One of health care’s biggest challenges is chronic disease management: the complexities of care and juggling multiple providers and the comorbidities that often arise. Our health care system has felt a strain on limited resources and seen rising costs to meet these needs. That’s why more health plans are embracing an in-home care model to deliver long-term, longitudinal care for chronic conditions.
The Problem: Care barriers for high-risk members
According to the CDC, 38% of the U.S. population has at least one major chronic disease (i.e. heart disease, cancer, diabetes, obesity, hypertension). Most of these individuals are in the later stages of life, facing social determinants of health like mobility challenges, frailty and transportation issues that make it difficult to visit their doctors in person for consistent care. Lack of transportation resources can result in delayed care and unnecessary emergency room visits and hospitalizations that could have been avoided.
The Result: Downstream issues for health plans
Without consistent, preventive and routine medical care, many members with chronic conditions rely on costly emergency room visits to receive care that could have been managed at a lower level. In fact, about 90% of the U.S. annual care expenditure is attributed to managing and treating chronic diseases and mental health conditions. What results are a strained health care system, inefficient and costly care, and worse outcomes for members.
The Answer: Longitudinal care in the home
To avoid these issues, the system must alleviate the burden of getting to care from high-risk members by meeting them where they are. The primary care home visit model combines four components of care: clinical services, nursing care and social-behavioral support. Home visits offer the opportunity to reach high-needs patients and solve the problem of access barriers, such as limited mobility and lack of transportation.
“In-home providers can see patients in an environment that is comfortable and familiar, and can spend up to 12 hours or more per year with them, compared to about 20 minutes per year in a clinical setting.”
Jill Sharp – SVP, Care Delivery
Benefits of home-visiting models for primary care
In-home care teams visit members in their homes or wherever they live. Going out of the home for care is difficult, if not impossible, for patients with chronic or complex health issues. Something as simple as visiting a clinic can mean having to find someone to drive them, packing a walker, waiting in the waiting room, filling out numerous forms — all for a face-to-face visit with a doctor that may only last 15-20 minutes.
With an-home care model for longitudinal care, members can receive:
- Annual Whole Health Evaluations: Ensures members’ needs are aligned with care plans and health plan resources
- Medical and Behavioral Health Gap Closure: Keeps members up to date with necessary preventive care and treatments
- Care Delivery: Extends PCP and specialist reach into the home to manage chronic and acute conditions comprehensively
- Accurate Hierarchical Condition Categories (HCC) Documentation: Ensures appropriate reimbursement for the resources dedicated to member care
- Medication Management: Promotes safe and effective medication use through reconciliation, ongoing management and adherence coaching
- Social Determinants of Health (SDoH) Screening & Coordination: Addresses transportation, food insecurity and other barriers to care
During home visits, providers can dig deeper to accurately determine patients’ health and social needs and to make sure they are being addressed and managed. Patient relationship-building also becomes stronger. In-home providers can see patients in an environment that is comfortable and familiar, and can spend up to 12 hours or more per year with them, compared to about 20 minutes per year in a clinical setting.
With home-visiting programs, health care can fulfill its primary goal: to truly connect with members beyond their conditions, get to know their unique and complex needs, and deliver broader, more holistic care. If you are interested in learning more about in-home longitudinal care with Lucet, reach out to sales@lucethealth.com.
Jill Sharp is senior vice president of care delivery at Lucet.
