Blog Post | September 16, 2019

Physicians Go the Last Mile to Manage Patients in the Home

How physicians can leverage community resources to improve outcomes and patient experience


Caring for a burgeoning Medicare population – many with a serious or advanced illness – places increased demands on physician practices.  Making this even more complex for physicians is the fact that the center of care is shifting outside the hospital and into the patient’s home.

Physicians are being asked to engage and manage an even greater number of patients, with those who are seriously ill requiring increased engagement and support.  This includes individuals who access care in the physician office as well as those who choose to remain at home. Add to this the pressures on physicians to take on more financial risk, increase care coordination through the medical home, handle time-consuming administrative tasks – and more.

Navigating this evolving Medicare landscape and value-based payment models that emphasize quality vs. quantity, compels physicians to focus on a host of other concerns beyond direct patient care. These challenges continue to build with CMS now reimbursing MA plans for home-based palliative care and supplemental benefits related to Social Determinants of Health (SDoH).

The net result of these combined issues can lead to higher cost of care, decrease in patient satisfaction with the health system as a whole – and physician burnout.  Clearly, these challenges require better support for physicians to provide high quality, patient-centered care for individuals with serious illness who are remaining at home.

Solution and Opportunity

Our PIM program starts with the basic tenets of CBPC and wraps them in structure and process.  Specialized care teams comprised largely of nurses and social workers use structured assessments for home-based palliative care. Our process-driven approach goes beyond the traditional referral model, using predictive analytics to identify patients earlier in the disease trajectory.

Dedicated care teams provide in-home palliative assessments and interventions designed to extend physician visibility into the member’s home, identifying and filling both clinical and non-clinical care gaps.  This includes medication reconciliation, symptom management, caregiver support and care coordination back to the treating physician.  It also incorporates sensitive conversations with patients and caregivers around goals of care and advance care planning,

Our approach utilizes systemized methodology that results in better support for the medical home, functionally increasing the reach and frequency of physician engagement.  In fact, an independent research study published in the April 2019 issue of the Journal of Palliative Medicine showed that a CBPC model results in more compassionate, affordable and sustainable high-quality care and can reduce utilization and medical costs.

Helping Physicians to Integrate Information Around Social Determinants of Health

There is now recognition of the services and programs that address Social Determinants of Health (SDoH), including a CMS directive that home-based palliative care is now a reimbursable benefit.  SDoH have become highly relevant to achieving optimal patient care coordination because they are designed to identify patients who are plagued by social and economic conditions that indicate the greatest need for health improvement.

In the process, CMS is redefining how plans and healthcare providers address end-of-life.  The expectation is that physicians will play an increased role in the medical management of members with a serious illness who remain in the home setting.

Enhancing Physician Capabilities Within Value-based Models

The Turn-Key model supports physician practices, MSOs, ACOs and other delegated entities that are taking on increased accountability for improved patient outcomes.  We help these groups to achieve their goals, enhance patient and caregiver satisfaction and reduce unplanned care.  This level of support enables treating physicians to scale their time and maximize resources, allowing them to better focus on what they do best:  provide high quality medical care.

Our approach to specialized, home-based palliative care is helping physicians to achieve the Triple Aim:  improving care quality and enhancing care coordination while supporting patient self-management and adherence to treatment.

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