‘Eyes In The Home’: ACOs Use Home Visits To Improve Care Management, Identify Needs, And Reduce Hospital Use

More than a half-century ago, it was not unusual for physicians to make house calls. Modern medicine, however, transitioned care from the patient’s home to the provider’s office in an effort to improve efficiency.^1,2 Still, there are advantages to house calls: to offer the patient convenience and safety, help providers build more personal relationships with patients, comprehensively assess patients’ needs, and identify issues related to the home environment.³ Moreover, many patients benefit from more intensive, home-based care,^4,5 and evidence suggests that care provided in patients’ homes can both reduce costs and improve quality.^4–7 Medicare has created new reimbursement models to support home visits for patients who are functionally unable to attend office-based visits.⁸

Home visits can improve the quality of care by easing transitions between care settings, enhancing care management, and helping older patients successfully age at home.^3,9 Home visits can be used for a variety of services and patient populations, such as care management for patients with chronic disease, home-based primary or acute care, postdischarge care transitions, and support for frail patients. Home visits have the potential to reduce spending by preventing readmissions or by helping people with complex needs manage their conditions in lower-acuity (and lower-cost) settings.^7,10 Home visits are particularly useful for addressing unforeseen challenges after discharge, such as those related to obtaining support from caregivers, understanding a care plan, understanding the full spectrum of medications a patient has at home, and making necessary adjustments to the home environment.^4,10

For patients with complex needs, primary care providers may experience challenges implementing home visits because of limitations in the Centers for Medicare and Medicaid Services (CMS) fee-for-service reimbursement model, which has specific requirements for home visit billing under the physician fee schedule—such as the presence of a physician in the home and the physical inability of the patient to attend an office-based visit.⁸ Under alternative payment models—including accountable care organization (ACO) contracts—providers may have greater motivation to improve care delivery for patients with complex clinical needs because they are responsible for the patients’ total cost of care.¹¹ Given the benefits of home visits for patients as well as their impact on costly utilization, ACO providers may be more likely than other providers to implement home visits,¹² even when they cannot be reimbursed under a traditional fee-for-service model.¹³ To better understand the use of home visits, we used national survey data to examine differences in the use of care transitions home visits by ACO and non-ACO practices and to compare characteristics of ACOs that use home visits with those of ACOs that do not. Using qualitative data gathered from ACOs, we describe similarities and differences in how ACOs design and implement all types of home visits—for care transitions and other purposes.

Study Data And Methods

We conducted a mixed-methods study to examine how ACOs implement home visits to care for patients with complex needs. We first used the National Survey of Healthcare Organizations and Systems (NSHOS) to determine whether ACO practices were more likely than non-ACO practices to use care transitions home visits. We then used the National Survey of ACOs (NSACO) to identify the types of ACOs that used home visits. Finally, we interviewed ACO leaders and managers to understand why and how they used home visits.

National Survey Of Healthcare Organizations And Systems

The NSHOS, funded by the Agency for Healthcare Research and Quality and led by the Dartmouth-Berkeley-Harvard-Mayo Clinic Center of Excellence on Comparative Health System Performance, was fielded in June 2017–August 2018. The survey collected nationally representative data from practices with three or more primary care physicians and included information on practice composition, participation in care delivery reform, and care delivery capabilities. We sampled 4,976 practices, identified using a commercial database, OneKey, that was developed by IQVIA. OneKey uses proprietary approaches, data from the American Medical Association Physician Masterfile, and publicly available information to characterize relationships among providers and organizations.¹⁴ We obtained 2,333 eligible responses, for a response rate of 47 percent. The target respondent was a medical director, physician, or practice manager.

We used data from the NSHOS to identify practices that used care transitions home visits for patients with complex health needs, stratified by self-reported current or prior ACO participation.

National Survey Of Accountable Care Organizations

The NSACO, conducted by Dartmouth College, is a survey that describes the structure, contracts, and capabilities of ACOs. We used data from NSACO wave 4, fielded in 2017–18. The response rate was 55 percent, and 48 percent of the respondents completed at least half of the core questions. There were significant differences in response rates by payer type: 69 percent of Medicare ACOs responded, compared to 36 percent of non-Medicare ACOs. We defined ACOs as groups of providers who voluntarily and contractually assumed responsibility for the total cost and quality of care for a defined patient population.¹⁵ The target respondent was a senior leader in the ACO, such as the CEO, chief medical officer, or director. For Medicare ACOs, we linked data from the NSACO to publicly available shared savings and quality data from CMS^16,17 (see “Performance and quality data linkage for ACOs” in the online appendix).¹⁸

We used data from the NSACO to compare the characteristics and, for Medicare ACOs, the performance of ACOs that used care transitions home visits for at least some patients (that is, ACOs that used the visits for all, most, or some patients) within seventy-two hours after discharge with the performance of those that did not use home visits.

