Steven H. Landers, MD, MPH

Home-based care will undoubtedly play an increasingly important role in the health care system as the United States seeks ways to provide cost-effective and compassionate care to a growing population of older adults with chronic illness. “Home health care,” a term that refers more specifically to visiting nurses, therapists, and related services, is currently the prominent home care model in this country.

Home health services were developed around the start of the 20th century to address the unmet health and social needs of vulnerable populations living in the shadows. Today, there are more than 10,000 home health agencies and visiting nurse organizations across the country that care for millions of homebound patients each year. With the onset of health reform and the increasing focus on value and “accountability,” there are many opportunities and challenges for home health providers and the physicians, hospitals, and facilities they work with to try to find the best ways to keep patients healthy at home and drive value for society.

There is a paucity of medical and health services literature to guide providers and policymakers’ decisions about the right types and approaches to care at home. Maybe this is because academic centers and American medicine became so focused on acute institutional care in the past half century that the home has been overlooked. However, that pendulum is likely swinging back as almost every sober analysis of our current health care environment suggests a need for better care for the chronically ill at home and in the community. It is important that research and academic enterprises emphasize scholarly efforts to understand and improve home and community care so that the anticipated shift in care to home is informed by the best possible evidence, ultimately ensuring that patients get the best possible care.

The articles in this online, CME-certified Cleveland Clinic Journal of Medicine supplement address contemporary topics in home health and other home-based care concepts. The authors have diverse backgrounds and discuss issues related to technology, palliative care, care transitions, heart failure, knee replacement, primary care, and health reform. Several articles share concepts and outcomes from innovative approaches being developed throughout the country to help patients succeed at home, especially when returning home from a hospitalization.

The articles should improve readers’ understanding of a wide range of initiatives and ideas for how home health and home care might look in the future delivery system. The authors also raise numerous yet-unanswered questions and opportunities for future study. The needs for further home care research from clinical, public health, and policy perspectives are evident. Health care is going home, and this transformation will be enhanced and possibly accelerated by thoughtful research and synthesis.

I am incredibly thankful to my fellow authors, and hope that we have produced a useful supplement that will help readers in their efforts to assist the most vulnerable patients and families in their efforts to remain independent at home.

Home-based care will undoubtedly play an increasingly important role in the health care system as the United States seeks ways to provide cost-effective and compassionate care to a growing population of older adults with chronic illness. “Home health care,” a term that refers more specifically to visiting nurses, therapists, and related services, is currently the prominent home care model in this country.

Home health services were developed around the start of the 20th century to address the unmet health and social needs of vulnerable populations living in the shadows. Today, there are more than 10,000 home health agencies and visiting nurse organizations across the country that care for millions of homebound patients each year. With the onset of health reform and the increasing focus on value and “accountability,” there are many opportunities and challenges for home health providers and the physicians, hospitals, and facilities they work with to try to find the best ways to keep patients healthy at home and drive value for society.

There is a paucity of medical and health services literature to guide providers and policymakers’ decisions about the right types and approaches to care at home. Maybe this is because academic centers and American medicine became so focused on acute institutional care in the past half century that the home has been overlooked. However, that pendulum is likely swinging back as almost every sober analysis of our current health care environment suggests a need for better care for the chronically ill at home and in the community. It is important that research and academic enterprises emphasize scholarly efforts to understand and improve home and community care so that the anticipated shift in care to home is informed by the best possible evidence, ultimately ensuring that patients get the best possible care.

The articles in this online, CME-certified Cleveland Clinic Journal of Medicine supplement address contemporary topics in home health and other home-based care concepts. The authors have diverse backgrounds and discuss issues related to technology, palliative care, care transitions, heart failure, knee replacement, primary care, and health reform. Several articles share concepts and outcomes from innovative approaches being developed throughout the country to help patients succeed at home, especially when returning home from a hospitalization.

The articles should improve readers’ understanding of a wide range of initiatives and ideas for how home health and home care might look in the future delivery system. The authors also raise numerous yet-unanswered questions and opportunities for future study. The needs for further home care research from clinical, public health, and policy perspectives are evident. Health care is going home, and this transformation will be enhanced and possibly accelerated by thoughtful research and synthesis.

I am incredibly thankful to my fellow authors, and hope that we have produced a useful supplement that will help readers in their efforts to assist the most vulnerable patients and families in their efforts to remain independent at home.

Home-based care will undoubtedly play an increasingly important role in the health care system as the United States seeks ways to provide cost-effective and compassionate care to a growing population of older adults with chronic illness. “Home health care,” a term that refers more specifically to visiting nurses, therapists, and related services, is currently the prominent home care model in this country.

Home health services were developed around the start of the 20th century to address the unmet health and social needs of vulnerable populations living in the shadows. Today, there are more than 10,000 home health agencies and visiting nurse organizations across the country that care for millions of homebound patients each year. With the onset of health reform and the increasing focus on value and “accountability,” there are many opportunities and challenges for home health providers and the physicians, hospitals, and facilities they work with to try to find the best ways to keep patients healthy at home and drive value for society.

There is a paucity of medical and health services literature to guide providers and policymakers’ decisions about the right types and approaches to care at home. Maybe this is because academic centers and American medicine became so focused on acute institutional care in the past half century that the home has been overlooked. However, that pendulum is likely swinging back as almost every sober analysis of our current health care environment suggests a need for better care for the chronically ill at home and in the community. It is important that research and academic enterprises emphasize scholarly efforts to understand and improve home and community care so that the anticipated shift in care to home is informed by the best possible evidence, ultimately ensuring that patients get the best possible care.

The articles in this online, CME-certified Cleveland Clinic Journal of Medicine supplement address contemporary topics in home health and other home-based care concepts. The authors have diverse backgrounds and discuss issues related to technology, palliative care, care transitions, heart failure, knee replacement, primary care, and health reform. Several articles share concepts and outcomes from innovative approaches being developed throughout the country to help patients succeed at home, especially when returning home from a hospitalization.

The articles should improve readers’ understanding of a wide range of initiatives and ideas for how home health and home care might look in the future delivery system. The authors also raise numerous yet-unanswered questions and opportunities for future study. The needs for further home care research from clinical, public health, and policy perspectives are evident. Health care is going home, and this transformation will be enhanced and possibly accelerated by thoughtful research and synthesis.

