IHE Journal Watch: Home Visits vs. Institutional Care

Background

Clinical home visit programs for Medicare beneficiaries are a promising approach to supporting aging in place and avoiding high-cost institutional care. Such programs combine a comprehensive geriatric assessment by a clinician during a home visit with referrals to community providers and health plan resources to address uncovered issues.

In 2010 almost 70% of Medicare fee-for-service beneficiaries ages 65 and older were classified as having multiple chronic conditions.¹ Many of these beneficiaries face barriers to receiving office-based primary care and other health services as a result of physical, mental and functional limitations. Delays in seeing their providers place them at risk of experiencing exacerbations of their chronic conditions that could lead to emergency department (ED) visits, hospitalizations and nursing home admissions.

Aware of those gaps, payers and providers have long experimented with approaches to reach out to elderly patients and extend care delivery beyond offices and facilities, either by the patient’s usual provider or through a third-party care-support organization. Evaluations of several Centers for Medicare and Medicaid Services (CMS) demonstration projects suggest that disease management models—which rely heavily on third-party call centers to provide self-management support, education, and sometimes biometric monitoring—are largely unsuccessful in this population.²

In this study researchers investigated the impact of one such care model, UnitedHealth Group’s HouseCalls program, which has been offered to Medicare Advantage plan members in Arkansas, Georgia, Missouri, South Carolina and Texas since January 2008, a program for older adults that is based on an annual comprehensive geriatric assessment in the patient’s home by a third-party clinician, combined with follow-up through communication with the patient’s usual providers and referrals to other resources such as social services, urgent care and medication therapy management.

Methods

Researchers estimated the program’s effects over a one-year post-intervention period using a difference-in-differences approach. They compared differential changes in outcomes among members of the intervention and comparison groups for a 12-month baseline period to outcomes for a 12-month post-intervention period. They implemented this approach with negative binomial models for count data (primary care visits, specialty visits, ED visits and hospital admissions) and with logistic regression for nursing home admission. In these regressions, researchers controlled for the covariates as well as state and year fixed effects. All analyses were performed using Stata MP, version 13.

Results

The HouseCalls program was associated with statistically and clinically meaningful reductions in the use of institutional care for Medicare patients over a 12-month period after the intervention, relative to statistically matched comparison groups.

The study found that, compared to non-HouseCalls Medicare Advantage plan members and fee-for-service beneficiaries, HouseCalls participants had reductions in admissions to hospitals (1% and 14%, respectively) and lower risk of nursing home admission (0.67% and 1.3%, respectively). In addition, participants’ numbers of office visits—chiefly to specialists—increased 2%–6% (depending on the comparison group). The program’s effects on emergency department use were mixed.

Discussion

The ability to reduce hospital admissions for high-risk Medicare patients with a scalable program represents significant progress, as attempts in the previous decade to achieve this goal largely failed. Assuming this effect is sustainable, this particular combination of an in-home assessment and follow-up on the care plan recommendations has the potential to help elderly patients safely age in place, access office-based care and avoid costly institutional care.

Researchers in this study indicate the results are consistent with a growing body of evidence on effective models of care for older adults that suggests three main lessons:

• First, home-based primary care, in which a patient’s regular provider extends services into the home, can reduce admissions to hospitals and nursing homes.
• Second, remote delivery of disease management through nurse-based call centers has shown little promise in this population. This led the Congressional Budget Office (CBO) to conclude that “on average, the 34 disease management and care coordination programs had little or no effect on hospital admissions.”³ The CBO review also found that programs with in-person interactions and direct contacts with a patient’s primary source of care were more likely than other programs to reduce hospitalizations.
• Third, home visit programs that focus on geriatric assessments without ongoing provision of care are effective only if there is follow-up on the care plan recommendations.

These finding are consistent with the results of a 2014 study published in the American Journal of Managed Care that suggests that hospitals, without collaborative relationships with community-based providers, may have limited ability to reduce readmissions, as they cannot ensure timely and continuous care for patients after discharge.⁴

As integrated care leaders continue to test new care delivery models to help achieve improved patient outcomes, improved experience of care and reduce healthcare expenditures, it is becoming more evident that to achieve desired results, a coordinated approach to care coordination that includes assessments and care delivery in the patient’s home setting are crucial to success.

References

1. Lochner KA, Cox CS. Prevalence of Multiple Chronic Conditions Among Medicare Beneficiaries, United States, 2010. Prev Chronic Dis, 2013; 10: 120137; https://dx.doi.org/10.5888/pcd10.120137.

2. Peikes D, Chen A, Schore J, Brown R. Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials. JAMA, 2009 Feb 11; 301(6): 603–18.

3. Nelson L. Lessons from Medicare’s Demonstration Projects on Disease Management and Care Coordination, https://www.cbo.govhttps://s3.amazonaws.com/HMP/hmp_ln/imported/cbofiles/attachments/WP2012-01_Nelson_Medicare_DMCC_Demonstrations.pdf.

4. Linden A, Butterworth SW. A Comprehensive Hospital-Based Intervention to Reduce Readmissions for Chronically Ill Patients: A Randomized Controlled Trial. Am J Manag Care, 2014; 20(10): 783–92.

Journal Source

Mattke S, Han D, Wilks A, Sloss E. Medicare Home Visit Program Associated With Fewer Hospital and Nursing Home Admissions, Increased Office Visits. Health Affairs, 2015 Dec; 34(12): 2,138–46; https://content.healthaffairs.org/content/34/12/2138.