We compared physician practices that did and did not use care transitions home visits by ACO status, and ACOs that did and did not use care transitions home visits. For analyses using NSHOS data on physician practices, we used weighted logistic regressions by ACO status to test the significance for each characteristic. For analyses using NSACO data, we used $t$-tests to test significance.

Interviews With Accountable Care Organization Leaders

To understand care processes, including the use of home visits for patients with complex health needs, we conducted thirty-nine semistructured interviews across eighteen ACOs. We defined patients with complex needs as those with chronic conditions, social needs, or behavioral illness and the frail elderly. We first interviewed an ACO leader such as the director, chief medical officer, or other executive-level person. Collectively in eleven ACOs, we conducted an additional twenty-one interviews with people who had on-the-ground experience, such as care managers, directors of care management, and practice leaders (see “Semistructured interview participants” in the appendix).¹⁸

Interviews were conducted via telephone in the period February–June 2018. All interviews were recorded, transcribed, and then analyzed using QRS NVivo software. ACOs were selected from respondents to the NSACO to ensure diversity in terms of geography, composition, leadership, and payer. All had a Medicare contract and had achieved shared savings in at least one year, and thirteen had at least one additional contract with a commercial or Medicaid payer (see appendix exhibit 4).¹⁸ The semistructured interviews lasted approximately one hour and focused on the ACO structure, leadership, engagement with participating practices, and approaches to caring for patients with complex health needs (see appendix exhibit 3).¹⁸

We defined home visits as any encounter between a care team member and a patient that occurred in the patient’s home. We used this broader definition to capture all home visit activities. Home visits could be conducted by any ACO employee or a representative of a partner organization. We excluded services that were home-based nursing, such as those provided by home health agencies, and services that were a replacement for office-based primary care. Twelve of the eighteen ACOs whose staff members we interviewed used home visits.

Our analytic approach was collaborative and iterative.¹⁹ Transcripts were first coded by a research assistant and then coded unblinded by the first author, after which any coding discrepancies were discussed and resolved. We developed a memo of observed themes based on initial coding. We included examples to support each theme and justified the inclusion or exclusion of each ACO in a given theme. The memo was then iteratively revised based on team discussions.

Limitations

Our study had some key limitations. First, most of our data were from the perspective of the organization’s leadership rather than that of patients or providers within the organization.

Second, while both the NSACO and the NSHOS had high response rates, there could be systematic differences between respondents and nonrespondents.

Third, qualitative data are not meant to be generalized. Rather, they provide context for how some ACOs use home visits.

Fourth, the interviewed ACOS might not have given us information on all of their activities related to home visits.

Study Results

Of the surveyed practices, 69.3 percent reported being part of a Medicare, Medicaid, or commercial ACO (data not shown). Practices in ACOs were more likely than practices not in ACOs to report using postdischarge care transitions home visits for their complex patients (25.7 percent versus 18.8 percent; $p=0.029$). (Exhibit 1 shows these percentages but not the significance testing for the comparison.) Among ACO practices, more of those in an integrated delivery system reported using care transitions home visits, compared to those not in such a system (71.6 percent versus 61.6 percent) (exhibit 1).

While only 25.7 percent of practices in ACOs said that they made home visits during care transitions for patients with complex health needs (exhibit 1), 79.6 percent of ACO leaders reported that their ACO used care transitions home visits within seventy-two hours of discharge for at least some of their patients (exhibit 2). For Medicare ACOs, 82.0 percent reported using care transitions home visits, compared with 86.7 percent of Medicaid ACOs and 79.6 percent of commercial ACOs.

ACOs that conducted home visits had, on average, more primary care and specialist physicians. They were more likely to be part of an integrated delivery system and include a hospital and were more likely to report participation in episode-based payment (50.8 percent versus 38.8 percent) and other risk-bearing contracts (52.5 percent versus 30.2 percent).

Among Medicare ACOs only, we observed no significant differences in quality scores or likelihood of achieving shared savings between ACOs that used care transitions home visits and those that did not (exhibit 3).

