In the U.S., it is estimated that more than 7 million older adults are homebound or home limited. And the overwhelming majority of these chronically ill, medically complex patients do not have access to primary health care and therefore often must rely on calls to 911 and visits to the emergency room to receive even basic care. And this group is growing exponentially, with 10,000 baby boomers turning 65 every day, and those aged 85 and over projected to quadruple by 2050. This group is also part of the 5% of high utilizers who consume 50% of Medicare's $800 billion budget. The good news is there is a solution. It's called home-based primary care, also known as the modern-day house call. With this type of care, physicians, nurse practitioners, and physician assistants provide ongoing health care to patients in their homes. These visits can include lab tests, EKGs, x-rays, ultrasounds, and more. House calls not only improve outcomes and the quality of life for patients and their caregivers, but also reduce the overall cost of care. Currently, however, only about 15% of those who need this type of care can get it. That is because there simply are not enough providers and practices offering longitudinal home-based primary care. Experts agree that due to the increased prevalence of value-based contracts and Medicare Advantage, not to mention the impact of the current global pandemic, demand for home-based primary care is predicted to grow at a rate of 10% annually for the next 10 to 20 years. The Home-Centered Care Institute is a national nonprofit organization focused on scaling home-based primary care and bringing it into the health care mainstream through four main focus areas – education, consulting, research, and advocacy. HCCI is an authoritative source for clinical and operational best practices. Clients can count on HCCI to answer questions and conduct market analysis to inform their business decisions and help them assess opportunities for starting or expanding practices that offer home-based primary care. Dr. Thomas Cornwell, founder and executive chairman of HCCI, explains the impact home-based primary care has on patients, their families and caregivers, clinicians, and payers. 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 fanning the sails 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 in that the least expensive 50% of the population consumes only 3% of total cost, but conversely, the top 5% consumes 50% and the top 1% consume an astounding 21% of all the cost 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. Government 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. 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. Medicare has increased fee-for-service payments to better support house call providers. This includes payments for advanced care planning discussions and chronic care management, where practices can be reimbursed monthly for the non-face-to-face care management time that occurs for patients with multiple chronic conditions. Medicare has also increased the amount it reimburses for transitional care management, which provides services during the handoff period between the inpatient and community settings. Research has shown programs with a formal transitional care program reduce hospital readmissions by up to 30%. Additional fee-for-service revenue opportunities include prolonged services before or after visits for reviewing extensive medical records and discussions with family caregivers. While increased fee-for-service payments help, new value-based payments are creating the economic engine stimulating the national expansion of home-based primary care. Value-based payments reward quality outcomes instead of the volume of services. Value-based organizations take on different levels of risk, including full risk, and then are rewarded when they improve care and drive down costs. Increased primary care dramatically improves the care of the sickest and costliest patients, and this includes quality end-of-life care. And under value-based payments, these providers are financially rewarded for the reduced acute care utilization. A great example of value-based payment reform is the highly successful Independence at Home Medicare House Call demonstration that began in 2012. There is an ongoing effort to expand it into a new Medicare program. Its greatest benefit has been to inform Capitol Hill and CMS of the value of home-based primary care. This has led to the creation of other models that benefit or incorporate home-based primary care, like Primary Care First and High Needs Direct Contracting, which requires only 250 patients to start. High-needs direct contracting entities are required to have 5,000 patients, a number not attainable for house call practices. Several DCEs have incorporated home-based primary care into their model to improve care and reduce costs. The direct contracting name will end in 2022 and be replaced in 2023 by ACO REACH, which stands for Realizing Equity, Access, and Community Health. The programs will be very similar, with ACO REACH having an increased emphasis on social determinants of health and health equity. There are opportunities for smaller, independent programs to partner with these and earlier ACO models to become preferred providers. To drive home how beneficial the new value-based models are for home-based primary care, I will give an example. If a direct contracting entity has 10,000 Medicare lives, you would expect the sickest 5% or 500 to benefit from home-based primary care. If we do a great job billing under fee-for-service, such as 10 visits a year and billing for chronic care management, advanced care planning, time spent before and after visits, and some procedures, we would expect about $1 million in revenue. Under full risk direct contracting, we would get around $16.3 million for these 500 patients. Out of these dollars, the DCE must have the infrastructure to pay all their medical bills, including those to hospitals, specialists, home health, hospice, and DME. The flexible reallocation of dollars gives DCEs the ability to transform health care by using money to provide great care in the home that is paid for mainly through reduced hospitalizations. This is the reason value-based and venture capital organizations have become interested in home-based primary care. CMS continues to expand value-based care models with a goal of all fee-for-service Medicare beneficiaries being in a care relationship with accountability for quality and total cost by 2030. With these forces creating a huge demand for home-based primary care, now we need the workforce. Over 7 million homebound and home-limited patients could benefit from home-based primary care, yet less than 15% are being served. In the United States, 3,000 full-time providers make at least 1,000 home visits per year, but we need 12,000 to meet the growing need. Three states—Alaska, South Dakota, and Vermont—do not have even one high-volume house call provider. It's critical we expand the workforce to enable all in need to have access to this wonderful care. Contact the Home-Centered Care Institute for industry-leading experience, products, and services that can help you succeed. HCCI exists to help ensure that those patients who need house calls get them. Because the future of healthcare is in the home.

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