“Especially for vulnerable and at-risk populations, IHAs can uncover risks that may otherwise go unnoticed. The challenge, however, is how our health care systems use these valuable insights.”
Patrick Kneeland, MD – Executive Medical Director, Lucet at Home
Health plans face a persistent challenge: identifying members who need support is often easier than ensuring they receive it.
The need is substantial. Nearly 40% of Medicare Advantage members have at least one unaddressed behavioral health or social need, while 27% of hospital admissions among Medicare beneficiaries are considered potentially preventable through earlier intervention. Twenty-six percent of adults report missing an annual routine checkup.
These statistics point to a common reality. Many members live with unmet needs, care gaps and barriers to accessing services long before they appear in claims data or become high-cost cases.
For health plans, this creates both a challenge and an opportunity. Traditional care models often struggle to identify emerging risks early enough to intervene effectively. In-home assessments (IHAs) help bridge that gap by providing a more complete view of a member’s physical health, behavioral health and social circumstances. Especially for vulnerable and at-risk populations, IHAs can uncover behavioral health concerns, care coordination needs, social determinants of health challenges and other risks that may otherwise go unnoticed. The challenge, however, is how our health care systems use these valuable insights.
Industry experience shows that approximately 65% of members had an issue escalated back to health plans that could have been addressed sooner. When members do not receive timely outreach, referrals or support, health plans risk missed opportunities to improve engagement, address rising risk and prevent avoidable utilization.
As organizations continue to focus on quality performance, member experience and total cost of care, what we do with IHA insights is an important area for innovation.
The follow-up gap is a critical vulnerability
An IHA can reveal a wide range of concerns, from unmanaged chronic conditions and medication issues to behavioral health needs and barriers related to transportation, housing or food insecurity.
Unfortunately, many health plans face operational challenges that make follow-up difficult. Care management teams often have limited capacity and must prioritize the highest-risk members. As a result, members with emerging or moderate needs may not receive the outreach necessary to connect them to appropriate resources.
Without timely intervention, manageable concerns may escalate into more serious health issues. Members can become disengaged, delay treatment or seek care in higher-cost settings. At the same time, health plans may miss opportunities to close care gaps, improve member satisfaction and support quality improvement initiatives.
A different approach to IHA support
To bridge this gap, health plans are increasingly looking for scalable solutions that extend support beyond the initial assessment.
A short-term care intervention model can provide focused outreach and navigation services designed to help members take the next step in their care journey. Rather than replacing existing care management programs, this approach complements them by addressing needs that might otherwise go unattended.
Through targeted engagement, members can receive assistance with scheduling appointments, accessing community resources, connecting with behavioral health providers and understanding available benefits. This proactive support helps reduce friction in the health care system and makes it easier for members to follow through on recommended care.
Supporting members before needs escalate
Many members identified through an IHA do not require long-term care management. However, they often need practical assistance to navigate next steps.
Lucet at Home’s IHA Advance program matches needs identified during an IHA with short-term intervention to help ensure the need is addressed, not just identified. When a member completes a Lucet at Home in-home assessment, the Lucet at Home care team facilitates coordinated care with the health plan and primary care providers. Members who may need more care but do not require a longitudinal plan are eligible for additional support to close gaps in care.
By engaging members shortly after an assessment, health plans can address barriers while motivation is highest. Early outreach creates an opportunity to reinforce the importance of care, answer questions and help members overcome obstacles that may prevent them from accessing services.
For members, that means a more connected and supportive experience. For health plans, it creates an opportunity to improve engagement and strengthen continuity of care.
“The value of an IHA can go beyond the findings of one appointment. Health plans that prioritize timely follow-up can strengthen engagement and maximize the impact of every assessment they conduct.”
Patrick Kneeland, MD – Executive Medical Director, Lucet at Home
Driving better outcomes
Health plans are under increasing pressure to improve quality metrics while managing costs and delivering a positive member experience. Achieving those goals requires more than identifying needs. It requires ensuring members receive support after those needs are discovered.
A scalable, short-term follow-up solution wrapped around an IHA can help health plans close care gaps, extend the reach of existing teams and create meaningful member connections without overburdening internal resources. Most importantly, it helps transform the IHA from a point-in-time assessment into a catalyst for action.
The value of an IHA can go beyond the findings of one appointment. Health plans that prioritize timely follow-up can better support member health, strengthen engagement and maximize the impact of every assessment they conduct.
Patrick Kneeland, MD is executive medical director of Lucet at Home at Lucet.