Home Visit Approaches

ACOs most often conducted home visits as part of a larger care management, care transitions, or condition management program that could include a variety of services and patient populations. A few ACOs used home visits as a foundational element of their care management, and they tried to conduct home visits with every qualified patient as one of their first care management activities—typically after a hospital stay. One ACO executive said: “If they engage with care management, then we have a pharmacist, and a nurse, and a social worker, and an MA [medical assistant] to go to the home, and they try to do that within seven days of a [hospital] visit. And they do their nursing assessment, they reconcile medications, they look for various challenges that the patient might have—any concerns they have in the home.”

Some ACOs used home visits as needed within their care management programs when, for example, there was concern about a patient’s safety or falls risk. An ACO manager said, “There are times that the care manager through the comprehensive assessment may get the red flags, as we commonly see, where something’s just not quite right, so there are times that the care manager will schedule a home visit.”

Some ACOs conducted home visits informally rather than as part of a structured care management program. For example, some ACOs used home visits to contact patients who had not responded to other methods of communication or when concerned about a patient’s welfare.

Patients Receiving Home Visits

Patients who received home visits were those considered clinically or socially complex. Clinical complexity was based on recent hospital use, multiple chronic conditions, or complex single conditions as part of a disease management program. Socially complex patients were described as those who were nonresponsive or noncompliant. For example, the care manager might have called the patient several times without making contact. ACOs used several methods to select patients for home visits, ranging from provider referrals to use of algorithms and identifying high utilizers of hospital-based care.

Motivations For Home Visits

ACOs reported three motivations for home visits: to see the patient’s home to identify unmet needs, reconnect patients perceived to be nonresponsive with office-based care, and build relationships with patients. ACOs that did not conduct home visits through a care management program were more likely to use home visits to locate a patient than as part of a care management program.

Activities During Home Visits

ACOs reported three main activities during home visits: needs assessment, medication reconciliation, and identifying patient barriers to effective or engaged care. Nearly all ACOs said that they used home visits to assess the patient’s living situation and get “eyes in the home,” as one ACO manager said. Needs assessments included evaluating the cleanliness and safety of the patient’s home, assessing the patient’s support system, and identifying social needs. An ACO executive said: “When you go in, that’s where that whole discovery starts…. With permission, they’ll look in the refrigerator, they’ll look to see that the patient has food or that the area that they’re living in is safe to get around in. Are we dealing with a home that is infested? So there’s a whole lot of things. You have to be somewhat of a detective and have your eyes and ears open when you’re going in those initial visits and trying to figure out what that patient needs.”

Some ACOs said that medication reconciliation was a major part of home visits. At one ACO, this involved collecting all medications and then reviewing each one with the patient.

Some ACOs used home visits as patient coaching opportunities, such as providing the patient with resources for managing chronic conditions (for example, teaching heart failure patients to weigh themselves daily) and instructing them about whom to call in various situations (such as when patients should call their care manager). Coaching focused on strengthening the relationship between the care team and the patient. An ACO executive said: “[We try] to get them to understand how we work and what our expectation is. We want to be there. We want to answer the phone for you. We want to get you what you need.”

Care Team Members Who Conducted Home Visits

Home visits were typically conducted by care management or nonphysician staff members—nurses, social workers, health coaches, pharmacists, or staff from government or community agencies. People varied not only in terms of their titles, but also in terms of their backgrounds and training. No ACOs reported using physicians for home visits.

Discussion

Physician practices that participated in an ACO were more likely than non-ACO practices to report using home visits, and 80 percent of ACO leaders reported using home visits for some complex patients. ACOs that implemented care transitions home visits were more likely to be larger and part of an integrated delivery system. This may be due to the high financial and staffing costs associated with starting a home visits program.

ACOs repeatedly stressed that the value of home visits was to gain information on a patient’s needs and home life.

Home visits are an evidence-based intervention, found to improve outcomes and reduce spending for patients with chronic conditions and those discharged from the hospital, and to support aging in place for the elderly.^5,6,20,21 Interviewed ACOs reported using home visits for each of these patient cohorts and others—even though they may have very different clinical needs. Contrary to our expectations, ACOs reported similar motivations for and activities during home visits across patient populations, but it is not clear that this uniform approach is effective. ACOs used home visits for a broader set of goals than typically discussed in the literature, such as relationship building, finding barriers to care engagement, and identifying reasons for noncompliance. ACOs repeatedly stressed that the value of home visits was to gain information on a patient’s needs and home life.