I am incredibly thankful to my fellow authors, and hope that we have produced a useful supplement that will help readers in their efforts to assist the most vulnerable patients and families in their efforts to remain independent at home.

Many technologies have emerged to monitor, interact with, and support patients at home and change home health care delivery.^1–5 This trend coincides with the explosion of consumer digital and mobile products such as “smartphones” and has brought with it many different names, such as telehealth, telemedicine, e-medicine, remote monitoring, “virtual” care, digital health, mobile medicine, interactive health, and distance health. Many of these terms and concepts raise concerns for those who value traditional expressions of caring, physical diagnosis, touch, and presence in health care. However, these new technologies may present opportunities to find ways to enhance humanism in home health care. This potential may be most evident among patients with serious chronic illness and their families, who often struggle 168 hours a week but find their access to help limited to brief visits at times convenient for the provider.

While our health care system offers heroic acute-care treatments for hundreds of life-threatening maladies, we seem to fall short in helping those with serious ongoing needs whose care must be coordinated over time and across health care venues. Thinking in terms of “connected health” may provide a more holistic nomenclature that suggests the bond between technology and the opportunity for closer personal relationships.^6–8

OPPORTUNITIES

Can technology better connect our home health patients and families to care during the “white space,”⁹ between our visits? Can we use new mobile and digital technologies to improve care for the seriously chronically ill? We have the technology to turn many challenges into opportunities in the next decade. For example:

1. Can we change our visit-based model of home health care to a model that provides 24/7 “inbound” multichannel access to home health care teams along with proactive “outbound” support between visits in the form of multimedia health education and virtual encounters? Can this free up time for longer visits targeted toward higher-risk and higher-complexity scenarios that require extensive team leadership and care coordination?
2. Can “smart” home monitoring be integrated into home-based long-term care for patients who have dementia, fall risks, other safety issues, or unaddressed limitations in activities of daily living to increase independence and quality of life and reduce institutionalization while decreasing cost of care and accommodating workforce constraints?¹⁰
3. How do we apply clinician-to-clinician and clinician-to-patient videoconferencing and other connected health approaches to increase home health patient access to specialized, but hard-to-find, clinicians for consultative and direct-care services?
4. Can emerging technologies accelerate the shift in care whereby most acute care for exacerbations of chronic illness and other common acute scenarios move from hospitals into home-based models of acute care, such as “Hospital at home”?¹¹
5. To what extent can apps and other technologies provide self-management support to truly deliver the home health care version of the automatic teller machine? For example, diabetes self-management support tools provide patients feedback about their disease based on information input into mobile devices.¹² Can this be expanded in a way that dramatically increases access, especially for vulnerable groups that have been hard to reach, while also decreasing costs?
6. Can we improve the home health care experience by using connected health concepts to improve transparency, minimize common scheduling delays and annoyances, and empower patients while they are receiving care?

REAL-WORLD BARRIERS

Despite the opportunities, barriers remain for innovative providers. With few exceptions, there is no direct third-party reimbursement for care that comes through a device rather than the front door. Medicare does not reimburse home health providers for services outside of a visit, but specific guidance has been issued that clarifies some of the opportunities:

An HHA (Home Health Agency) may adopt telehealth technologies that it believes promote efficiencies or improve quality of care…. An HHA may not substitute telehealth services for Medicare-covered services ordered by a physician. However, if an HHA has telehealth services available to its clients, a doctor may take their availability into account when he or she prepares a plan…. If a physician intends that telehealth services be furnished while a patient is under a home health plan of care, the services should be recorded in the plan of care along with the Medicare covered home health services to be furnished.¹³

Thus, there is no reimbursement for telehealth services, but if telehealth is part of a physician-directed plan of care, it may be included if it promotes home health quality and efficiency. Beyond reimbursement, there are other regulatory barriers. If monitoring or other digital or virtual services are provided across state lines, the clinicians involved in a regional or national “command center” likely must meet the licensure requirements (or obtain waivers) for every jurisdiction in which their patients reside. Providers should seek counsel regarding the extent to which new devices and software need to be approved by the US Food and Drug Administration before being deployed. And, as with all health-related communication, it is essential that information transmitted in nontraditional ways be secure, private, and compliant with all mandated standards for privacy. Finally, if the technology or service is rolled out in a fashion that could be construed as a “gift” or “freebie” for marketing purposes rather than a tool to improve clinical outcomes and health care value, then there may be a risk that the approach runs afoul of laws to prevent undue inducements.

In addition to reimbursement and regulatory concerns, there are technical barriers to fully realizing the connected health opportunities in home care. Even if patients are provided with devices, there is variability in internet connectivity or bandwidth in any given home. Providing devices with built-in cellular capabilities can reduce these barriers, but cellular data coverage varies across different geographies. High-quality health care videoconferencing tends to require more bandwidth than that provided in the typical “3G” connection. Use of existing cable television connections, which are almost ubiquitous, is another option, but it typically requires a more customized set-up than consumer mobile devices with cellular and wireless capabilities. If the services were delivered or coordinated by the cable provider, some of these inconveniences might be resolved.

As with most innovation, there is no “cookbook,” and there is limited and conflicting evidence in the clinical sciences literature to guide best practices. Organizations that commit to using technology to improve the quality and efficiency of care will experience fits and starts before they find the right types and “doses” of technology in their new care models. The home health community should beware of these frustrations leading to undue skepticism, like that of Newsweek author Clifford Stoll, who in 1995 infamously wrote about the developing internet:

…today, I’m uneasy about this [trend]…. Visionaries see a future of telecommuting workers, interactive libraries and multimedia classrooms. They speak of electronic town meetings and virtual communities. Commerce and business will shift from offices and malls to networks and modems. And the freedom of digital networks will make government more democratic. Baloney. Do our computer pundits lack all common sense? The truth is no online database will replace your daily newspaper … no computer network will change the way government works.¹⁴

Like the internet of 15 years ago, mobile and digital technologies are now changing how people live and relate to one another and how businesses function. It is unlikely that the impact of these technologies on health care will be fully elucidated by controlled trials that consider incremental changes to existing care models and workflows. Rather, innovative providers and the next generation of clinicians that “grew up,” with mobile devices as part of their lives will create new home care workflows and care realities. Home health providers can use these technologies to better connect their patients and find new ways to reduce suffering, increase health and independence, and improve the care experience while lowering costs and increasing value. The individuals and organizations that seize the moment and “answer” these key questions in connected health with successful new approaches to care will be the winners of the future. There is such an opportunity to make a difference.

