ACOs more likely to use home visits to help manage complex patients’ care

The Agency for Healthcare Research and Quality (AHRQ) reports that Accountable Care Organizations (ACOs) are more likely to use home visits to manage patients who have complex medical needs than non-ACO physician practices. Medicare’s new reimbursement models also support home visits for some patients.

The new AHRQ-funded study, published in Health Affairs, shows home visits improve care transitions following hospital discharge and enhance overall care management. In the study, ACOs reported three main home visit activities: assessing patients’ needs, reconciling medications use and identifying patient barriers to effective care.

Among Medicare ACOs, AHRQ says the researchers found no differences in quality scores or likelihood of achieving shared savings between ACOs that used home visits and those that did not. Researchers noted that, despite their perceived value, implementing home visits for some types of patients can be challenging because of barriers related to reimbursement, staffing and resources.

On the other hand, another study, also in the June issue of Health Affairs, indicates that ACOs have potential to care for the nation’s seriously ill patients at lower costs and improved quality, but few are taking steps to do so, according to a media release from Duke-Margolis Center for Health Policy and Leavitt Partners, which conducted the study. In fact, although 94 percent of ACOs worked to identify their seriously ill patients, only 8 to 21 percent widely implemented serious illness initiatives, such as advance care planning or home-based palliative care, according to a national study featured in the Duke release.

An earlier report by AHRQ shows among 626 health systems in its compendium, 56 percent have at least one hospital participating in an ACO contract and that 44 percent of system-hospitals participate in an ACO contract compared to only 13 percent of non-system hospitals.

ACOs are ripe to improve the care of people living with serious illness for two reasons:

·   Hospitalizations and emergency room visits at the end of life are often unnecessary or harmful, and the ACO model prevents inappropriate visits.

·   The ACO model offers flexible spending of Medicare dollars to pay for important serious illness services that fee-for-service does not cover.

Keys to successful programs included:

Upfront investment: ACO infrastructure can cost up to $1 million or more, and additional infrastructure for serious illness care requires additional capital. Data infrastructure and a workforce to identify and care for the seriously ill patients were singled out as particular needs. A key element of success was building on prior infrastructure. Many ACOs were able to extend prior efforts in complex care management and value-based care redesign by developing care programs for seriously ill patients. Also important to success was the ability to connect patients to existing community resources that address social drivers of health (e.g., legal assistance, food insecurity, housing, and transportation), along with hiring social workers or community health workers.

Business plan and organizational buy-in: The fact that many ACOs identify seriously ill patients but have few dedicated care programs suggests that the business case for serious illness care is often underdeveloped. Short-term data derived from serious illness care efforts, however, resonated with leaders and helped with organizational buy-in. Importantly, the mission to care for seriously ill patients is also a big motivator for providers, staff and many leaders: “We’re just doing it because it’s the right thing to do. Period. For the patient,” stated one interviewee. 

Data and health information technology: Capturing actionable data to identify and track seriously ill populations is still a work in progress, most interviewees noted. However, ACOs found data dashboards helpful in tracking important serious illness care metrics and helping to schedule and coordinate patient care across different settings.

Context matters: ACOs in rural or poor urban areas had greater difficulty investing in new initiatives to care for seriously ill patients due to resource constraints.