My name is Dr. Tom Cornwell, and I'm the Executive Chairman of the Home-Centered Care Institute. I would like to welcome you to our presentation on Home-Based Primary Care equals Value-Based Care. Our learning objectives are to describe home-based primary care in the U.S. and explore the socioeconomic drivers and the business case for home-based primary care. We also want to demonstrate in quantifiable terms the value of home-based primary care and assess the role of new supportive payment models. We also want to discuss the alignment of home-based primary care with the geriatric 5Ms, which stands for what matters most, mind, mobility, medications, and multi-complexity. So what is home-based primary care? Home-based primary care brings providers, as well as modern technology, into the homes of mostly homebound patients in order to improve their quality of life, the lives of their caregivers, while reducing health care costs by enabling them to stay at home and avoid hospitals and nursing homes. A perfect storm of forces is spanning the sales of the modern house call movement. Just some of these include the aging population, advancing technology, increased home and community-based services being funded by the government, the value of house calls, and payment reform. The first force is the aging of society and the cost of increased chronic disease burden. The extremes on this graph are surprising. The least expensive 50% of the population consumes only 3% of total costs, but conversely, the top 5% consume 50% of costs at over $50,000 per patient, and the top 1% consume an astounding 23% of all the costs at an average cost of over $100,000 per patient. These high costs are caused by our fragmented health care system that is not set up to care for the sickest patients who are often homebound. Bringing home-based primary care to these patients has been shown to dramatically improve their quality of life and, again, the lives of their caregivers while reducing these health care costs. Advancing technology is another force. I like to say that house calls are principally high-touch primary care in the home, but we also have the high-tech capability to provide quality care in the home. Just some examples are smartphones that can do rhythm strips in seconds. They have numerous apps now that I can do vision testing, drug databases, decision support, and much more. Portable x-rays and ultrasounds can be done in the home. Labs can be done in the home, including point-of-care testing, as well as we can draw blood in the home and spit it down in the car in a centrifuge that's plugged into the lighter. Modern technology has enabled me to do more in the home than most primary care practices can do in their offices. The third force is increased funding of home and community-based services. Increased funding of long-term support and services are made up of institutional care, nursing home care, and home and community-based services. This graph shows that back in 1983, 99% of all funding went to nursing home care, so your only option if you needed help was to go to a nursing home. Over the past two decades, there has been a remarkable shift in funding, where now over half of all the dollars goes to home and community-based services, and this enables nursing home-eligible individuals to remain in the community. These individuals create an increased demand for home-based primary care. Recently, there was a study in the Journal of the American Geriatric Society showing how integrating home-based primary care and home and community-based services delayed nursing home placement by 13 months. A major force has been the data that has come out showing the value of house calls, but before getting to the data, I wanted to share a couple stories illustrating just how valuable this care is. Our first story is about Amanda, who when I met her in June of 2017, was 34 years old, suffering from type 1 diabetes that she had had since she was a child. She had kidney failure and was on renal dialysis. She also had coronary artery disease and already had had four stents. She also suffered from chronic pain. In the four months before we saw her, she had been in the hospital 30% of the days. We were able to dramatically reduce that over the following seven months of 2017. In 2018, she was so much better that she did not spend one day in the hospital and sent me this wonderful picture of her at an art festival in the fall. In 2019, she did go back to the hospital because she had gotten so much better that she now qualified for a kidney transplant, and she had a kidney and pancreas transplant, which cured her of her diabetes and removed her need for dialysis. What a joy to be able to give someone their life back like this. Elsa was born in Germany in 1921 and came to the United States after World War II. I was called out to see her to fill out nursing home paperwork. When I met her, I learned she was no longer able to get out to see her doctor because of her right foot being amputated and her left leg being amputated, and had been in the hospital six times over the previous four months because of multiple chronic problems, including heart failure and diabetes and pressure sores. The patient shared with me that part of the reason she lost her legs was from frostbite caused by cold winters in a concentration camp. Through quality home-based primary care, we were able to quickly get her heart failure and diabetes under control. We ordered home health that she was previously not able to get because there was no doctor to sign orders. We got her a hospital bed and enabled her pressure sores to heal. She got so much better that we were able to arrange and pay for transportation to an outpatient rehabilitation center where she got new prosthesis so she could actually walk again. Over the next eight years, she only went back to the hospital twice. Besides powerful stories, we also have compelling data, such as from the VA's Home-Based Primary Care Program, which is the largest home-based primary care program in the country. The program's director, Dr. Tom Eades, about 2005, was told to cut the program because they were spending $11,000 more per veteran sending doctors and nurse practitioners and physician assistants, mental health workers, and others into the home than usual care, such as home health. Dr. Eades asked to have all the cost data reviewed, and they went back to 2002. And what they found, I think, even surprised Dr. Eades. They found an 87% reduction in nursing home use, 87%. They found a 63% reduction in hospital use, an overall savings of $9,000 per veteran. And when you multiply that by the 11,000 veterans in the program, it came out to $103 million savings by giving them $11,000 more care in the home, by giving them what they wanted. As a result of this data, the VA program has grown to over 30,000 veterans, and would serve even more were it not for the shortage of providers. This data also led to significant support for home-based primary care on Capitol Hill and at CMS. The last part of home-based primary care's value equation I would like to discuss is cost-effective quality end-of-life care. The last year of life is the most medically expensive, consuming 25% of all Medicare dollars. 