Many technologies have emerged to monitor, interact with, and support patients at home and change home health care delivery.^1–5 This trend coincides with the explosion of consumer digital and mobile products such as “smartphones” and has brought with it many different names, such as telehealth, telemedicine, e-medicine, remote monitoring, “virtual” care, digital health, mobile medicine, interactive health, and distance health. Many of these terms and concepts raise concerns for those who value traditional expressions of caring, physical diagnosis, touch, and presence in health care. However, these new technologies may present opportunities to find ways to enhance humanism in home health care. This potential may be most evident among patients with serious chronic illness and their families, who often struggle 168 hours a week but find their access to help limited to brief visits at times convenient for the provider.

While our health care system offers heroic acute-care treatments for hundreds of life-threatening maladies, we seem to fall short in helping those with serious ongoing needs whose care must be coordinated over time and across health care venues. Thinking in terms of “connected health” may provide a more holistic nomenclature that suggests the bond between technology and the opportunity for closer personal relationships.^6–8

OPPORTUNITIES

Can technology better connect our home health patients and families to care during the “white space,”⁹ between our visits? Can we use new mobile and digital technologies to improve care for the seriously chronically ill? We have the technology to turn many challenges into opportunities in the next decade. For example:

1. Can we change our visit-based model of home health care to a model that provides 24/7 “inbound” multichannel access to home health care teams along with proactive “outbound” support between visits in the form of multimedia health education and virtual encounters? Can this free up time for longer visits targeted toward higher-risk and higher-complexity scenarios that require extensive team leadership and care coordination?
2. Can “smart” home monitoring be integrated into home-based long-term care for patients who have dementia, fall risks, other safety issues, or unaddressed limitations in activities of daily living to increase independence and quality of life and reduce institutionalization while decreasing cost of care and accommodating workforce constraints?¹⁰
3. How do we apply clinician-to-clinician and clinician-to-patient videoconferencing and other connected health approaches to increase home health patient access to specialized, but hard-to-find, clinicians for consultative and direct-care services?
4. Can emerging technologies accelerate the shift in care whereby most acute care for exacerbations of chronic illness and other common acute scenarios move from hospitals into home-based models of acute care, such as “Hospital at home”?¹¹
5. To what extent can apps and other technologies provide self-management support to truly deliver the home health care version of the automatic teller machine? For example, diabetes self-management support tools provide patients feedback about their disease based on information input into mobile devices.¹² Can this be expanded in a way that dramatically increases access, especially for vulnerable groups that have been hard to reach, while also decreasing costs?
6. Can we improve the home health care experience by using connected health concepts to improve transparency, minimize common scheduling delays and annoyances, and empower patients while they are receiving care?

REAL-WORLD BARRIERS

Despite the opportunities, barriers remain for innovative providers. With few exceptions, there is no direct third-party reimbursement for care that comes through a device rather than the front door. Medicare does not reimburse home health providers for services outside of a visit, but specific guidance has been issued that clarifies some of the opportunities:

An HHA (Home Health Agency) may adopt telehealth technologies that it believes promote efficiencies or improve quality of care…. An HHA may not substitute telehealth services for Medicare-covered services ordered by a physician. However, if an HHA has telehealth services available to its clients, a doctor may take their availability into account when he or she prepares a plan…. If a physician intends that telehealth services be furnished while a patient is under a home health plan of care, the services should be recorded in the plan of care along with the Medicare covered home health services to be furnished.¹³

Thus, there is no reimbursement for telehealth services, but if telehealth is part of a physician-directed plan of care, it may be included if it promotes home health quality and efficiency. Beyond reimbursement, there are other regulatory barriers. If monitoring or other digital or virtual services are provided across state lines, the clinicians involved in a regional or national “command center” likely must meet the licensure requirements (or obtain waivers) for every jurisdiction in which their patients reside. Providers should seek counsel regarding the extent to which new devices and software need to be approved by the US Food and Drug Administration before being deployed. And, as with all health-related communication, it is essential that information transmitted in nontraditional ways be secure, private, and compliant with all mandated standards for privacy. Finally, if the technology or service is rolled out in a fashion that could be construed as a “gift” or “freebie” for marketing purposes rather than a tool to improve clinical outcomes and health care value, then there may be a risk that the approach runs afoul of laws to prevent undue inducements.

In addition to reimbursement and regulatory concerns, there are technical barriers to fully realizing the connected health opportunities in home care. Even if patients are provided with devices, there is variability in internet connectivity or bandwidth in any given home. Providing devices with built-in cellular capabilities can reduce these barriers, but cellular data coverage varies across different geographies. High-quality health care videoconferencing tends to require more bandwidth than that provided in the typical “3G” connection. Use of existing cable television connections, which are almost ubiquitous, is another option, but it typically requires a more customized set-up than consumer mobile devices with cellular and wireless capabilities. If the services were delivered or coordinated by the cable provider, some of these inconveniences might be resolved.

As with most innovation, there is no “cookbook,” and there is limited and conflicting evidence in the clinical sciences literature to guide best practices. Organizations that commit to using technology to improve the quality and efficiency of care will experience fits and starts before they find the right types and “doses” of technology in their new care models. The home health community should beware of these frustrations leading to undue skepticism, like that of Newsweek author Clifford Stoll, who in 1995 infamously wrote about the developing internet:

…today, I’m uneasy about this [trend]…. Visionaries see a future of telecommuting workers, interactive libraries and multimedia classrooms. They speak of electronic town meetings and virtual communities. Commerce and business will shift from offices and malls to networks and modems. And the freedom of digital networks will make government more democratic. Baloney. Do our computer pundits lack all common sense? The truth is no online database will replace your daily newspaper … no computer network will change the way government works.¹⁴

Like the internet of 15 years ago, mobile and digital technologies are now changing how people live and relate to one another and how businesses function. It is unlikely that the impact of these technologies on health care will be fully elucidated by controlled trials that consider incremental changes to existing care models and workflows. Rather, innovative providers and the next generation of clinicians that “grew up,” with mobile devices as part of their lives will create new home care workflows and care realities. Home health providers can use these technologies to better connect their patients and find new ways to reduce suffering, increase health and independence, and improve the care experience while lowering costs and increasing value. The individuals and organizations that seize the moment and “answer” these key questions in connected health with successful new approaches to care will be the winners of the future. There is such an opportunity to make a difference.

