The Government's Secret to Living Longer


NEW YORK (MainStreet) — On a recent home visit to see a frail 93-year-old female patient, co-founder and chief medical officer of Doctors Making Housecalls Dr. Shohreh Taavoni determined, after ordering Doppler ultrasound studies, which also took place in the patient's home, that her patient's swollen leg resulted from deep venous thrombosis, a potentially dangerous blood clot. Treatment – anticoagulants -- also took place at home, as did monitoring of the patient with the same laboratory studies typically available only at hospitals.

Doctors Making Housecalls is one of 15 independent practices and three consortia in 17 states participating in the Centers for Medicare & Medicaid Services (CMS) Independence at Home program. Home visits under the three-year "demonstration" began in 2012.

The Independence at Home program focuses on providing long-term primary care management to Medicare patients with complex medical histories in home settings to determine if doing so improves their care and reduces costs. The idea is to treat medical problems before they progress and require a visit to the emergency room or hospitalization.

Elderly people who have complex medical conditions often have a difficult time connecting with a doctor, because they are homebound or have no transportation, so they wait until there is a crisis to seek medical attention, explains Alan Kronhaus, who heads up Doctors Making Housecalls in North Carolina. He says that they get most of their care from emergency room visits and acute care hospitals, which are the most dangerous settings for this population. Kronhaus points out that studies show high rates of hospital acquired infections, falls, trauma, sundowning (where elderly patients get agitated and confused in their new surroundings, typically as the sun sets) and cognitive decline, even if there are no adverse events, among this population.

"By visiting patients in their homes, you get insights that are invisible during a routine office visit," says Ina Li, M.D., the associate director of geriatrics and the medical director of the Visiting Nurse Association at Christiana Care. "Through our visits, we are able to learn how patients are living with their medical conditions, how they are using their medications, their lifestyles and support system."

The CMS demonstration is funded by the savings it achieves. It grew out of a similar program created by the Veteran's Administration, which saved the department 24% and is now available to vets nationwide, says Constance Row, executive director of the American Academy of Home Care Physicians.

To participate, you must have two or more qualifying chronic conditions, be covered by the original fee-for-service Medicare, need assistance with at least two "functional dependencies," such as walking and eating, have been hospitalized in the last 12 months and have received rehabilitation services in the last 12 months.

The CMS demonstration is also testing the shared savings concept, Kronhaus says. Participating doctors and nurse practitioners must reduce costs by 5%, improve patient outcomes and in return receive a share (up to 80%) of the savings beyond the 5%.

In order to reap the benefits, though, patients or caregivers must be satisfied with their work.

Kronhaus says that if it proves positive, the demonstration will probably be made a permanent Medicare benefit. And, so far, Kronhaus reports that the demonstration "is enormously effective" both in terms of cost savings and showing improvement of quality of care.

Home visits saves money by lavishing care rather than limiting care, Kronhaus points out.

The program has just begun its second year and has not yet been fully evaluated by CMS to determine the next steps.

"We see no reason to delay what is obviously beneficial," Kronhaus says. He projects that the demonstration will probably show cost savings in the neighborhood of 15% to 20%. It's the only thing that shows it actually works without rationing care, he says.

--Written for MainStreet by S.Z. Berg, author of College on the Cheap

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