70% of Americans say they would like to be at home at the end of life, but in 2009, only 33% died at home. Hospice use markedly increased over the past decade from 22% to 42%, and is now up to 50%. But also over the last decade, ICU stays in the last month of life increased to 29%, and hospitalizations in the last three months of life went up to 69%. End-of-life care at the House Call program I founded, Northwestern Medicine's Home Care Physicians, is much different. A quarter of our patients die yearly, and over the past five years, 76% have died at home, 77% were on hospice, and the median house call length of stay that they were on our program was 1.3 years, and so we covered them during that costly last year of life and dramatically reduced hospitalizations. One side benefit to this is because we have so many patients pass away at home and less go to the hospital, we actually were able to help reduce our hospital's mortality rate, which is another selling point to health systems. The last force we will discuss, which is helping to expand home-based primary care, is payment reform, and we're going to start with fee-for-service. We have seen an increase in fee-for-service payments to support house calls. As you can see in this slide, over the past two decades, payments have doubled for both house calls as well as assisted living facilities, where now I am getting paid over $180 for a typical house call. Medicare has also created new payments that support house call providers, such as advanced care planning, chronic care management, transitional care management, and for prolonged services before or after a visit for things like reviewing medical records. A great example of value-based payment reform is the highly successful Independence at Home Medicare house call demonstration that began in 2012. The ongoing demonstration involves 14 experienced home-based primary care programs that care annually for over 10,000 medically complex patients with functional impairments. IEH is a shared savings program where the first 5% of savings goes to Medicare. Additional savings are split with 80% going to practices if they meet the quality indicators and the remaining 20% going to Medicare. IEH has been Medicare's most successful demonstration. It improves quality and patient satisfaction while reducing hospitalization and emergency department use. This has resulted in cost savings of over $100 million in the first five years, which came out to over $2,000 savings per beneficiary. Cost savings paid for the program and qualifying practices received a share of the savings. Since its launch, the three-year demonstration has been extended twice because of its success and interest in becoming a new Medicare program. The most impactful payment reform is the new value-based models. CMS has announced new value-based programs such as the Primary Care First program that would pay a per-member per-month fee for complex patients as well as a visit fee and would provide shared savings. There's also the possibility that home-based primary care programs could come together to participate in the direct contracting program where currently you need to have 5,000 Medicare beneficiaries. These programs are rewarded from the cost savings they generate from the wonderful care they give in the home. The last thing I want to say is we are seeing venture capital come into this space to start home-based primary care and, again, take risk on these patients and share in the cost savings. Successful programs have also contracted with Medicare Advantage programs for per-member per-month payments on their costliest patients as well as participate with them in shared savings that has helped increase revenue to their programs. With these forces creating a huge demand for home-based primary care, now we need the workforce. Over 2 million patients could benefit from home-based primary care and this number is expected to double over the next 20 years. Only 15% are currently being served. Imagine if only 15% of oncology patients were being served. Currently there are about 1,000 house call providers that make 500 or more visits and their distribution can be seen on this map. What you can also see is that there are 13 states that do not have even one high-volume house call provider. We need about 10,000 providers in order to meet the need of the 2 million patients that are homebound in this country. The geriatric 5Ms is a framework for caring for complex patients. As you'll see, these geriatric 5Ms align perfectly with the home-based primary care model. This is what we do every day. The first M is what matters most and it is the one that matters most. We need to understand health goals and preferences of our patients. We need to help them consider prognosis and medical decision making, take into account risks, burdens, benefits, their functional status, and quality of life. We need to make sure a person's goals and care preferences are reflected in their treatment plans and most importantly that they are honored. Finally, we have to help coordinate advanced care planning. The second M is mind and mentation. We need to help them maintain mental activity, help manage their dementia. We need to help treat and most importantly prevent delirium and work to evaluate and to treat depression. The next one, mobility. We need to help them maintain the ability to walk and improve their balance, improve their function. We need to help prevent falls and other types of common injuries. And we need to help create home environments that facilitate mobility. And nothing better than home-based primary care can do that because we are in the home to make that happen. Medications. We need to help reduce polypharmacy through deprescribing. And we need to help optimize medication for an older person's needs. The fifth M is multi-complexity. We need to help older adults manage a variety of health conditions. We need to assess their living conditions when they are impacted by age, health conditions, and social concerns. We need to optimize therapies and care plans. We need to choose therapies that optimize benefit, minimize harm, and enhance quality of life. And again, the most important M is what matters most to our patients. So what are some of the key takeaways? We have reviewed the converging forces that are creating a tremendous demand for home-based primary care. We have also seen the great value that comes with home-based primary care and how it is being rewarded by the new payment models. In order to meet the need and realize the value, though, we must expand the workforce. Because if we don't, the vast majority of those patients who need home-based primary care won't get it.

home-based primary care

healthcare costs

aging population

payment reform

workforce expansion