Many technologies have emerged to monitor, interact with, and support patients at home and change home health care delivery.^1–5 This trend coincides with the explosion of consumer digital and mobile products such as “smartphones” and has brought with it many different names, such as telehealth, telemedicine, e-medicine, remote monitoring, “virtual” care, digital health, mobile medicine, interactive health, and distance health. Many of these terms and concepts raise concerns for those who value traditional expressions of caring, physical diagnosis, touch, and presence in health care. However, these new technologies may present opportunities to find ways to enhance humanism in home health care. This potential may be most evident among patients with serious chronic illness and their families, who often struggle 168 hours a week but find their access to help limited to brief visits at times convenient for the provider.

While our health care system offers heroic acute-care treatments for hundreds of life-threatening maladies, we seem to fall short in helping those with serious ongoing needs whose care must be coordinated over time and across health care venues. Thinking in terms of “connected health” may provide a more holistic nomenclature that suggests the bond between technology and the opportunity for closer personal relationships.^6–8

OPPORTUNITIES

Can technology better connect our home health patients and families to care during the “white space,”⁹ between our visits? Can we use new mobile and digital technologies to improve care for the seriously chronically ill? We have the technology to turn many challenges into opportunities in the next decade. For example:

1. Can we change our visit-based model of home health care to a model that provides 24/7 “inbound” multichannel access to home health care teams along with proactive “outbound” support between visits in the form of multimedia health education and virtual encounters? Can this free up time for longer visits targeted toward higher-risk and higher-complexity scenarios that require extensive team leadership and care coordination?
2. Can “smart” home monitoring be integrated into home-based long-term care for patients who have dementia, fall risks, other safety issues, or unaddressed limitations in activities of daily living to increase independence and quality of life and reduce institutionalization while decreasing cost of care and accommodating workforce constraints?¹⁰
3. How do we apply clinician-to-clinician and clinician-to-patient videoconferencing and other connected health approaches to increase home health patient access to specialized, but hard-to-find, clinicians for consultative and direct-care services?
4. Can emerging technologies accelerate the shift in care whereby most acute care for exacerbations of chronic illness and other common acute scenarios move from hospitals into home-based models of acute care, such as “Hospital at home”?¹¹
5. To what extent can apps and other technologies provide self-management support to truly deliver the home health care version of the automatic teller machine? For example, diabetes self-management support tools provide patients feedback about their disease based on information input into mobile devices.¹² Can this be expanded in a way that dramatically increases access, especially for vulnerable groups that have been hard to reach, while also decreasing costs?
6. Can we improve the home health care experience by using connected health concepts to improve transparency, minimize common scheduling delays and annoyances, and empower patients while they are receiving care?

REAL-WORLD BARRIERS

Despite the opportunities, barriers remain for innovative providers. With few exceptions, there is no direct third-party reimbursement for care that comes through a device rather than the front door. Medicare does not reimburse home health providers for services outside of a visit, but specific guidance has been issued that clarifies some of the opportunities:

An HHA (Home Health Agency) may adopt telehealth technologies that it believes promote efficiencies or improve quality of care…. An HHA may not substitute telehealth services for Medicare-covered services ordered by a physician. However, if an HHA has telehealth services available to its clients, a doctor may take their availability into account when he or she prepares a plan…. If a physician intends that telehealth services be furnished while a patient is under a home health plan of care, the services should be recorded in the plan of care along with the Medicare covered home health services to be furnished.¹³

Thus, there is no reimbursement for telehealth services, but if telehealth is part of a physician-directed plan of care, it may be included if it promotes home health quality and efficiency. Beyond reimbursement, there are other regulatory barriers. If monitoring or other digital or virtual services are provided across state lines, the clinicians involved in a regional or national “command center” likely must meet the licensure requirements (or obtain waivers) for every jurisdiction in which their patients reside. Providers should seek counsel regarding the extent to which new devices and software need to be approved by the US Food and Drug Administration before being deployed. And, as with all health-related communication, it is essential that information transmitted in nontraditional ways be secure, private, and compliant with all mandated standards for privacy. Finally, if the technology or service is rolled out in a fashion that could be construed as a “gift” or “freebie” for marketing purposes rather than a tool to improve clinical outcomes and health care value, then there may be a risk that the approach runs afoul of laws to prevent undue inducements.

In addition to reimbursement and regulatory concerns, there are technical barriers to fully realizing the connected health opportunities in home care. Even if patients are provided with devices, there is variability in internet connectivity or bandwidth in any given home. Providing devices with built-in cellular capabilities can reduce these barriers, but cellular data coverage varies across different geographies. High-quality health care videoconferencing tends to require more bandwidth than that provided in the typical “3G” connection. Use of existing cable television connections, which are almost ubiquitous, is another option, but it typically requires a more customized set-up than consumer mobile devices with cellular and wireless capabilities. If the services were delivered or coordinated by the cable provider, some of these inconveniences might be resolved.

As with most innovation, there is no “cookbook,” and there is limited and conflicting evidence in the clinical sciences literature to guide best practices. Organizations that commit to using technology to improve the quality and efficiency of care will experience fits and starts before they find the right types and “doses” of technology in their new care models. The home health community should beware of these frustrations leading to undue skepticism, like that of Newsweek author Clifford Stoll, who in 1995 infamously wrote about the developing internet:

…today, I’m uneasy about this [trend]…. Visionaries see a future of telecommuting workers, interactive libraries and multimedia classrooms. They speak of electronic town meetings and virtual communities. Commerce and business will shift from offices and malls to networks and modems. And the freedom of digital networks will make government more democratic. Baloney. Do our computer pundits lack all common sense? The truth is no online database will replace your daily newspaper … no computer network will change the way government works.¹⁴

Like the internet of 15 years ago, mobile and digital technologies are now changing how people live and relate to one another and how businesses function. It is unlikely that the impact of these technologies on health care will be fully elucidated by controlled trials that consider incremental changes to existing care models and workflows. Rather, innovative providers and the next generation of clinicians that “grew up,” with mobile devices as part of their lives will create new home care workflows and care realities. Home health providers can use these technologies to better connect their patients and find new ways to reduce suffering, increase health and independence, and improve the care experience while lowering costs and increasing value. The individuals and organizations that seize the moment and “answer” these key questions in connected health with successful new approaches to care will be the winners of the future. There is such an opportunity to make a difference.

