Abstract
Background
Home-based primary care (HBPC) is a multidisciplinary, ongoing care strategy that can provide cost-effective, in-home treatment to meet the needs of the approximately four million homebound, medically complex seniors in the U.S. Because there is no single model of HBPC that can be adopted across all types of health organizations and U.S. geographic regions, we conducted a six-site HBPC practice assessment to better understand different operation structures, common challenges, and approaches to delivering HBPC.
Methods
Six practices varying in size, care team composition and location agreed to participate. At each site we conducted unstructured interviews with key informants and directly observed practices and procedures in the field and back office.
Results
The aggregated case studies revealed important issues focused on team composition, patient characteristics, use of technology and urgent care delivery. Common challenges across the practices included provider retention and unmet community demand for home-based care services. Most practices, regardless of size, faced challenges around using electronic medical records (EMRs) and scheduling systems not designed for use in a mobile practice. Although many practices offered urgent care, practices varied in the methods used to provide care including the use of community paramedics and telehealth technology.
Conclusions
Learnings compiled from these observations can inform other HBPC practices as to potential best practices that can be implemented in an effort to improve efficiency and scalability of HBPC so that seniors with multiple chronic conditions can receive comprehensive primary care services in their homes.
Background
The United States’ population of adults ages 65 and over is projected to double between 2005 and 2030, escalating the demand for medical care and increasing the national healthcare burden [1]. Those over age 80 are the most likely to be frail with multiple functional impairments and chronic conditions, and this population segment accounts for the highest health care consumption. In financial terms, it is well established that spending on health care services is highly concentrated among the highest consumers with just 5% of the US population accounting for 50% of health care spending in 2009 [2].
Chronic care for the frail elderly requires ongoing, low-intensity support, much of it not strictly medical [3], which is in stark contrast to acute care delivered in U.S. hospital systems. There are an estimated four million homebound seniors in the U.S. who need chronic care management and ongoing supportive services and account for a significant proportion of Medicare expenditures [4,5,6]. In the U.S., Medicare beneficiaries are considered homebound if they need the help of another person or medical equipment, such as a walker or wheelchair, to leave their home, and if their doctor believes their health could get worse if they leave home. Without easy access to primary care, homebound seniors resort to the emergency department and hospitalizations when they experience exacerbations of their chronic conditions [4].
Home-based primary care (HBPC) is a multidisciplinary ongoing care model for providing in-home treatment primarily to medically-complex, functionally impaired homebound seniors. Recent studies have demonstrated that HBPC can be a cost-effective strategy for delivering care to frail patients while maintaining or improving quality of care and patient satisfaction [7]. For example, a multidisciplinary team-based HBPC approach has been shown to increase physicians’ ability to see patients by 40%, reduce costs per patient by 20%, and maintain quality as well as patient and provider satisfaction compared to usual care [8]. A major advantage of long-term care provided in the home is that it enables the physician to evaluate the patient’s home environment, and be responsive to changes in health status, patient goals, and family caregiving capacity [9]. Using a case-study design, Muramatsu et al. concluded that primary care delivered in the home enhances quality of care, increases patient and caregiver satisfaction, and can replace the need for emergency and hospital visits [10]. Unfortunately, of the 2 to 4 million people in the U.S. who are homebound only about one quarter receives medical care at home [4, 11].
Overall, primary care home visits have steadily declined throughout most of Europe and North America since the mid-twentieth century, and are no longer considered part of usual care [12, 13]. By 2001, fewer than 18% of physicians in the U.S. made home visits. The decline of house calls in the U.S. can be attributed to the shift to managed care, and the pressure for providers to increase their productivity by seeing patients in centralized clinic settings, enabling them to see more patients each day [12]. However, the prevalence of physicians who make home visits has increased in the last decade in the U.S. following improved reimbursement for house calls by physicians [11, 12]. In Canada and Europe, physicians still make a sizeable number of home visits [12]. For example, in Germany, the traditional culture of house calls remains strong with GPs making a median of 6.5 home visits per week [13]. Many German GPs are self-employed, and competition to retain patients accounts in part for the motivation for patient home visits. There is consensus from physicians in Europe and North America that medical home visits are important for frail older adult patients to prevent unnecessary emergency department and visits and hospitalizations [13, 14].
Many HBPC practices in the U.S. are provider-led by a physician or nurse practitioner. The practice may also include a registered nurse, and medical assistants who support providers by triaging patients, assisting with patient intakes, and handling medication refills [8, 15]. Larger practices may employ administrative coordinators who provide scheduling, billing, procurement of supplies, and other administrative tasks; social workers who focus on the patient’s home environment and link patients to community supports and services; medical coders and billers; and transition nurses who facilitate the patient transfer from the hospital to the HBPC practice [16].
Home-base primary care patients in the U.S. primarily receive medical coverage through Medicare, in which care delivery is reimbursed on a fee-for-service basis for physician face-to-face patient visits [17]. This payment structure does not work well for coverage of a multi-discipline care team approach where care coordination outside of the home visit is necessary to meet the needs of HBPC patients [18]. In a study of the Mount Sinai Visiting Doctors HBPC program, it was estimated that 20.5% of providers’ time was spent on care coordination activities outside of home visits, and 2.4 h each week were not reimbursed [18]. When factoring in additional time spent during weekend hours, late nights, or on call, providers were unable to obtain reimbursement for nearly 4 to 8 h of care coordination each week. These large demands on providers, combined with the emotional toll of caring for frail seniors, may contribute to provider burnout and workforce shortages.
Our aim was to gain insight into HBPC programs across the U.S. by conducting a six-site HBPC practice assessment designed to better understand different structures, common challenges and approaches to address the complexities and complications of delivering ongoing care in the home. No single model of HBPC can be adopted widely without variation [3]. With this in mind, we aimed to learn what was working (and not working) across all six practices, which varied widely in terms of their business models, number of practice sites, practice locations in the United States, size, use of technology, and other factors.