A rising number of hospice and palliative care providers are establishing home-based primary care service lines in order to engage patients further upstream and to enable participation in new payment models such as Primary Care First and direct contracting.
According to Julie Sacks, chief operating officer and newly appointed president of the Illinois-based Home Centered Care Institute (HCCI), providers that historically focused on hospice can develop home-based primary care business lines with minimal resources to bring in new revenue streams and support patients earlier in their illnesses.
HCCI is a national non-profit organization focused on advancing home-based primary care to ensure that medically complex and homebound patients have access to high-quality care in their homes. Sacks joined the organization in 2015 as vice president of operations and advancement and rose through the ranks to become chief operating officer. She was named president of the organization in February.
Hospice News recently spoke with Sacks about the rising demand for home-based primary care and how hospices are working to fill gaps in access to those services.
What are your top priorities as you come into this new role?
We’ve been working for so long for the world to know about home-based primary care. In some ways, the pandemic really brought to the forefront the need and desire to keep the elderly and the frail out of the hospital and keep them at home.
Our core mission all along, our core mission has been to spread advance and increase the adoption of home-based primary care. We do that in a variety of ways through education, consulting with practices, research and advocacy. We’ve done a lot in partnership with the American Academy of Home Care Medicine to help advance payment models that help support this kind of a treatment model.
We’re also looking at how we get our arms around the new opportunities to expand education. Historically, we’ve been educating providers who want to do home-based primary care. There’s so many mergers and acquisitions taking place on all ends of the continuum, home health, home-based primary care. On the other end, you’ve got palliative and hospice. I really believe strongly that all of the care needs to be integrated. Home-based primary care is a perfect way to manage that integration.
What types of payment models that you were advocating for?
We were one of the organizations that helped [the Center for Medicare & Medicaid Innovation (CMMI)] develop the Primary Care First model, which includes direct contracting and the Serious Illness Population model. That whole initiative is really home-based primary care friendly, and so we do see a lot of programs looking to take advantage of those new payment models.
Can you say more about how the pandemic impacted home-based care?
There’s two major impacts. One is awareness; the need for this kind of care and the value of this kind of care came to the forefront. That’s huge, and we really need leaders and policymakers as well as the public to really understand that need.
The other thing that the pandemic changed is telehealth. The loosening of the restrictions around telehealth made people much more comfortable with it. At HCCI we don’t believe that telehealth can replace home-based primary care. One of the really valuable things about home-based primary care is the relationship between the provider and the patient and family. You just can’t develop the same kind of relationship if you only do telehealth. But if you do some combination, it’s incredibly valuable. It’s more cost effective for the practice, and it’s more beneficial to the patient.
Are organizations that traditionally have been focused on hospice are becoming more interested in offering home-based primary care?
Absolutely, we have a lot of clients that are traditionally hospice and palliative care organizations that want to move further upstream that come to us for help in creating a new service line that’s more specifically home-based primary care.
What are some of the factors that are driving that interest, in addition to the pandemic?
When you’re at more risk for the cost of the patient, if you can start treating them much earlier in their disease much earlier, you can eliminate potentially a lot of hospitalizations by treating things early and at home. You can decrease the cost to the payer by keeping that person in their homes. The patient might not need palliative care or hospice as early.
Ultimately, it means better care for the patient. It aligns more with their goals of care, but you still have the palliative and hospice when you need them. It provides more kind of seamless care across a continuum, which we believe is needed.
Are there benefits to the organization from a business perspective?
What we’ve heard from hospices is that the way that you run a home-based primary care practice from a business perspective is very similar to how you run a hospice or palliative care program. Hospice and palliative care have traditionally struggled the same way home-based primary care practices have to make ends meet in a fee-for-service environment. How do you survive in fee-for-service, but at the same time ready yourself to take advantage of some of the new payment models?
The business practices are very much the same. If you’ve got a home-based palliative or hospice program, and you apply some of the same kinds of best practices and principles that we teach home-based primary care practices to do, your bottom line should improve. That allows you to have some funding to develop the home-based primary care service line.
What are some of the challenges that organizations may encounter when they’re seeking to add a new service like home-based primary care?
They often feel like they don’t know where to start. There’s no reason to reinvent the wheel. There’s a lot of practices that are doing this successfully.
People often have this idea that they have to start big. They think that if they don’t have 5,000 patients then they can’t be in a direct contracting situation. Really, all you need to start a home-based primary care program is a physician or a nurse practitioner.
You don’t even need them full-time. You could start with a half-day nurse practitioner who sees the practice’s most seriously ill patients. This could include those who haven’t been able to get into the office for a certain amount of time or those that you’re particularly worried about.
Home-based primary care is something that not everybody needs, but the people who do need it, the most seriously ill, benefit from it tremendously.