Mrs. Smith, age 82, has chronic heart failure. She also has difficulty walking because of arthritis in her knee and osteoporosis. Her son has taken the day off work to bring her in to see her primary care physician, Dr. Jones, because of increasing swelling of her legs and feeling tired.

See related editorial

Even on a good day, Mrs. Smith faces challenges getting to the doctor’s office: she has difficulty getting dressed, taking the stairs, and transporting her walker and oxygen, not to mention parking the car, getting out, getting in to the doctor’s office, and then returning home.

After a careful evaluation Dr. Jones concludes that the leg swelling and fatigue are due to an exacerbation of heart failure triggered by excess dietary sodium and uncontrolled hypertension. She decides to increase the dosages of Mrs. Smith’s diuretic and angiotensin-converting enzyme inhibitor and advises her and her son about dietary sodium restriction. She reviews with them the symptoms that should trigger a call to the office, and she says she wants to see Mrs. Smith again in 3 days.

Mrs. Smith and her son do not seem to understand the instructions, and they explain how difficult it will be to make the follow-up visit, so Dr. Jones recommends hospital admission. Mrs. Smith protests, as she has had multiple hospitalizations during the past year and she dreads the idea of returning. And her son explains, “Mom always seems worse after going to the hospital. Last winter when she was there her days and nights got mixed up, and when she called out at night they gave her some drug that knocked her out for 2 days. Doctor, isn’t there any safe way to keep her at home?”

CHRONIC ILLNESS: A CHALLENGE, AND AN OPPORTUNITY

The growing number of older adults with chronic illnesses poses a serious challenge to the US health care system, placing unprecedented pressures on the financial sustainability and overall effectiveness of the Medicare program.^1,2 Of particular concern is the plight of Medicare beneficiaries like Mrs. Smith who have multiple chronic conditions and whose activity and mobility are limited. These patients account for a disproportionate share of Medicare expenses and, despite all the money spent, often struggle without optimal care that is accessible, individualized, and coordinated.

But this challenge is also an opportunity. We may be able to improve the care of these vulnerable patients—and control costs—by taking their primary care to their own homes. To these ends, the Patient Protection and Affordable Care Act (ie, the “health care reform law”) has several provisions for pilot and demonstration projects.^3–5 In light of the new policies and as part of a grassroots effort to change the delivery of care for patients with chronic conditions, primary care physicians like Dr. Jones are redesigning their practices to provide a patient-centered medical home.⁶

As envisioned, the primary care physician’s office will be the patient’s “medical home.” The primary care physician will lead, coordinate, and oversee the efforts of a multidisciplinary team, referring patients when necessary to specialists and community resources. Primary care practices that become medical homes would potentially be paid care management fees in addition to fees for visits, but with new expectations for care coordination and integration.

The emergence of the medical home, independence-at-home, and related concepts makes it a good time for physicians to explore how they can collaborate with home health providers to better meet the needs of older patients with chronic illness (Table 1).

UNDER MEDICARE, WHO IS ELIGIBLE FOR HOME HEALTH SERVICES?

Primary care physicians who are transforming their offices into a medical home must consider how to deliver the care (it must be accessible, team-based, and aimed at the “whole person”), coordinate the care, and measure its quality.⁷ Many Medicare beneficiaries with serious chronic illness have limited mobility that makes it difficult to regularly travel to medical offices, and thus they need home visits or regular contact by telephone or computer.

Many home health agencies are using new conceptual models, programs, technologies, and services so they can play a supportive role.⁸ These agencies employ nurses, therapists, social workers, personal caregivers, and nutritionists. In many instances these people can become the physician-directed team responsible for key aspects of caring for patients with chronic illness in their homes, coordinating and integrating the care, and measuring its quality. Additionally, in-home assessment provides a holistic view of patients that potentially promotes patient- and family-centered care options.

To be eligible for home health services, a beneficiary must be “homebound,” must need intermittent skilled nursing care or skilled therapy, and must be under the care of a physician. The health reform law has also mandated that patients have a face-to-face visit with their physician or with certain nonphysician practitioners in order to certify the home health care plan.

Even though the homebound requirement limits the number of people eligible, many older adults like Mrs. Smith who have chronic illness meet this criterion. Others may only be homebound during an exacerbation of a chronic illness that temporarily limits their mobility. However, patients can still be considered homebound for the Medicare benefit even if they leave their home (infrequently) for medical care, religious services, family events, adult day programs, and other reasons.⁹

The Medicare Home Health benefit covers several services that are especially important for patients with chronic illness. These include nursing visits for observation and assessment, evaluation and management of a care plan, and teaching and training.

How this applies to Mrs. Smith

In the case of Mrs. Smith, Dr. Jones could order home nursing care to make sure she is taking her medications as directed, to teach her about self-management and nutrition, and to assess the impact of medication changes—both the intended effects and adverse effects such as hypotension.

Other team members bring other skills. For example, home health social workers may be able to address complex psychosocial needs that can affect adherence.

The time Dr. Jones spends developing this care plan and reviewing the patient’s condition with home health field staff by telephone or other communication methods is reimbursable under Medicare as “care plan oversight”¹⁰ and can substitute for the revenue lost due to less-frequent office visits.¹⁰ In the new practice models, a medical home or independence-at-home care-management fee or anticipated revenues from “gain-sharing” could cover nonvisit supervision of in-home services.

