Opportunities in Value-based Care: In-home health care may revolutionize safe care delivery for complex populations

Landmark Health | April 6, 2020

The coronavirus pandemic has shined a glaring spotlight on cracks in our healthcare system. Older adults age 65 and up with chronic conditions are at heightened risk of serious complications or death related to COVID-19, and are told – along with everyone else – to stay home and shelter in place.1 However, these complex patients need to proactively manage their conditions, or risk an exacerbation that will land them in a healthcare facility dealing with the pandemic.

Specific to COVID-19, a study published in The Lancet found that out of 32 patients who were intubated for the coronavirus, 31 died (Zhou et al 20202). However, on a more promising note, another recent study out of Evergreen Hospital in Washington State found that the survival rate with intubation could be a little higher (Arentz et al 20203). A third study of 24 patients across nine Seattle-area hospitals showed a survival rate for patients on a ventilator for COVID-19 to be around 30 percent (Bhatraju et al 20204).

Ventilators can be burdensome for older patients even without coronavirus. For people over 65 who require emergency ventilator use, about one in three die in the hospital (Ouchi et al 20185). A related study showed that for elderly people who survive an illness requiring a ventilator, about 7 in 10 die within the next year (Barnato et al 20116). Beyond simple survival, the chance of recovery to the former quality of life is low.

For this complex population, new care delivery models can limit a patient’s exposure to the virus, while addressing assessment and treatment needs.

Telehealth Helps Facilitate Patient Assessments and Social Support

Last month, the Trump administration expanded telehealth services to allow Medicare patients to connect with providers by phone or videoconference using services such as FaceTime, Skype and What’s App. This unprecedented change allowed older adults to quickly shift from in-person medical visits to virtual visits. This change helps in the quarantine effort, while allowing providers to continue to assess and triage care needs.

The value of telehealth extends beyond needs assessments, especially in times of social isolation. A virtual connection can be a lifeline to someone living alone or a caregiver managing the needs of another. Psychiatric evaluations, medication recommendations, and social work support and services can all take place via a video visit.

Condition education, diet and lifestyle advice, fall hazard recommendations, along with other coaching services can be completed via telehealth. With proper in-home medical devices – such as a pulse oximeter, blood pressure cuff, body weight scale – providers can remotely monitor key vitals for daily health checks to know quickly if medical care is needed.

In-home Medical Care Addresses High-touch Needs

There are limitations to the care medical providers can deliver by telehealth. A patient with COPD may need breathing treatments or steroid medications. A patient experiencing dehydration may need IV fluids. A patient retaining fluid may need Lasix treatments. Even a minor accident while preparing dinner may require stitches. These high-touch medical needs require in-person treatments, and home-based medical services can easily address these scenarios with the patient never leaving the comfort of home.

The value of treatment in place has always been around convenience, comfort and accessibility for those homebound, home-limited or without convenient transportation. But considering the current pandemic, treatment in place helps protect patients from exposure to the coronavirus and helps keep hospital beds open for those fighting the disease.

Current Opportunities for New Care Delivery Models for Complex Patients

Modern medical models are moving beyond the constraints of fee-for-service payment. Value-based care through shared risk arrangements makes longitudinal in-home medical care financially feasible, while improving patient satisfaction and outcomes. Aligning the incentives between provider and payer has been found to be most effective in achieving the best quality and cost outcomes.

Done correctly, in-home medical care with telehealth can deliver:
↓ 15-25% Utilization Reduction
↓ 20-30% Medical Loss Ratio Reduction, across a complex cohort
↑ 10-15% Risk Adjustment Factor Increase, across a complex cohort
↑ Improved HEDIS star ratings increase

Additionally, high-touch programs that offer more provider-patient visit time can improve primary care provider access, provider satisfaction and an enhanced patient experience.

In-home medical care delivery for older adults should encompass:
• Physician-led geriatric medical groups dedicated to ongoing clinical training on chronic disease management.
• Palliative care expertise to bring patients support and comfort, drive advance care planning, and offer appropriate and timely referrals to hospice.
• Clinical documentation that goes beyond an annual evaluation, and offers an ongoing comprehensive assessment of physical, behavioral and social health to determine an appropriate acuity for care needs.
• Comprehensive care plans communicated and coordinated with patients’ other physicians.
• In-home visits within 72 hours of hospital or skilled nursing facility discharge.
• Provider-staffed call centers for 24/7/365 urgent triaging with ability to deploy clinical team members as needed.
• Sophisticated analytics and technology-enabled teams to bring the right care, to the right people, at the right time, in the right manner.

The Future of Medical Care Delivery

The questions on many CEOs’ minds are—How do I bring the right care to patients in the appropriate setting? Can avoidable spend be managed during the pandemic while keeping our patients and communities safe? The combination of in-home medical care services and periodic telehealth offers a solution to both questions. These care delivery models have been seeing rapid expansion in the U.S., and growth in the immediate future should now be expected. However, high coordination among these efforts, along with a patient’s complete healthcare network, will be paramount to the success of a care delivery model that meets the needs of older adults, and that of our aging population in general.

2. Zhou, Fei, et al. “Clinical Course and Risk Factors for Mortality of Adult Inpatients with COVID-19 in Wuhan, China: a Retrospective Cohort Study.” The Lancet, vol. 395, no. 10229, 2020, pp. 1054–1062., doi:10.1016/s0140-6736(20)30566-3.
3. Arentz, Matt, et al. “Characteristics and Outcomes of 21 Critically Ill Patients With COVID-19 in Washington State.” Jama, 2020, doi:10.1001/jama.2020.4326.
4. Bhatraju, Pavan K., et al. “Covid-19 in Critically Ill Patients in the Seattle Region — Case Series.” New England Journal of Medicine, 2020, doi:10.1056/nejmoa2004500.
5. Ouchi, Kei, et al. “Prognosis After Emergency Department Intubation to Inform Shared Decision-Making.” Journal of the American Geriatrics Society, U.S. National Library of Medicine, July 2018,
6. Barnato AE et al. Disability among Elderly Survivors of Mechanical Ventilation. Am J Respir Crit Care Med. 2011 Apr 15; 183(8): 1037–1042. Parotto & Herridge. (2017) Outcomes after 1 week of mechanical ventilation for patients and families. ICU Mgmt & Practice, 17, 174-176. “Mechanical Ventilation”.

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.