The Value of Quality In-Home Health Services
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janvier 12, 2025
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This FTI Consulting whitepaper was published in partnership with Matrix Medical Network and co-authored with Dr. Michael Cantor, Chief Medical Officer, Matrix Medical Network.
Healthcare policymakers are increasingly emphasizing “Whole Person Care,” (“WPC”) a holistic approach to patient care that goes beyond just diagnoses and treatments and includes other aspects of overall health such as functional status, behavioral health, social determinants and more.1 Successful WPC relies on access to primary care and working in tandem with other community resources. However, access to these critical resources varies widely across the country and, in most cases would benefit greatly from integrating in-home care capabilities.
In-home health and care assessments are an important way to provide WPC, especially for populations of older adults and others who lack access to primary care and/or are challenged to coordinate their own care, find reliable transportation and secure other necessary services.
Health plans and at-risk provider organizations have been ahead of the trend, supporting in-home assessments and care for many years. Data from a Medicare Advantage plan showed that approximately 1 in 20 beneficiaries receiving in-home assessments had no other claims during the year, suggesting some challenges with access to care.2 In addition, one in 5 beneficiaries lived in rural areas that traditionally lack access to primary care.3
In-home care creates incremental value compared to other visits by allowing providers and payers to gain insights into risk factors that might prevent beneficiaries from receiving the care they need. It also makes possible care navigation that connects/reconnects people to primary care and other needed services.4
Leading in-home care organizations such as Matrix Medical Network, and their payer partners are expanding and enhancing their programs to include:
- Comprehensive assessments augmented by tests for cardiovascular, kidney, and metabolic disorders (e.g., diabetes and obesity)
- Care coordination and navigation to ensure diagnoses and social needs such as transportation are managed appropriately
- Remote patient monitoring of chronic disease and personal emergency response systems
Demographics and Patient Needs Are Driving Growth of In-Home Health Services
The U.S. population is aging—currently, more than 61 million people are enrolled in Medicare, and that figure has grown by approximately 8% annually over the past few years. By 2030, estimates indicate that one in five Americans will be eligible for Medicare.5 In addition, since the population is living longer, many Americans live with one or more chronic health conditions that require regular care.
The combination of an aging population and structural problems in the healthcare system that limit access to primary care and other needed healthcare services has led to an increase in functional impairment that makes it difficult to live independently and a rising prevalence of chronic illnesses. These challenges can lead to a vicious cycle in which chronic illnesses are poorly managed, leading to functional impairments that make it more difficult to access needed services, which leads to more challenges managing chronic illnesses.
One challenge of living independently is access to non-emergency medical transportation. As many as one-fifth of older adults no longer drive, and as many as one-third of those who do drive face driving restrictions.6 These figures are higher for people with chronic diseases or who are from lower socioeconomic strata.7 People with these challenges are reliant on family members, caregivers, public transportation or existing government-sponsored ride programs, which may be costly, inefficient and ineffective.8 In order to ensure all patients with chronic conditions see a provider regularly to have their conditions assessed, monitored and treated, providing several convenient care access options, including in-home visits, can help maximize access to care.
In-home care is rapidly increasing in popularity as an effective means of providing patients with convenient yet comprehensive care.9 The recent growth in hospital-at-home, urgent care in the home (community paramedicine), and home-based primary care programs demonstrates the value of bringing care literally to where the patient lives. And given the 61 million Medicare beneficiaries (which will continue to grow as baby boomers turn 65), patient demand and overall popularity, in-home care is an attractive target for innovation.10
Table 1: In-Home Care Continuum
| CURRENT STATE IN-HOME ASSESSMENT | FUTURE STATE WPC MODEL | |
|---|---|---|
| Clinical Focus |
— Medical diagnoses — Functional status — Care gap identification and closure |
— Medical diagnoses — Functional status — Care gap identification and closure — SDOH evaluation — Health equity assessments |
| Clinical Focus Testing |
— Diabetes (hemoglobin A1c) — Kidney disease in people with diabetes — Colorectal cancer screening — Peripheral artery disease — Digital retinal scanning |
— Kidney disease in people with diabetes — Colorectal cancer screening — Peripheral artery disease — Cognitive assessment — Cardiac arrhythmia testing — AI-driven digital retinal screening — Spirometry |
| Data integration | Limited | Connected to clinical care team and payer-based care management |
| Chronicity | Annual visit | Longitudinal relationship providing enhanced services care navigation in the home throughout the year |
In-home care providers using expanded capabilities and supporting technologies are natural partners and extensions of providers and payers. In-home models add value by extending the capabilities of both primary care providers and payer care management programs to bridge gaps in care and provide timely education, care support and access to resources.