Oversight in the computer age

Dr. Jones may be reluctant to rely on a home health agency because she cannot directly oversee what they are doing and may in fact be uncertain as to what they are doing. Home care may seem like a “black box” to physicians, but it shouldn’t in this era of electronic health records and advanced electronic information systems. Seamless communication is possible without playing “telephone tag” and sending multiple faxes. Physicians may prefer to work only with home care providers who use electronic information systems and who can interface their systems with the physician’s electronic systems, or at least offer shared viewing through Web access. Of course, such arrangements must be initiated with respect for the patient’s preference for a home care agency.

Home health providers are also well positioned to help measure and monitor the quality of care. Medicare requires that home health providers track a comprehensive set of quality outcomes, adjusted for risk, and ranging from improvement in function to acute hospitalization rates.^11,12 Given that most home care providers are swimming in data about their patients, it would be reasonable for home care agencies to provide physician partners with more nuanced reports for specific subpopulations, such as those from a particular physician practice, or for patients with a particular disease.

NEW CONCEPTS, PROCESSES, AND TECHNOLOGIES

To care for a patient like Mrs. Smith, the home health team must embrace new, chronic-care-oriented concepts, processes, and technologies. Many agencies now have nurses and therapists skilled in chronic illness care, self-management support, and health coaching. Ancillary staff collaborate with the physician by assuming time-consuming but necessary tasks such as patient education, care coordination and integration, and quality measurement and improvement initiatives.

Several groups and authors have proposed a “home-based chronic care model,” built upon the well-studied “chronic care model,” ^13–16 as a framework to help home care providers change their approach to patients with chronic illness. This model offers a standardized curriculum and certification program, as well as practice guidelines, which standardize best-practice care delivery from agency to agency.

A core tenet of this model is a strong focus on teaching clinicians how to teach their patients to care for themselves, since bad outcomes are often due to patients not following physicians' recommendations. Since successful chronic care management requires adherence to specific self-care behaviors, the focus on behavior change must not be neglected if positive outcomes are to be realized.

New technologies are also emerging. Some home health providers are using in-home telemetry with remote call centers to track the patient’s health status on a daily basis. Physicians and patients can follow the data, allowing for quick intervention, if necessary, and reinforcement of self-management learning.^17–20 Some home care agencies could monitor, via telemetry, Mrs. Smith’s weight, blood pressure, oxygen saturation, heart rate, and dyspnea symptoms. This information could be fed back to call-center clinicians who have predetermined parameters for titrating the diuretic dose and for notifying the physician.

Some monitoring technology allows for interactive assessment and teaching via live videoconferencing. Some home health agencies also use telephone-based health coaching.²¹ Information system interfaces between the home health agency and the medical home coordinator could make the content of this in-home monitoring and care management visible in the physician’s record.

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.

Mrs. Smith, age 82, has chronic heart failure. She also has difficulty walking because of arthritis in her knee and osteoporosis. Her son has taken the day off work to bring her in to see her primary care physician, Dr. Jones, because of increasing swelling of her legs and feeling tired.

See related editorial

Even on a good day, Mrs. Smith faces challenges getting to the doctor’s office: she has difficulty getting dressed, taking the stairs, and transporting her walker and oxygen, not to mention parking the car, getting out, getting in to the doctor’s office, and then returning home.

After a careful evaluation Dr. Jones concludes that the leg swelling and fatigue are due to an exacerbation of heart failure triggered by excess dietary sodium and uncontrolled hypertension. She decides to increase the dosages of Mrs. Smith’s diuretic and angiotensin-converting enzyme inhibitor and advises her and her son about dietary sodium restriction. She reviews with them the symptoms that should trigger a call to the office, and she says she wants to see Mrs. Smith again in 3 days.

Mrs. Smith and her son do not seem to understand the instructions, and they explain how difficult it will be to make the follow-up visit, so Dr. Jones recommends hospital admission. Mrs. Smith protests, as she has had multiple hospitalizations during the past year and she dreads the idea of returning. And her son explains, “Mom always seems worse after going to the hospital. Last winter when she was there her days and nights got mixed up, and when she called out at night they gave her some drug that knocked her out for 2 days. Doctor, isn’t there any safe way to keep her at home?”

CHRONIC ILLNESS: A CHALLENGE, AND AN OPPORTUNITY

The growing number of older adults with chronic illnesses poses a serious challenge to the US health care system, placing unprecedented pressures on the financial sustainability and overall effectiveness of the Medicare program.^1,2 Of particular concern is the plight of Medicare beneficiaries like Mrs. Smith who have multiple chronic conditions and whose activity and mobility are limited. These patients account for a disproportionate share of Medicare expenses and, despite all the money spent, often struggle without optimal care that is accessible, individualized, and coordinated.

But this challenge is also an opportunity. We may be able to improve the care of these vulnerable patients—and control costs—by taking their primary care to their own homes. To these ends, the Patient Protection and Affordable Care Act (ie, the “health care reform law”) has several provisions for pilot and demonstration projects.^3–5 In light of the new policies and as part of a grassroots effort to change the delivery of care for patients with chronic conditions, primary care physicians like Dr. Jones are redesigning their practices to provide a patient-centered medical home.⁶

As envisioned, the primary care physician’s office will be the patient’s “medical home.” The primary care physician will lead, coordinate, and oversee the efforts of a multidisciplinary team, referring patients when necessary to specialists and community resources. Primary care practices that become medical homes would potentially be paid care management fees in addition to fees for visits, but with new expectations for care coordination and integration.

The emergence of the medical home, independence-at-home, and related concepts makes it a good time for physicians to explore how they can collaborate with home health providers to better meet the needs of older patients with chronic illness (Table 1).

UNDER MEDICARE, WHO IS ELIGIBLE FOR HOME HEALTH SERVICES?

Primary care physicians who are transforming their offices into a medical home must consider how to deliver the care (it must be accessible, team-based, and aimed at the “whole person”), coordinate the care, and measure its quality.⁷ Many Medicare beneficiaries with serious chronic illness have limited mobility that makes it difficult to regularly travel to medical offices, and thus they need home visits or regular contact by telephone or computer.

Many home health agencies are using new conceptual models, programs, technologies, and services so they can play a supportive role.⁸ These agencies employ nurses, therapists, social workers, personal caregivers, and nutritionists. In many instances these people can become the physician-directed team responsible for key aspects of caring for patients with chronic illness in their homes, coordinating and integrating the care, and measuring its quality. Additionally, in-home assessment provides a holistic view of patients that potentially promotes patient- and family-centered care options.

