More hospices have embraced home-based primary care in recent years. Providers pursuing these opportunities are carefully weighing their options, including whether they should partner with existing practices or offer those services themselves.
The gradual move of reimbursement systems to value-based care models is partly fueling a resurgence in home-based primary care, according to a 2018 study in the journal Geriatrics. Patients in the United States received more than 2.2 million home-based primary care visits during 2016, up from less than 1 million in 1996, the study found. Patients in assisted living facilities, group homes and other facilities received 3.2 million primary care visits in 2016.
“For hospice and palliative care organizations and others in the home care space, they see the opportunity for transforming to value-based care,” Brianna Plencner, senior consultant and manager for practice development for the Home-Centered Care Institute (HCCI), told Hospice News. “They know that if we’re going to take risk and keep people out of the hospital and have better outcomes, patients need more of a continuum of care. Providers want to be that innovative solution.”
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.
Factors contributing to this growth also include demographic trends related to the aging population, the growing prevalence of serious and chronic illnesses, a favorable regulatory landscape and a gradual move of more care into the home setting — which has accelerated during the COVID-19 pandemic.
As with hospice and palliative care, cost savings from reduced hospitalizations, emergency department visits and nursing home admissions is a key component to the value proposition of these services, according to Plencner.
Engaging with patients further upstream is a rising priority for hospice providers, leading many to diversify their services to include home-based primary care, along with palliative care, PACE and other services. These programs also offer hospices new revenue streams and widen opportunities to participate in emerging payment models.
Starting January 2021, the U.S. Centers for Medicare & Medicaid Services (CMS) rolled out the Primary Care First initiative. A few months later, CMS launched its direct contracting program. Both focused on improving the quality and continuity of patient care as their illnesses progress.
These models are oriented around functions of comprehensive primary care, including care management, patient access and continuity of care, comprehensiveness and coordination, patient and caregiver engagement, and planned care and population health.
Hospice and palliative care companies are also working more closely with Medicare Advantage plans, both in terms of their upstream services and end-of-life care, through the new hospice component of the value-based insurance design (VBID) demonstration, commonly called the Medicare Advantage hospice carve-in.
“If you really want to make some money in the home-based primary care world, eventually you will need to do a shared savings agreement or work with Medicare Advantage plans,” Aaron Yao, Ph.D, research director for HCCI, said. “If you are only focused on fee-for-service patients, you probably will focus on assisted living, group homes and other facilities, saving you time on the road.”
Upstream services like home-based primary care also show promise when it comes to increasing hospice length of stay. Too many patients come to hospice with only a few days to live, which often means they lack time to experience the full benefits of that care.
In 2018, nearly 30% of Medicare decedents received seven hospice care days or less, according to the National Hospice and Palliative Care Organization. Close to 13% were in hospice for 7 to 14 days.
An HCCI analysis of Medicare claims data found that the median length of stay for hospice patients was 24 days in 2020. The median was 79 days for patients who had received four or more home-based primary care visits.
Plencner and Yao pointed to five key considerations for hospices seeking to pursue home-based primary care. Providers must identify their target market, consider their reasons for offering or partnering with this service, set up operations and identify community resources and referral partners.
“You need to evaluate the demand in your local market. There are many factors you can look at — population or health care factors, HCC scores, frailty or comorbidity index, etc.,” Yao said. “Who are your competitors among home-based primary care practices? Look at all the top Medicare Advantage plans in your market that you could work with.”
The advantages of partnering versus launching a new service can vary from organization to organization, as well as conditions in their local markets.
A key consideration is whether the hospice can develop the necessary staffing models to provide home-based primary care, which is distinct from high-touch, 24/7 hospice and palliative care care delivery.
“A partnership may be the better option when the palliative and hospice organization wants to stay in that symptom management role, but doesn’t want to take on that primary responsibility,” Plencner said. “They find a home-based primary care program or a larger entity that needs that service because they can’t get to their patients as frequently and aren’t specialized in that kind of care model.”
Taking on a primary care role may require some retooling for hospice providers. If a provider takes primary responsibility for an ill population it opens more opportunities from a payment perspective, but it also requires a cultural decision that they are going to manage a patient population over time, possibly the last 10 years of life.
Clinical staff must understand how to manage patients with serious illness across health care settings, and business staff must know how to operate and bill for primary care programs. Negotiation with payers to develop value-based contracts is also an essential skill that hospices must develop in order to be successful.
“I think the biggest difference comes down to the billing. When we work with hospice and palliative care organizations, [Medicare] Part B billing is generally new to them, because hospice is a bundled payment mechanism,” Plencner told Hospice News. “They need to understand billing for outpatient services. That’s generally the biggest knowledge curve.”
Companies featured in this article:
