3 Keys to Building a Strong Home-Based Care Program

How point of care tools can help stop the revolving door 

Can an investment in post-acute care keep patients safe at home while saving costs? The experience at one major west coast health system suggests that a carefully designed approach can achieve those goals for both COVID-19 patients and those at higher risk with multiple chronic conditions. The journey to home-based care started three years earlier, when one of the health system’s hospitalist groups recognized that a cohort of complex medical patients with significant psychosocial needs continuously returned to the hospital.  

revolving door patient hospital
The lessons from this experience showed that, when three key factors are in place, many of these ‘revolving door’ patients can be safely cared for at home:

  1. Creating the right interdisciplinary care team 
  2. Securing administrative and technical support 
  3. Addressing social determinants of health

The first step: A chronic home-based care program 

The health system first launched a home-based care program for homebound patients with multiple co-morbidities such as advanced heart failure, diabetes, stroke, cancer, or neurological disorders, who needed aggressive complex care in the home.  

The program included a daily huddle to coordinate care among a team comprised of physicians, complex case managers, and a social worker. The team quickly learned that you can’t help patients manage their care until you see first-hand how they live — what food they eat, how they take their medications, etc. The team assessed the home environment, completed safety checks, and discussed their care goals.  

food in home environment

They learned that small things can make a huge impact. For example, they found that having home care aides help with bathing and other daily living activities for a few hours twice a week was as important as a doctor visit for many patients.  

Applying lessons to COVID-19  

When COVID hit in early 2020, the program’s caseload of about 500 patients experienced a sudden surge in referrals. The new challenge they faced was to make the program work for the COVID population, which was significantly overwhelming hospital capacity. At the peak, 70% of inpatients had COVID, with an average length of stay (LOS) over five days versus a more typical average LOS of 3.5 days. Compounding the problem, skilled nursing facilities (SNFs) weren’t taking COVID-positive patients, which created a backlog of patients. Further, patients resisted going to SNFs because they couldn’t receive visitors. The health system recognized the urgent need to create an intensive program that leveraged its home care experience for CMS’ hospital-at-home model. 

The team learned that the COVID home population differed in some significant ways from the typical chronic care population.  They’re more engaged with their care, are generally younger and more facile with technology. The key is to have a nurse involved before and after discharge. In contrast to working in the hospital, where personnel and resources are readily available, going into a patient’s home entails walking into an unknown environment and takes longer. 

telehealth technology

One hurdle was establishing mobile lab services that simulated the rounding environment in the hospital. The team was able to use the health system’s mobile lab to draw labs for patients in the morning. Then, patients received a daily physician visit and a nurse visit from a participating home health agency. Each patient also received an afternoon or evening “tuck-in call” from a nurse. Administrative commitment and support from other hospital departments was essential.  

Meaningful results 

Over three years, the home-based care program has cared for about 1,500 patients, with impressive results that included cutting hospitalizations by about 60%, ED visits by 50%, and average costs per patient about $5,000. Readmissions for congestive heart failure fell from 22% to 16% and pneumonia COPD readmissions fell to 10%. In total, the program has saved the healthcare system over $5 million. 

Ingenious Med’s point-of-care tools: Critical to financial viability and strong analytics 

Limited reimbursement has been a significant challenge for hospital-level home programs. In late 2020, CMS introduced an Acute Hospital Care at Home waiver (which may be extended for another two years) that enables common acute conditions to be treated in home settings. During the pandemic, 92 health systems participated in the waiver.  

Accurate and timely charge capture contributes to financial challenges as well.  EMR limitations make this even more challenging outside the hospital than in an acute care setting. That makes it essential to have robust, easy to use tools for providers to capture charges and collaborate remotely.  

To make it easy for physicians to accurately record charges at the point-of-care, the home care team created a superbill in its charge capture platform, Ingenious Med. The platform generates dashboards with analytics to track each patient cohort, enabling them to analyze results and report to health plans.  

doctor with mobile phone

The platform enabled the team to avoid creating spreadsheets to track information, as it could cross check and build the patient panel off of the Ingenious Med reports. It also facilitated care collaboration among physician teams by enabling them to record care-plan notes in the care coordination section of the app.  

The team set up different sites for each of the home-based care cohorts, so it could run data from the app rather than creating a separate EMR-type report to track progress by cohort. The app also let administrators calibrate a reasonable workload and compare physician productivity, while recognizing the greater physician time and resources required for home-based care. The program plans to pursue a CMS waiver to become an approved Acute Hospital Care at Home program.   

While COVID has devastated the health and livelihoods of many Americans, it has also widened recognition of the value of a carefully constructed home-based care model. The right model, supported by the right point of care tools like Ingenious Med, can deliver high quality care to a wide range of patients and make life better for the providers who care for and about them.