To be eligible for home health services, a beneficiary must be “homebound,” must need intermittent skilled nursing care or skilled therapy, and must be under the care of a physician. The health reform law has also mandated that patients have a face-to-face visit with their physician or with certain nonphysician practitioners in order to certify the home health care plan.

Even though the homebound requirement limits the number of people eligible, many older adults like Mrs. Smith who have chronic illness meet this criterion. Others may only be homebound during an exacerbation of a chronic illness that temporarily limits their mobility. However, patients can still be considered homebound for the Medicare benefit even if they leave their home (infrequently) for medical care, religious services, family events, adult day programs, and other reasons.⁹

The Medicare Home Health benefit covers several services that are especially important for patients with chronic illness. These include nursing visits for observation and assessment, evaluation and management of a care plan, and teaching and training.

How this applies to Mrs. Smith

In the case of Mrs. Smith, Dr. Jones could order home nursing care to make sure she is taking her medications as directed, to teach her about self-management and nutrition, and to assess the impact of medication changes—both the intended effects and adverse effects such as hypotension.

Other team members bring other skills. For example, home health social workers may be able to address complex psychosocial needs that can affect adherence.

The time Dr. Jones spends developing this care plan and reviewing the patient’s condition with home health field staff by telephone or other communication methods is reimbursable under Medicare as “care plan oversight”¹⁰ and can substitute for the revenue lost due to less-frequent office visits.¹⁰ In the new practice models, a medical home or independence-at-home care-management fee or anticipated revenues from “gain-sharing” could cover nonvisit supervision of in-home services.

Oversight in the computer age

Dr. Jones may be reluctant to rely on a home health agency because she cannot directly oversee what they are doing and may in fact be uncertain as to what they are doing. Home care may seem like a “black box” to physicians, but it shouldn’t in this era of electronic health records and advanced electronic information systems. Seamless communication is possible without playing “telephone tag” and sending multiple faxes. Physicians may prefer to work only with home care providers who use electronic information systems and who can interface their systems with the physician’s electronic systems, or at least offer shared viewing through Web access. Of course, such arrangements must be initiated with respect for the patient’s preference for a home care agency.

Home health providers are also well positioned to help measure and monitor the quality of care. Medicare requires that home health providers track a comprehensive set of quality outcomes, adjusted for risk, and ranging from improvement in function to acute hospitalization rates.^11,12 Given that most home care providers are swimming in data about their patients, it would be reasonable for home care agencies to provide physician partners with more nuanced reports for specific subpopulations, such as those from a particular physician practice, or for patients with a particular disease.

NEW CONCEPTS, PROCESSES, AND TECHNOLOGIES

To care for a patient like Mrs. Smith, the home health team must embrace new, chronic-care-oriented concepts, processes, and technologies. Many agencies now have nurses and therapists skilled in chronic illness care, self-management support, and health coaching. Ancillary staff collaborate with the physician by assuming time-consuming but necessary tasks such as patient education, care coordination and integration, and quality measurement and improvement initiatives.

Several groups and authors have proposed a “home-based chronic care model,” built upon the well-studied “chronic care model,” ^13–16 as a framework to help home care providers change their approach to patients with chronic illness. This model offers a standardized curriculum and certification program, as well as practice guidelines, which standardize best-practice care delivery from agency to agency.

A core tenet of this model is a strong focus on teaching clinicians how to teach their patients to care for themselves, since bad outcomes are often due to patients not following physicians' recommendations. Since successful chronic care management requires adherence to specific self-care behaviors, the focus on behavior change must not be neglected if positive outcomes are to be realized.

New technologies are also emerging. Some home health providers are using in-home telemetry with remote call centers to track the patient’s health status on a daily basis. Physicians and patients can follow the data, allowing for quick intervention, if necessary, and reinforcement of self-management learning.^17–20 Some home care agencies could monitor, via telemetry, Mrs. Smith’s weight, blood pressure, oxygen saturation, heart rate, and dyspnea symptoms. This information could be fed back to call-center clinicians who have predetermined parameters for titrating the diuretic dose and for notifying the physician.

Some monitoring technology allows for interactive assessment and teaching via live videoconferencing. Some home health agencies also use telephone-based health coaching.²¹ Information system interfaces between the home health agency and the medical home coordinator could make the content of this in-home monitoring and care management visible in the physician’s record.

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.

Mrs. Smith, age 82, has chronic heart failure. She also has difficulty walking because of arthritis in her knee and osteoporosis. Her son has taken the day off work to bring her in to see her primary care physician, Dr. Jones, because of increasing swelling of her legs and feeling tired.

See related editorial

Even on a good day, Mrs. Smith faces challenges getting to the doctor’s office: she has difficulty getting dressed, taking the stairs, and transporting her walker and oxygen, not to mention parking the car, getting out, getting in to the doctor’s office, and then returning home.

After a careful evaluation Dr. Jones concludes that the leg swelling and fatigue are due to an exacerbation of heart failure triggered by excess dietary sodium and uncontrolled hypertension. She decides to increase the dosages of Mrs. Smith’s diuretic and angiotensin-converting enzyme inhibitor and advises her and her son about dietary sodium restriction. She reviews with them the symptoms that should trigger a call to the office, and she says she wants to see Mrs. Smith again in 3 days.

Mrs. Smith and her son do not seem to understand the instructions, and they explain how difficult it will be to make the follow-up visit, so Dr. Jones recommends hospital admission. Mrs. Smith protests, as she has had multiple hospitalizations during the past year and she dreads the idea of returning. And her son explains, “Mom always seems worse after going to the hospital. Last winter when she was there her days and nights got mixed up, and when she called out at night they gave her some drug that knocked her out for 2 days. Doctor, isn’t there any safe way to keep her at home?”

CHRONIC ILLNESS: A CHALLENGE, AND AN OPPORTUNITY

The growing number of older adults with chronic illnesses poses a serious challenge to the US health care system, placing unprecedented pressures on the financial sustainability and overall effectiveness of the Medicare program.^1,2 Of particular concern is the plight of Medicare beneficiaries like Mrs. Smith who have multiple chronic conditions and whose activity and mobility are limited. These patients account for a disproportionate share of Medicare expenses and, despite all the money spent, often struggle without optimal care that is accessible, individualized, and coordinated.

