Home-Based Primary Care Program for Home-Limited Patients

Abstract

Home-based care includes both short-term and long-term models, and serves the most vulnerable individuals in our society. This chapter reviews home-based primary care (HBPC). HBPC has evolved from an era when solo practitioners made episodic visits to patients at home; now teams of professionals deliver and coordinate longitudinal medical care of medically complex, frail individuals. These teams link with the broader system of long-term services and supports to enhance the effectiveness of those services to maintain individuals in the community. Some organizations like the Department of Veteran Affairs provide large, internally funded teams, while other core teams are leaner but link to many community services. Academic house call programs are a key resource in developing service models and training the future workforce. HBPC for sick patients is costly, so targeting to those at highest risk is crucial for cost-effectiveness. Recent reports indicate potential for annual overall health care cost savings of 15 % or more. Teams with close ties to community long-term support services have also substantially reduced long-term institutionalization and Medicaid expenses. Yet the nearly four million Medicare home visits billed in 2012 represent perhaps 20 % of the needed volume based on estimates of community population health, assuming that we provide truly evidence-based and patient-centered care. Funding the cement that holds these teams together is challenging under fee-for-service payment. New models linking service models and aligning funding based on value are appearing including the Independence at Home demonstration that uses a shared-savings model to extend HBPC to frail elders throughout the community.