transitions, manage chronic conditions, and reduce or prevent the need for costly readmissions.
Using Home Visits During Care Transitions
In 2019, the Centers for Medicare & Medicaid Services (CMS) published a care coordination toolkit exploring different strategies ACOs use to care for beneficiaries. Many surveyed ACOs have implemented care transitions management interventions that involve sending care providers to beneficiaries’ homes, particularly within a few days of discharge.
These visits commonly include assessments to evaluate the beneficiary’s social support, ability to manage daily activities, and safety at home. In addition to these assessments, visits also include reviewing medications and discharge instructions, as well as identifying challenges relating to social determinants of health.
A study published in Health Affairs found that nearly 80 percent of surveyed ACOs reported using care transitions home visits within 72 hours of discharge for at least some patients. This varied slightly by ACO type with 86.7 percent of Medicaid, 82 percent of Medicare, and 79.6 percent of commercial ACOs using care transitions home visits.
Typically, patients who received home visits were considered clinically or socially complex. Those considered clinically complex had multiple chronic conditions or single conditions considered complex. Patients described as socially complex were often considered nonresponsive or noncompliant.
Preventing Admissions & Saving On Costs
Home health can be an effective way for ACOs to control care costs. Research published in JAMA Internal Medicine found that home care was associated with $5,385 in care cost savings per beneficiary and an average savings of $4,514 per beneficiary in Medicare payments when compared to post-acute care in a skilled nursing facility.
Home visits can also save on costly admissions. Within the first 12 months after a home visit, there was a reported shift from institutional care toward outpatient care according to a research article on HouseCalls—a home visit program for some Medicare Advantage plans. This study found that participation in the program was associated with a decline in both acute hospital and nursing home admissions.
Housecall Providers, a member of the CareOregon family, helps meet the needs of complex patients right within their homes. Housecall Providers participates in the Medicare Independence at Home Demonstration that looks to identify the quality of home-based care through factors like readmission rates, need for hospitalization, and patient and caregiver satisfaction.
Using care collaboration has helped Housecall Providers meet or exceed quality metrics while saving time on administrative tasks—allowing staff to care for more patients. In just one year, Housecall Providers saved Medicare $1.8 million in care costs.
Home visits can be a powerful tool for both ACOs and other healthcare organizations in cutting down on wasteful spending, reducing the need for acute care, improving care management, and providing quality care to patients and beneficiaries.
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