But this challenge is also an opportunity. We may be able to improve the care of these vulnerable patients—and control costs—by taking their primary care to their own homes. To these ends, the Patient Protection and Affordable Care Act (ie, the “health care reform law”) has several provisions for pilot and demonstration projects.^3–5 In light of the new policies and as part of a grassroots effort to change the delivery of care for patients with chronic conditions, primary care physicians like Dr. Jones are redesigning their practices to provide a patient-centered medical home.⁶

As envisioned, the primary care physician’s office will be the patient’s “medical home.” The primary care physician will lead, coordinate, and oversee the efforts of a multidisciplinary team, referring patients when necessary to specialists and community resources. Primary care practices that become medical homes would potentially be paid care management fees in addition to fees for visits, but with new expectations for care coordination and integration.

The emergence of the medical home, independence-at-home, and related concepts makes it a good time for physicians to explore how they can collaborate with home health providers to better meet the needs of older patients with chronic illness (Table 1).

UNDER MEDICARE, WHO IS ELIGIBLE FOR HOME HEALTH SERVICES?

Primary care physicians who are transforming their offices into a medical home must consider how to deliver the care (it must be accessible, team-based, and aimed at the “whole person”), coordinate the care, and measure its quality.⁷ Many Medicare beneficiaries with serious chronic illness have limited mobility that makes it difficult to regularly travel to medical offices, and thus they need home visits or regular contact by telephone or computer.

Many home health agencies are using new conceptual models, programs, technologies, and services so they can play a supportive role.⁸ These agencies employ nurses, therapists, social workers, personal caregivers, and nutritionists. In many instances these people can become the physician-directed team responsible for key aspects of caring for patients with chronic illness in their homes, coordinating and integrating the care, and measuring its quality. Additionally, in-home assessment provides a holistic view of patients that potentially promotes patient- and family-centered care options.

To be eligible for home health services, a beneficiary must be “homebound,” must need intermittent skilled nursing care or skilled therapy, and must be under the care of a physician. The health reform law has also mandated that patients have a face-to-face visit with their physician or with certain nonphysician practitioners in order to certify the home health care plan.

Even though the homebound requirement limits the number of people eligible, many older adults like Mrs. Smith who have chronic illness meet this criterion. Others may only be homebound during an exacerbation of a chronic illness that temporarily limits their mobility. However, patients can still be considered homebound for the Medicare benefit even if they leave their home (infrequently) for medical care, religious services, family events, adult day programs, and other reasons.⁹

The Medicare Home Health benefit covers several services that are especially important for patients with chronic illness. These include nursing visits for observation and assessment, evaluation and management of a care plan, and teaching and training.

How this applies to Mrs. Smith

In the case of Mrs. Smith, Dr. Jones could order home nursing care to make sure she is taking her medications as directed, to teach her about self-management and nutrition, and to assess the impact of medication changes—both the intended effects and adverse effects such as hypotension.

Other team members bring other skills. For example, home health social workers may be able to address complex psychosocial needs that can affect adherence.

The time Dr. Jones spends developing this care plan and reviewing the patient’s condition with home health field staff by telephone or other communication methods is reimbursable under Medicare as “care plan oversight”¹⁰ and can substitute for the revenue lost due to less-frequent office visits.¹⁰ In the new practice models, a medical home or independence-at-home care-management fee or anticipated revenues from “gain-sharing” could cover nonvisit supervision of in-home services.

Oversight in the computer age

Dr. Jones may be reluctant to rely on a home health agency because she cannot directly oversee what they are doing and may in fact be uncertain as to what they are doing. Home care may seem like a “black box” to physicians, but it shouldn’t in this era of electronic health records and advanced electronic information systems. Seamless communication is possible without playing “telephone tag” and sending multiple faxes. Physicians may prefer to work only with home care providers who use electronic information systems and who can interface their systems with the physician’s electronic systems, or at least offer shared viewing through Web access. Of course, such arrangements must be initiated with respect for the patient’s preference for a home care agency.

Home health providers are also well positioned to help measure and monitor the quality of care. Medicare requires that home health providers track a comprehensive set of quality outcomes, adjusted for risk, and ranging from improvement in function to acute hospitalization rates.^11,12 Given that most home care providers are swimming in data about their patients, it would be reasonable for home care agencies to provide physician partners with more nuanced reports for specific subpopulations, such as those from a particular physician practice, or for patients with a particular disease.

NEW CONCEPTS, PROCESSES, AND TECHNOLOGIES

To care for a patient like Mrs. Smith, the home health team must embrace new, chronic-care-oriented concepts, processes, and technologies. Many agencies now have nurses and therapists skilled in chronic illness care, self-management support, and health coaching. Ancillary staff collaborate with the physician by assuming time-consuming but necessary tasks such as patient education, care coordination and integration, and quality measurement and improvement initiatives.

Several groups and authors have proposed a “home-based chronic care model,” built upon the well-studied “chronic care model,” ^13–16 as a framework to help home care providers change their approach to patients with chronic illness. This model offers a standardized curriculum and certification program, as well as practice guidelines, which standardize best-practice care delivery from agency to agency.

A core tenet of this model is a strong focus on teaching clinicians how to teach their patients to care for themselves, since bad outcomes are often due to patients not following physicians' recommendations. Since successful chronic care management requires adherence to specific self-care behaviors, the focus on behavior change must not be neglected if positive outcomes are to be realized.

New technologies are also emerging. Some home health providers are using in-home telemetry with remote call centers to track the patient’s health status on a daily basis. Physicians and patients can follow the data, allowing for quick intervention, if necessary, and reinforcement of self-management learning.^17–20 Some home care agencies could monitor, via telemetry, Mrs. Smith’s weight, blood pressure, oxygen saturation, heart rate, and dyspnea symptoms. This information could be fed back to call-center clinicians who have predetermined parameters for titrating the diuretic dose and for notifying the physician.

Some monitoring technology allows for interactive assessment and teaching via live videoconferencing. Some home health agencies also use telephone-based health coaching.²¹ Information system interfaces between the home health agency and the medical home coordinator could make the content of this in-home monitoring and care management visible in the physician’s record.

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.