A new Dartmouth-led study, published this week in the June issue of Health Affairs, offers new details about how one key approach--home visits--is helping many ACOs improve care management and identify patient needs while aiming to reduce hospital use. The study was part of a broader set of research based at Dartmouth focused on how ACOs care for patients with complex clinical and social needs.
ACOs--groups of physicians, hospitals, and other healthcare providers who voluntarily form partnerships and agree to take responsibility for meeting certain quality and total costs of care measures--may employ a variety of strategies, approaches, and processes to meet their goals. Over the past decade, they have played an increasingly prominent role in efforts to reform the American healthcare system.
"We focused on ACOs because we felt that their responsibility for total costs of care might motivate them to implement care delivery innovations that otherwise might be too resource-intensive," explains lead author Taressa Fraze, PhD, a research scientist at The Dartmouth Institute for Health Policy and Clinical Practice.
The researchers used national survey data from physician practices and ACOs, paired with qualitative interviews with 18 ACOs across the country to learn more about home-visiting programs.
They found that the majority of ACOs believed that home visits were valuable--80 percent reported using home visits within 72 hours of post-discharge for at least some of their patients. These ACOs were more likely to be larger and part of a system, including a hospital, and to participate in risk-bearing contracts or other payment reforms. They also found that physician practices with ACO contracts were more likely to report using home visits for care transition than non-ACO practices.
Home visits were typically embedded as part of a larger care management, care transition, or disease management program. "ACOs used home visits much more broadly than we might have expected, and they were usually conducted by a care management team member rather than a clinician," says Fraze, who is presenting the study's findings this week in Washington, DC, as part of a national panel discussion on community care for high-needs patients.
"These visits were not focused on providing clinical care," she emphasizes. "At their heart, they were essentially a fact-finding mission--described by several ACOs as providing 'eyes in the home.'"
The three most commonly reported activities during home visits were: needs assessments, which included inspecting the patient's home; medication reconciliation; and identifying patient barriers to managing their health. These activities provided staff members with an opportunity to coach patients on how to manage their health needs.
Interestingly, the researchers also found that home visits functioned similarly across different patient cohorts--patients who were post-discharge, for example, had similar home visits as those with social risks or specific chronic conditions.
"One of the things that was quite unique about ACOs, and that we really didn't expect, was that several used home visits as a way to locate patients, such as those who might have missed their primary care appointment, were unresponsive, or if the ACO was concerned that the patient might be at especially high risk for costly utilization," Fraze says.
However, despite the value perceived in home visits, ACOs continued to face challenges such as reimbursement, staffing capacity, and the inability to address observed patient needs.
"Our findings that larger and system-based ACOs were more likely to implement resource-intensive home visits creates concerns about the ability of smaller, independent practices and organizations to use home visits as a tool to engage patients and discover barriers to improved care," she says. "These organizations may need further financial or logistical support to implement home visits."
This study received support from the following funding organizations: Six Foundation Collaborative (which includes the Commonwealth Fund, the Peterson Center on Healthcare, The Robert Wood Johnson Foundation, SCAN Foundation, John A. Hartford Foundation, and the Milbank Memorial Fund); National Institute of Mental Health of the NIH; the California Health Care Foundation; and the Agency for Healthcare Research and Quality's Comparative Health System Performance Initiative.
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