Years ago, it was not uncommon for physicians to make house calls. But in the past 50 years, care has largely transitioned to physicians’ offices. Office-based visits are more efficient, and reimbursement for home visits can be challenging under fee-for-service payment. However, there are advantages to home visits: they can improve health outcomes, and they can decrease spending on patients with complex needs, including patients with chronic conditions and those recently discharged from the hospital. With support in part by a six-foundation collaborative that includes the Commonwealth Fund, Peterson Center on Healthcare, Robert Wood Johnson Foundation, SCAN Foundation, John A. Hartford Foundation, and Milbank Memorial Fund, researchers looked at whether health care providers contracted with accountable care organizations (ACOs) were more likely than non-ACO practices to employ home visits. The study, published in Health Affairs, used 2017–2018 survey results as well as data obtained from interviews with 18 ACO leaders.
Use of postdischarge home visits among ACOs, by payer Medicaid ACOs: 86.7% Medicare ACOs: 82.0% Commercial ACOs: 79.6%
What the Study Found
- ACO physician practices were more likely than non-ACO practices to conduct home visits for complex patients within 72 hours of hospital discharge (25.7% vs. 18.8%).
- ACOs using home visits tended to be larger (include a hospital or contract with more physicians) and more likely to be part of an integrated delivery system than ACOs that did not use home visits.
- More than 50 percent of ACOs that participated in risk-bearing payment arrangements, such as episode-based bundled payment, employed home visits. In comparison, only 30.2 percent of ACOs that did not have risk-bearing contracts used home visits.
- In addition to using home visits as part of a care management or care transitions program for complex patients, ACOs used home visits for patients who were noncompliant or nonresponsive with office-based care.
- Postdischarge visits were common, but some ACOs also used home visits on an as-needed basis, such as when care teams sense something is not right with a patient or a patient cannot be reached by phone or other means.
- Care team members who conducted home visits included care management staff, nurses, social workers, health coaches, and pharmacists.
- Looking at only Medicare ACOs, the researchers saw no significant differences in quality scores or likelihood of achieving shared savings between ACOs that used care transition home visits and those that did not.
The Big Picture
Under ACO contracts, providers are responsible for the quality and total costs of care of a patient population. The higher use of home visits among ACOs suggests that these alternative payment models are driving changes in care delivery approaches. ACOs reported that home visits help them gain a greater understanding of a patient’s home life, including any safety issues and barriers to health, while providing an opportunity to build relationships with patients and engage them in managing their health to reduce hospital and other care use. Challenges to widescale adoption of home visits include their cost and the current lack of evidence-based best practices.
The Bottom Line
ACOs, which take on risk for patient populations, are more likely than other health care organizations to use home visits to support complex patients, including during care transitions and times when a patient is out of contact.