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● Thought Leaders: Care Management

Benefi ting from the changing nature

By Kelly Monical T

he concept of home visits is not new, and they are often called home assessments. A health plan sends a healthcare provider into a member’s home to address certain care needs. Often, these interac-

tions have been thought to focus less on providing optimal patient care and more on optimizing risk scores for signifi cant fi nancial return for the health plan. As technology evolves and health plans are better able to

analyze and segment their member populations, some health plans are becoming more deliberate in their use of home assess- ments. T ey are running data analytics (such as those provided by Outcomes Health) to identify those patients who have several chronic conditions and may not have recently seen their primary care physician. T ese patients are often at risk for adverse events, such as severe asthma attacks, spikes in insulin, falls and so on. By providing a home visit, health plans and physicians can address the immediate care needs of these members. T e clinician can determine whether the member has the

necessary tools and capacity to care for his or her own health, create a care plan and schedule follow-up appointments. T e clinician acts as an extension of the physician’s practice, oftentimes making arrangements for transportation to the offi ce, spending time getting to know the member and preparing information for the provider. T e report generated from the home visit can be particularly

valuable for physicians. T is document paints a comprehensive picture of a patient’s health, detailing the patient’s current medical conditions, medication adherence regimen, environment and care needs. T is report is created by leveraging technology to gather data from multiple sources – including any healthcare claims data and reports from the Centers for Medicare and Medicaid Services (CMS) – and marrying that data with information from the environmental assessment and other results from the one-hour interaction with the patient during the home visit. By bringing all this information together in a convenient package, the health plan can off er clear, concise and patient-specifi c data to the pro-

24 May 2013

vider. T e providers use this valuable information to help make important decisions about patients’ plans of care. T e report can be delivered electronically or as a paper document, depending on where the provider is along the technology continuum. Providers may not be able to obtain this breadth of detail about a patient in an offi ce setting. Most providers only have access to patient-provided information obtained during a short appoint- ment. To develop a picture of the patient’s health and care needs, the provider is completely reliant on what the patient remembers to say during the appointment and any information sent by other physicians. So, if the patient forgets to mention a visit to the car- diologist, the primary care physician has no way of knowing one actually occurred, unless the cardiologist sends a report. T e home visit report, on the other hand, includes more than just what the patient describes during an offi ce visit. It relays to the provider how the patient lives day to day, off ering a fuller medical history and health status. For example, a report may reveal that the patient said they saw a cardiologist six months ago when they had chest pains during a family vacation in another state, and they need a follow-up appointment to manage this condition. It may also note some risks in the patient home, such as a Parkinson’s patient who does not have shower rails in the bathroom to prevent falls. T is unique level of detail gives the provider a better sense of the patient’s overall health status so they can be proactive and take action to help resolve issues when necessary. T en when the physician sees the patient in the offi ce, he or she has a leg up on what the patient requires, allowing for greater effi ciency and ef- fective care during the typical 15-minute appointment. Home visits can help providers as they transition from episodic

care to population health management. T ese interactions can help providers better manage high-risk patients who have gaps in care and unique needs. Providers can leverage home-visit programs to render more proactive care management. By partnering with a health plan to respond to home visits, providers can improve the overall health of their patient population and enhance the value of the healthcare system.


of home visits Utilizing home-visit programs to render more proactive care management.

Kelly Monical is president at SeniorCare.

For more on Outcomes Health (www. outcomes-health. com): www.rsleads. com/305ht-206


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