Complex, Chronic Populations: Today’s CEOs must evaluate their options to build care programs, buy them, or shift risk to providers

Landmark Health | February 24, 2020

The medical community has developed innovative and patient-centered ways to deliver care to patients with multiple chronic conditions—through a combination of house calls, telephone support, and telemedicine. Proven, comprehensive in-home medical care models have shown medical loss ratio reductions of more than 20 percent, creating margin for health plans on members that traditionally cause a loss in profit. Participating plans can enhance their Medicare Advantage member benefit packages and improve the well-being of their most vulnerable patients through partnerships with established value-based medical groups.

Most older adults in the U.S. have at least two chronic conditions. One in four senior citizens suffer from behavioral health conditions.1 Many elderly people with multiple chronic conditions frequently seek care urgently from ambulatory services such as urgent care or emergency departments. These urgent visits can lead to unnecessary hospitalizations.

Patients with complex and chronic conditions comprise much of the five percent of patients who make up 50 percent of all health care spending.2 The increasing size of this population is raising health care costs nationally. Mobility issues and difficulty visiting physician offices contribute to the cost of treating this patient population.

Whole-patient care delivery models provide coordinated, in-home routine medical care, 24/7 telephone support, urgent and post-hospital home visits, behavioral health support, social work services, and palliative care. For some organizations, this new delivery model has proven effective in improving longitudinal outcomes that help patients live longer, while reducing medical costs.3

In-home medical care changes the status quo in health care by implementing complex panel management, expertise in delivering in-home medical care, operational excellence, and risk-based partnership arrangements and financial models.

House calls, past and present

Less than 100 years ago, physician house calls made up 40 percent of doctor-patient encounters. What may seem like old-fashioned concept, in-home medical care provides a modern opportunity for providers to deliver patient-centered care to the most vulnerable and frail patients. The house-call model can offer ease of access, a multidisciplinary care team, family involvement, and extra time to discuss health needs and goals.

Because house calls take place in the comfort of the patient’s home environment, they can be more conducive to creating a strong patient-provider relationship. During a house call, providers can actively engage patients in the health care discussion, educate them on their conditions, and ask them how they understand their health status.

The needs of patients with multiple chronic conditions are ongoing and require proactive treatment and diagnoses. To address this, house-call teams of specialists can be specially trained to care for patients with complex needs. Beyond providing medical care, providers can also see to the long-term physical, social, and mental health and well-being of patients.

Regular in-home visits by a multidisciplinary care team can help to:

  • Improve patient access to medical care
  • Identify health conditions and prevent conditions from worsening
  • Detect mental, behavioral, and social needs
  • Address urgent issues and avoid unnecessary hospital visits
  • Educate patients on taking their medications properly
  • Coordinate care and access community services
  • Assess and recommend safety measures (e.g. fall risk)
  • Ensure care aligns with patient goals and wishes

A good in-home medical model includes the integration of medical, behavioral, mental, social, and palliative care.

Barriers to caring for the whole patient

Many patients with complex health needs encounter barriers to even the most basic care. For example, many complex patients:

  • Have difficulty or inability to make it to a doctor’s office
  • Have functional or physical impairments
  • Require palliative or end-of-life care
  • Are not given access to disease-specific management programs
  • Are unaware of community services available to them

By providing the right level of care in the setting most comfortable for the patient, the health care system can improve care and patient outcomes, while reducing the total cost of care.

A patient-centered house call model can provide “wraparound care” – meaning, patients keep their primary care provider and other doctors and specialists. The house calls are provided in addition to the care they receive from their other providers. A patient-centered approach is important to making effective health care decisions and optimizing the patient’s quality of life. At the same time, this approach tends to maximize patient satisfaction and health outcomes.

Goals of In-home Medical Care

Goals of in-home medical care for complex patients should include:

  • Giving complex patients easier access to patient-centered, multidisciplinary care
  • Alleviating social and behavioral issues that can inhibit healthy habits
  • Improving patient satisfaction and quality of life
  • Achieving better patient outcomes
  • Lowering the overall cost of care through prevention, appropriate levels of treatment, and reduction in hospitalizations

Comprehensive in-home medical care of the whole patient can reduce costs through preemptive efforts to reduce unnecessary readmissions, emergency room visits, complications that are avoidable with proper care, and medication errors through regular medication reviews

The aging population is an opportunity to evolve the US health care system to better meet the needs of all Americans. We can reduce the growth in health care spending, while providing high-touch, longitudinal care through disruptive care delivery models.

2. “How Home-Based Primary Care Can Reduce Expensive Hospitalizations” Harvard Business Review. May 16, 2019.
3. “Home-based Primary Care – New standard of care curbs high costs of care for 2 million sick and frail homebound adults”. American Academy of Home Care Medicine and The John A Hartford Foundation. October, 2018.

About the Author

Landmark Health, Author

Landmark Health and its affiliated medical groups partner with health plans and delivery systems to bring in-home medical care to complex and chronically ill patients. The company bears risk for more than 100,000 lives across 13 states. Its value-based model relies on physician-led multidisciplinary care teams available to patients 24/7. These fully employed teams help drive long-term outcomes for patients by bringing medical, behavioral, social and palliative care to individuals, where they reside and when they need it.