It’s easy to be risk-adverse in the homecare industry. Small mistakes can cost your company big when it comes to patient care and satisfaction. But some companies leverage risk-based approach to care in the home that’s bringing more value to patient care.
HomeCare sat down with Dr. Julian Harris, chairman and CEO of ConcertoCare, one provider of risk-based homcare, to talk about value in home health and how technology can help manage company risks.
HOMECARE: The Medicare Improvements for Patients and Providers Act (MIPPA) opened the door for value- and risk-based health care. How is ConcertoCare balancing risk in home health?
JULIAN HARRIS: A concerto has been called a “conversation between a soloist and an orchestra.” At ConcertoCare, we deploy an interdisciplinary team of providers—our orchestra—in support of patients who would benefit from having access to an intensive model of care in the home. In certain cases, services are delivered by our own clinicians, and in other cases, we partner with other providers. In all of our markets, home health agencies are key partners for us as we look to ensure that patients have access to an integrated model of care. As a former policymaker at both the federal and state levels and as a former health plan executive, it’s been exciting to see how much government and the private sector have collaborated to accelerate the shift towards value-based care.
At ConcertoCare, we deliver the kind of integrated and value-based in-home care needed to improve patient outcomes for adults with complex health and social needs, all while reducing cost and risk. And because we are a direct care provider with the ability to serve as the primary care physician of record for our patients or to partner in support of their existing primary care providers, we offer a full range of in-home care capabilities that allow us to keep patients out of the hospital and in the comfort of their own homes.
This means we offer a full spectrum of services outside of hospitalization. We do all we can to keep patients home and well, not just physically, but also mentally and emotionally.
HOMECARE: What are some of the ways home health agencies can provide value in health care?
HARRIS: One of the key ways health agencies can provide value in health care is to expand the notion of health to include social determinants in the assessment and treatment plans for their patients. This has been a core factor and a growth driver of the ConcertoCare model and a core motivator for me throughout my career.
As a clinician I worked in a community health center where I was treating patients who had challenges getting access to food, housing, transportation and economic opportunity. This made me passionate about ensuring that we consider patients’ holistic care needs. That set of social determinants of health, I think, has gained much greater currency of late.
However, I think health providers need to recognize that loneliness and isolation are also key social determinants of health. In some ways, COVID-19 brought greater focus to this as a challenge, but in practice for seniors, it isn’t a new phenomenon. We spend a lot of time addressing how to engage our patients and find social opportunities for them, whether that is virtually or in person.
During my grandmother's illness, at one point she stopped talking, and we couldn't quite figure out why. I was a medical student at the time and had recently learned that patients who suffer from dementia can also suffer from depression. We decided to have her screened and ultimately treated for depression, and once we did, she started talking again. To think that we lost my grandmother's voice for two years was such a painful experience. But it illustrated to me, personally, the importance of recognizing all of the physical and behavioral aspects of care that are needed to enable patients to stay in their homes. It’s not solely physical health that needs to be addressed in comprehensive care, but rather all aspects of health, including the mental, emotional and unmet social needs of patients.
HOMECARE: How does technology support better care planning? How does this help with risk?
HARRIS: There are some companies that might give people the impression that for this very complex population, technology is replacing rather than enhancing work that we can do with human beings on the ground in the home. While there is a key role for technology in the work that we do or the patient population that we serve, we believe that having an intensive in-home model is key to helping these patients maintain their health and wellness and their independence. We have a combination of very deep clinical geriatrics expertise across our care model, from home-based primary care to the Program of All-Inclusive Care for the Elderly (PACE), allowing for empathetic and human-first care. But we also have a deep expertise around data analytics and mental health.
We’ve found that many traditional electronic medical records (EMRs) don’t allow for accessibility, transparency and coordination across providers and clinicians. Meaning, the lines of communication between different providers are often broken and the responsibility of coordinating care is on the patient and/or their family. Patient3D is meant to mitigate this by allowing for a 360 view of all a patient’s recent visits so providers are aware of every detail of a patient’s condition and treatment. This level of integrated tech enablement ensures our care teams can focus on what matters most—delivering the kind of human-first care we would desire for our own family members. And the impact is real and measurable—our model consistently delivers improved outcomes and produces an average net promoter score (NPS) in the mid to high 90s.
