Bringing home the ‘medical home’ for older adults

TOWARD ONGOING CARE MANAGEMENT

In spite of these opportunities, the Medicare home health benefit rarely permits uninterrupted ongoing home care. Thus, the home health collaboration developed around Mrs. Smith’s heart failure exacerbation is likely to be temporary, and when her condition stabilizes she may no longer meet the criteria for home health services.

This episodic-payment model contrasts with the ongoing needs of the typical high-risk older patient with chronic illness. Changing the home health benefit to allow for ongoing home health care for beneficiaries like Mrs. Smith may be an opportunity for patient-centered reform. Although ongoing home health care for a given patient may not be possible, the medical home model offers the opportunity for ongoing physician-home health collaboration because at any time a physician’s practice is likely to have patients requiring these services. The independence-at-home model does provide for uninterrupted ongoing in-home physician and mid-level care for some patients, but it may require changing primary care physicians, and this may be undesirable to some patients. If a viable financing model is established for medical homes and independence-at-home practices, they may choose to contract with home health agencies to provide ongoing telephone or telemetric care management between (or outside of) episodes of eligibility for traditional home health care. All of these potential arrangements would need legal review and would need to be structured to avoid violation of the letter and spirit of laws prohibiting self-referrals and kickbacks.

PHYSICIAN HOME VISITS

In the case of Mrs. Smith, Dr. Jones has the option of making a follow-up home visit, or even ongoing home visits.

Granted, home visits may be impractical due to the time involved and the impact of that downtime on the physician’s medical practice and responsibilities to other patients. However, larger practices may employ a specific physician, nurse practitioner, or physician’s assistant to provide in-home care to patients in need.

Some communities have house-call practices to which Dr. Jones could refer Mrs. Smith for in-home physician care, and, where available, this may be a preferred care model— somewhat analogous to how a primary care physician might collaborate with a hospitalist for inpatient care of a specific patient.²² These homecare physician practices will likely become more prevalent if the independence-at-home Medicare demonstration project is successful.

In the future, even if Mrs. Smith needed more intensive inpatient care, an emerging concept called “hospital at home” may be able to provide this acute care in her home.^23,24 These in-home physician services are increasingly supported by new mobile diagnostic technologies.²⁵

However, adding or changing physicians may not be possible or desirable for Mrs. Smith and could lead to further fragmentation of care. In the future, teleconferencing may provide options for “virtual visits” that would partially solve this problem.

Whether the physician care is provided in the office, in the home, or as a virtual visit, much of the care Mrs. Smith needs can and should be done by nonphysician home health care providers in partnership with informal caregivers.

MRS. SMITH GETS BETTER AT HOME

Dr. Jones decided to refer Mrs. Smith for home health nursing and maintained close telephone contact with her and the home health nurse during the first 2 weeks. Mrs. Smith responded well to the changes in medication and diet, her leg swelling decreased, and she was feeling more like her usual self. At a follow-up office visit 3 months later, Mrs. Smith hugged Dr. Jones and thanked her profusely for helping her get better at home.