Our finding on the use of home visits by ACOs to locate and seek to understand noncompliant patients illustrates the impact of policy reform models on care delivery approaches. ACOs are responsible for the quality and cost of services for attributed patients, even those who cannot follow medical advice such as participating in care management or going to primary care visits.¹¹ This accountability may have driven ACOs to track down patients more aggressively and use home visits as one tool to engage patients and discover care barriers.

While only a quarter of the practices participating in ACOs reported using home visits, 80 percent of ACO leaders reported using home visits for some patients. This discrepancy may be due to implementation processes. For example, home visits may be implemented by ACO-level centralized care management programs that are largely independent of the practices within the ACO, so that practice leaders may have limited knowledge of home visits. Or ACOs may implement home visits in some practices and not others.

Despite the value perceived in home visits, ACOs experienced challenges such as reimbursement, staffing capacity, and an inability to address identified social needs. Our finding 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. These organizations may need further financial or logistical support to implement home visits.

An interesting question is what is the “right” population for home visits. Evaluations of home visits have focused on the postacute care episode, independent living programs, and patients with chronic conditions.^4,5,21 Despite the unique clinical needs of each of these populations, interviewed ACOs described remarkably similar activities during different types of home visits. ACOs perceived value in home visits for a large population of patients, but the group for whom the benefits outweigh the costs may be smaller. Most home visits were conducted by nonphysician care team members, typically a care coordinator or nurse. Identifying the right team to complete home visits, the best patients to focus on, the ideal services suited for home visits, and the optimal workflow to incorporate home visits are questions that need ongoing research.

Policy makers and others should be aware that, given the intense resources needed for home visits, organizations may struggle to systematically implement care delivery programs with home-based components. Interviewed ACOs typically used care coordination staff members rather than physicians, nurse practitioners, or physician assistants to conduct home visits, which limits their options for reimbursement for services provided in patients’ homes.⁸

CMS allows physicians to bill for home visits. However, visits must be used for patients who are not functionally able to have an office visit.⁸ Most of the home visits described by ACOs would not qualify for reimbursement from CMS using home visits billing. ACOs could bill CMS for home visits using Chronic Care Management codes, but meeting the requirements is often challenging.²² Policy makers and administrators should continue to align reimbursement with evidence-based care innovations such as home visits.²³

The arc of home visits over time is fascinating: Visits were moved into physicians’ offices as a way to make doctors more efficient.²⁴ Now, under new payment models, services are being moved to the lowest-intensity setting possible, including the home.²⁵ It remains uncertain whether providers will be able to offer home visits in all cases where patients could benefit.

ACKNOWLEDGMENTS

Part of the qualitative analysis in the article was presented at the AcademyHealth Annual Research Meeting in Washington, D.C., June 2, 2019. The authors are grateful for support from the Six Foundation Collaborative, whose members are the Commonwealth Fund (Grant No. 20171072), the Peterson Center on Healthcare (Grant No. 18011), the Robert Wood Johnson Foundation (Grant No. 74883), the SCAN Foundation (Grant No. 17-013), the John A. Hartford Foundation, and the Milbank Memorial Fund. Wave 4 of the National Survey of Accountable Care Organizations was supported by the Commonwealth Fund (Grant No. 20160616), the National Institute of Mental Health of the National Institutes of Health (Grant No. R01MH109531), and the California Health Care Foundation (Grant No. 20249). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. This work was supported in part by the Agency for Healthcare Research and Quality’s Comparative Health System Performance Initiative (Grant No. 1U19HS024075), which studies how health care delivery systems promote evidence-based practices and patient-centered outcomes research in delivering care. For this work, Adam Briggs was a Harkness Fellow funded by the Commonwealth Fund. The views presented here are those of the authors and should not be attributed to the Commonwealth Fund or its directors, officers, or staff. The statements, findings, conclusions, views, and opinions contained and expressed in this article are based in part on data obtained under license from IQVIA information services (OneKey subscription information services 2010–17, IQVIA Inc., all rights reserved). The statements, findings, conclusions, views, and opinions contained and expressed herein are not necessarily those of IQVIA Inc. or any of its affiliated or subsidiary entities. The American Medical Association (AMA) was the source for the raw physician data; statistics, tables, and tabulations were prepared by the authors using data from the AMA Physician Masterfile.

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