Innovation in home visiting programs that enhance access to care for Medicare beneficiaries with chronic conditions can deliver savings by keeping these individuals out of the hospital, according to research recently conducted by NORC at the University of Chicago and published in Health Affairs. The latest reports from NORC’s Evaluation of Health Care Innovation Awards, under contract with the Center for Medicare and Medicaid Innovation (CMMI), include a look at five programs that send teams to meet beneficiaries where they live. These programs aim to improve quality of care, enhance the experience of patients and their caregivers, and lower the cost of health care.
The five programs are:
- Indiana University’s Aging Brain Care (ABC), for patients with dementia and/or depression.
- Johns Hopkins School of Nursing’s CAPABLE, offering beneficiary-directed functional improvements tied to the home environment, to delay entry to skilled nursing.
- Ochsner Health System’s Stroke Mobile, for those recovering from stroke.
- Palliative Care Consultants of Santa Barbara’s Doctors Assisting Seniors at Home (DASH), a subscription-based assessment and coordination service to help older adults avoid emergency department visits.
- Sutter Health’s Advanced Illness Management (AIM), providing a bridge between hospital and hospice care for patients with late-stage illness.
We found promising results. Two programs are associated with significant reductions in measures of costs, three with significant decreases in hospitalizations, and two with significant decreases in emergency department visits, relative to matched comparison groups. Beneficiaries report increased confidence and positive change in managing their health and improved communication with their providers, for example, through on-call access at night and on weekends. Care coordination and consumer engagement appear to contribute to improved quality of care and reduced total cost of care for a diverse group of beneficiaries with multiple chronic conditions.
Home visit teams for these programs are interdisciplinary, led by nurses or lay health workers and often including social workers, physicians, occupational therapists, and even handymen. These programs differ in scale and scope, in addition to the populations they serve and their staffing: they ranged in size from one site that enrolled fewer than 300 beneficiaries to multiple locations that enrolled over 9,000.
The key to success for this diverse group of programs may be a shared focus on delivering services complementary to clinical care, to strengthen the connections that high-risk Medicare beneficiaries have with their physician or other primary or palliative care provider. Teams coordinate care across settings (e.g., between hospital and doctor’s office) and engage patients, as well as their caregivers and family members, to better understand and manage chronic health conditions. All five programs were centered on a beneficiary’s home: some addressed factors from the home context (e.g., supports and safety hazards) that affect patients’ functioning and inform development of “person-directed” care plans. These care plans may call for the introduction of assistive devices that make it easier to live independently or referrals to Meals on Wheels or transportation. Others used the home as a site to monitor health and functioning, to deliver education about chronic disease self-management, and to assess care plan implementation, making adjustments as needed.
NORC used Medicare claims for beneficiaries enrolled in each of the five programs in order to compare health care utilization, quality of care, and cost with those of comparison beneficiaries not enrolled in the programs. In addition, we collected data from team members trained to work in these innovative home-based teams and from enrolled beneficiaries, and in some cases their caregivers, to learn more about their experiences. NORC’s evaluation reports offer detailed case studies for all five home visit programs, looking at implementation and its challenges, as well as outcomes, in the communities where each was tested.
Our findings present a strong case for the potential value of home visits, by teams led by registered nurses or lay health workers, to reduce Medicare expenditures and service use in a particularly vulnerable and costly segment of the Medicare population. We have more to learn about what specific groups of older adults might benefit the most from home visits provided by staff other than clinicians, about staffing approaches appropriate to these groups, and about how specific home visit tasks create or strengthen relationships between beneficiaries and the health care system.
For more information, please see NORC’s recently released Third Annual Reports on Evaluation of the Health Care Innovation Awards, available on the CMMI website, for the Complex/High-Risk Patient Targeting and the Disease-Specific awardees.