Home-Based Medical Care for High-Risk Seniors Underutilized, Study Finds

Research indicates homebound seniors and non-homebound seniors with complex medical conditions benefit from home-based medical care.

For older patients, there are opportunities to expand home-based medical care, which can lower cost of care and improve clinical outcomes, a new research article says.

In particular, there is untapped potential to provide home-based medical care to homebound seniors. According to estimates, there are about two million homebound seniors in the United States and about five million seniors who can only leave home with assistance or significant difficulty.

Home-based medical care, which includes services such as primary care and medical interventions, is more intense than standard home health services such as physical and occupational therapy.

Home-based primary care has been associated with decreased hospitalizations and emergency room visits. A home-based primary care program for high-risk seniors launched by the Center for Medicare and Medicaid Innovation—Independence at Home Demonstration—lowered cost of care significantly. "In its first two years, Independence at Home saved an average of $2,700 per beneficiary per year over expected patient costs," the new research article's co-authors wrote.

The research article, which was published today by Health Affairs, is based on survey data collected from more than 7,500 community-dwelling, fee-for-service Medicare beneficiaries. The study features several key data points.

• Almost 5% of the Medicare beneficiaries had received home-based medical care during the study period from 2011 to 2017
   
• Among the Medicare beneficiaries who received home-based medical care services, 75% were homebound
   
• Compared to homebound Medicare beneficiaries who did not receive home-based medical care services, those homebound beneficiaries who did receive this kind of care were more likely to live in a metropolitan area or assisted living facility
   
• Compared to non-homebound Medicare beneficiaries who did not receive home-based medical care, non-homebound beneficiaries who did receive this kind of care had more chronic illnesses, more functional impairment, and higher healthcare utilization
   
• Compared to non-homebound Medicare beneficiaries who did not receive home-based medical care, non-homebound beneficiaries who did receive this kind of care were more socially disadvantaged

For healthcare providers, there is a golden opportunity to provide home-based medical care to homebound seniors and medically complex non-homebound seniors, the research article's co-authors wrote. "The significant unmet needs of this high-need, high-cost population and the known health and cost benefits of home-based medical care should spur stakeholders to expand the availability of this care."

Fee-for-service model ill-suited to home-based medical care

Fee-for-service payment models are a primary barrier to expansion of home-based medical care, according to the research article.

"Our finding of higher rates of home-based medical care among those living in assisted living facilities and in metropolitan areas likely reflects the fact that favorable factors related to geography and the built environment create operational efficiencies and opportunities to improve the financial sustainability of home-based medical care practices," the research article's co-authors wrote.

Value-based payment models are a better fit with home-based medical care, the lead author of the research article told HealthLeaders.

"Even in the absence of broader payment reform, many home-based medical care practices are pursuing value-based contracts with insurers that provide per member per month reimbursements to care for high-risk patients," said Jennifer Reckrey, MD, an associate professor at the Icahn School of Medicine at Mount Sinai in New York City.

There are strategies that home-based medical care providers can pursue to make fee-for-service payment models financially sustainable, she said. "Examples include forgoing physical office space and relying on advanced practice nurses or physician assistants to provide the majority of patient care."

Helping underserved patients

The finding that non-homebound seniors who received home-based medical care tend to be socially disadvantaged is highly significant, Reckrey said.

"Because home-based medical care provides highly personalized team-based care in the home, it is uniquely able to care for high-risk patients who are not currently well-served by the healthcare system. While the homebound as a group have difficulty accessing care, among the non-homebound social factors like poverty, lack of access to transportation, and racial and ethnic discrimination are also potentially powerful barriers to accessing needed care. Home-based medical care may be an important way for these individuals to build trust with an engaged care team and receive needed care."