There is a small, often underrepresented population in the U.S. healthcare debate that is critical to how we think about improving patient-centered care and lowering costs. Meet the frail elderly — some of Medicare’s most complex patients. This group accounts for only five percent of the Medicare population, but drives almost 50 percent of its costs. Frail elderly are patients suffering from multiple comorbidities and are largely homebound. As a result, they are often not able to receive care on a regular basis and their conditions may go untreated, becoming progressively worse. Eventually a trip to the emergency room and/or a hospital stay often results, and, with continued exacerbation of their conditions, those trips can become more frequent. Rather than living out their life in the comfort and dignity of their home, many of these patients end up at the most expensive locations (emergency departments and hospitals). This often results in more costly interventions and worse outcomes. One alternative approach is home-based primary care where a mobile primary care team of providers visits these patients at home, harkening back to the 19th century practice of a doctor making house calls. A pioneer of this care model is the Medical House Call Practice (MHCP) at MedStar Washington Hospital Center. It has been providing longitudinal and coordinated care to frail elders in the D.C. metropolitan area for the past 15 years. They proactively monitor and manage their patients’ health, which helps prevent acute events, emergency department visits and hospitalizations. Most importantly, the care plans are tailored to each patient’s unique needs. A recent study2 on the impact of this program on Medicare spending showed a 17 percent reduction in costs. It examined a cohort of 722 patients under the care of the medical house calls practice and compared them to a randomly chosen control group of patients. These results show that this model of care holds a lot of promise – both in terms of cost savings and in helping our seniors and frail elders age at home, where they are the most comfortable.
BARRIERS TO HOME-BASED CARE
While this patient-centric model of care has proven to be effective, there are fundamental barriers to scaling it across the nation, such as sustainability and replicability. For example, consider the challenges a mobile medical practice might face in scheduling patients who reside in many different locations. Most modern care systems have evolved “in service of efficiency” – the caregivers stay in one central location, while the patients visit them. For homebound patients with complex comorbidities, this is clearly not possible. The care providers will need to visit the patients in their homes. As one can imagine, the number of patients a provider is able to see in one day would have a significant impact on operational efficiency, and therefore on the sustainability of the business model. While some home-based primary care practices have found solutions that work for them, there is a lack of standardized solutions that can be adopted by all practices.
As the Gary and Mary West Health Institute’s Innovator-in-Residence at the Department of Health and Human Services (HHS), I’m on a team that is working with MHCP to help better understand these barriers and catalyze innovative solutions. Together, we’re building a set of processes, tools and services that can help efficiently route this team of care providers in a cost- and outcome-optimal manner. Based on our research, some options to be considered include the following:
- Reduce travel time by setting up a dedicated car service for care providers to use;
- Reimburse travel time by pursuing a policy change that makes it possible for providers to charge a visit fee;
- Reduce number of physical visits through telehealth solutions that could help providers virtually see some of their patients; and,
- Improve the quality of transit time for the provider by continuing to advocate for interoperable mobile electronic medical records solutions that allow for efficient, comprehensive documentation and coding while on the move.
Left to itself, it will likely take a while for the market-driven innovation engine to innovate for this small, but growing group of providers. It’s a classic “chicken or the egg” dilemma because the lack of such solutions prevents these models from growing big enough to attract serious innovation. The current needs of such a provider model are not big enough to warrant solutions providers to build specialized tools and solutions for it. The West Health Institute is playing a pivotal role in identifying relevant innovations in the form of processes, technologies, services, policy changes and guidelines in order to catalyze the growth of such models of care. It would be great not to have to “go it alone,” and we encourage others to propose original solutions to address these innovation challenges. Patients are waiting! The following was cross-posted from the West Health Institutes Blog.