HOMECARE: How has ConcertoCare built a model that supports value in health care?
HARRIS: Health care for adults with complex needs is often fragmented with little coordination between primary care, specialists, behavioral health and social services. This leaves many patients and family members frustrated and disheartened.
This is the issue we set out to solve.
We’ve orchestrated a human-first, tech-enabled approach to meet the care needs of geriatric and high-risk adult patients through comprehensive in-home care that leverages our proprietary technology platform, Patient3D, and a combination of intensive virtual and in-person supports.
Like a concerto—composed and performed in three movements—we offer three programs for seniors:
1. ConcertoCare Partners
2. In-Home Primary Care Provider
3. Program of All-Inclusive Care for the Elderly (PACE) Services
We offer our three models of care in six states across the United States, and are quickly expanding to new geographies. ConcertoCare Partners and our in-home primary care services provide in-home care supported by a team of clinicians, including pharmacists, behaviorists, social workers, and home health aides. We also offer ConcertoPACE services through both local PACE centers and in-home care. Telehealth supports all three of our care programs.
Each is orchestrated to improve patients’ health outcomes and quality of life, enabling our patients to maintain their health, independence and happiness in the home, while providing peace of mind for their loved ones.
Our expert care teams address the multidisciplinary needs of our patients with personalized treatment plans including clinical care, behavioral health and social services. This includes everything from intensive health services to helping to coordinate patients’ meals and transportation, as well as counseling visits. We also work closely with other providers caring for patients, including local home health agencies in all of the markets where we work.
HOMECARE Any thoughts on the future of the home health industry?
HARRIS: COVID-19 drove quite a bit of disruption across the health care ecosystem, and especially accelerated provider comfort with telehealth and home-based models of care. We’ve learned a lot about which categories of providers can conduct telehealth visits effectively (most) and how to think flexibly about leveraging providers across state lines, which has been and can continue to be beneficial for those with limited access to health care. We’ve also learned more about how to effectively deploy remote patient monitoring.
In addition to supporting patients post-discharge, there is a growing recognition that home health providers—leveraging remote patient monitoring (RPM) and working in collaboration with physicians and nurse practitioners (NPs) via telehealth—have a unique role to play in helping patients receive hospital-level care in their homes.
In many cases, they can also enable patients who might have historically been discharged to a skilled nursing facilities (SNF) to transition to the home. COVID-19 accelerated the focus on hospital-at-home, with the Centers for Medicare & Medicaid Services (CMS) and other payers recognizing the vital role that this model of care can play.
Home health agencies can also partner with Medicare Advantage plans and value-based organizations like ConcertoCare in support of our collective efforts to enable patients to maintain their independence and to receive a diverse array of care in the home.
The bottom line is that there are ways to think flexibly about the technology platforms that we use, all while ensuring that we have the right kind of protections in place for patients. I hope that we build on that foundation and find other ways to make sure we are expanding that access to care by leveraging telehealth and RPM, particularly in areas where we still have gaps.
Additionally, I believe we’ll continue to see significant growth in PACE in the years ahead, and likely will see health care providers leveraging PACE insights to develop new care models for patients who aren’t PACE-eligible. There are elements of the PACE model that innovative Medicare Advantage plans could have the flexibility to implement on their own. That’s part of what is exciting about this moment.
There is also the opportunity within the CMS Direct Contracting Model for providers to think creatively about new care models and to invest in care models that they may not have been able to offer historically in original Medicare. And, increasingly, we are seeing new and innovative models of value-based care for dual-eligible patients with Medicare and Medicaid for patients who have complex needs in the Medicaid program.
Most important, in the end, is to serve the patient and put their needs first. If we do so and think about them holistically across their medical, behavioral, long-term social services and supports, and unmet social needs, we would radically transform the experience and outcomes of care for patients who need it the most. We would impact communities that have been historically underserved and have a meaningful impact on health equity. And we would take a human-first, tech-enabled approach to delivering care.
If that sounds a lot like ConcertoCare, that’s because we are leading a movement with a very simple goal: to make health care work for the patients who need it the most and in the place where they are often best served: in their homes.
