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The Centers for Medicare & Medicaid Services’s (CMS) Independence at Home demonstration aims to find out if delivering comprehensive, home-based primary care can lead to positive outcomes and lowered costs.
One demonstration participant, Northwell Health, has been able to realize this goal.
Broadly, the Independence at Home demonstration allows Medicare beneficiaries who have multiple chronic conditions to receive primary care services at home. The participating primary care practices that are able to meet CMS’ quality measures and generate Medicare savings are eligible to receive incentive payments.
The first performance period began back in 2012. In the first few years of its existence, the demonstration had a cap of 10,000 beneficiaries.
Since the demonstration began, it has been extended a couple of times. The most recent extension period began on Oct. 1, 2015. For now, the demonstration is slated to end Dec. 31, 2023, barring any Congressional action.
Overall, the demonstration has succeeded in some areas and has been slower to see results in other areas.
“In its first five years, the demonstration has been able to reduce emergency department visits and avoidable hospital admissions in some demonstration years, but total admissions in only one year,” a CMS spokesperson told Home Health Care News.
In terms of cost savings, sites have trended towards reductions in total spending, but the demo size and small number of participants have not been large enough to show significant savings, according to the spokesperson.
“Coupled with the $37 million in incentive payments to Independence at Home sites, the demonstration has resulted in $44.3 million in losses to the Medicare program,” the spokesperson said. “In 2019, total incentive payments were $11.1 million distributed to 12 demonstration sites, serving an average of 580 enrollees per site. Independence at Home practice attrition in later years of the demonstration was in part motivated by the perceived onerous participation requirements.”
In its latest performance year, all 10 of the demonstration’s participants met three or more of the six quality measures; three of those practices met the performance thresholds for all six quality measures.
Northwell’s house calls program
Of the 10 Independence at Home demonstration participants, Northwell was one of the top performers. Northwell received $6.54 million for its house calls program’s ability to save costs and meet quality measures in 2020.
Through Northwell’s house calls program, patients are offered a number of care services, such as in-person visits from doctors and clinicians, EKG heart rhythm checkups, vaccinations and more – all while remaining at home.
Northwell is a large integrated care delivery network — and the largest health system in New York. The organization employs 77,000 people and provides care across 22 hospitals. Northwell also has skilled nursing facilities (SNFs) and is a medical school, as well as research institute.
Northwell’s house calls program focuses on patients that are at “the highest risk of the health pyramid,” Dr. Zenobia Brown, senior vice president and associate chief medical officer at Northwell, told HHCN.
“They are patients who you would categorize as having advanced illness,” she said. “They are not quite ready for hospice, so their prognosis is typically more than six months, more than a year. But they are also in this group, where they are having multiple hospitalizations and where they are spending more time in rehab.”
Currently, the house calls program has 600 participants. The average age for the program’s patient population is 86 years old. These patients typically stay in service for 18 months to two years.
Part of what Brown calls the house calls program’s “special sauce” is its utilization of community paramedics, which allows for paramedics to evaluate patients at home without transporting them to the hospital.
“Normally, you call 911, they come, and they have to transport you,” Brown said. “That’s all they can do, they can’t treat you there and leave. You’ve got to be transported. In this program, the paramedic is overseen by the provider remotely with telehealth. That then allows the paramedic to treat the patient with the same kind of drugs you’d find on an ambulance, often saving the patient a trip to the emergency room.”
For example, if a patient’s problem is dehydration, they are treated with IV fluids, according to Brown.
“Let’s not transport the patient to the emergency room where they then get delirious, and now you have to admit them because they’re deteriorating,” she said.
This component of the house calls program has aided Northwell’s success when it comes to hospitalization and emergency room visits.
The house calls program also has nurses covering the phones 24/7 to ensure that patients always have access to clinicians.
Though Northwell already had a house calls program in place, its participation in the demonstration allowed the organization to grow its program. It has been part of the demonstration since 2014.
“If you’re taking great care of patients, if they don’t end up in the hospital lots and lots of times, if they don’t end up needing to go to a rehab facility — you are benefiting from that,” Brown said. “You can then reinvest these dollars into just sustaining the fact that providers can’t see 20 patients a day, as well as wraparound services that benefit the patient.”
These wraparound services include things like social work, education and nurses entering the home to deliver care.
In general, it’s often difficult for house calls programs to be financially sustainable.
“In a traditional kind of model, you are billing Medicare, or the insurance company or the payer, for the number of times you see a patient — that’s how practices work,” Brown said. “That’s very hard to sustain with a house calls model, because you might spend an hour traveling to a patient and you can’t bill that time. Whereas, if I’m sitting in an office, I can see 20 patients a day. If I’m going to people’s homes, that number comes down to half of that, but the expense is still there.”
Ultimately, Brown believes that the house calls program has been successful because of its care delivery model.
“There’s a lot of detail in the program, but the heart of the matter is having a service where the patient is very engaged, where the provider and the patient have a strong relationship,” Brown said. “All of this relies on the patient and their family feeling like when they need help, it comes to them right away, whenever and wherever. That is the foundation of why any of this works.”
Companies featured in this article:
Northwell Health, The Centers for Medicare and Medicaid Services