In-Home Care Designed to Address Access and Care Coordination
Generally, payers do not disrupt the established physician-patient relationship and instead utilize skilled, licensed providers in the home to facilitate payer-led initiatives, such as chronic care management, transition of care programs and/or programs that facilitate aging at home. These are very specific, well-defined initiatives targeted at segments of the beneficiary population who will benefit the most.
In addition, payers cover the costs of using providers to conduct in-home wellness assessments. These wellness assessments are designed to ensure beneficiary care needs are being addressed by a licensed provider, including physicians, nurse practitioners and physician assistants. In-home providers comprehensively assess a beneficiary’s medical condition and functional status and identify gaps in quality and care-related measures such as in Healthcare Effectiveness Data and Information Set (“HEDIS”) measures.11 In-home providers can also reconcile medications, identify opportunities to optimize medication regimens and evaluate social needs like challenges with access to healthy food and transportation and decent housing.
As more organizations understand the value in-home care creates, including payers and providers, the more likely they are to embrace the benefits and seek new opportunities to employ the channel.
Value Created by In-Home Assessments
FTI Consulting and Matrix Medical Network performed a recent analysis of in-home health and care assessments with 2023 dates-of-service for the beneficiaries of a national Medicare Advantage plan to determine the health and cost-related benefits resulting from these visits. Among other benefits, the analysis found that in-home assessments provided beneficiaries access to care and services that may not otherwise have been received, and beneficiaries who received an in-home assessment subsequently became more engaged with their care.12 Key findings from the analysis included:
Table 2: Learnings From Analysis of In-Home Assessments13
| IN-HOME ASSESSMENTS IMPROVE ACCESS TO CARE | |
|---|---|
| 5% | Percent of beneficiaries whose in-home assessment was the only source of care in 2023; in these visits, nearly 60% had at least one chronic condition |
| 21% | Percent of visits to beneficiaries located in areas defined as rural; this is 1.5 times greater than the nearly 14% of Americans living in rural areas14 |
| IN-HOME ASSESSMENTS HELP BENEFICIARIES ADDRESS CRITICAL CARE AND SUPPORT NEEDS | |
|---|---|
| 21% | Percent of visits where Matrix was the first provider to identify new chronic conditions, where that condition was subsequently assessed and treated by a provider in another setting |
| 32,000 | Beneficiaries with challenges in being able to shop, cook or feed themselves |
| 12,000 | Beneficiaries with problems related to housing and economic circumstances |
| 12,000 | Beneficiaries with at least two limitations in activities in daily living |
FTI Consulting and Matrix Medical Network found that 21% of in-home health and care assessments were to individuals located in rural areas, and 5% of visits were to members who had no other source of care in 2023.15 This finding was consistent with those from a September 2024 publication in the Annals of Internal Medicine, in which a group of gerontologists studied the prevalence, characteristics, predictors, health service use, and mortality outcomes of homebound beneficiaries of a large national Medicare Advantage plan. The study found that the overall homebound prevalence was 22.0% and was associated with increased health service utilization and mortality.16
In the analysis of 2023 in-home health and care assessments, FTI Consulting and Matrix Medical Network also found that the in-home health and care assessments identified tens of thousands of beneficiaries challenged to shop, cook or feed themselves, faced with housing or other economic challenges, or had two or more limitations in Activities of Daily Living.17
The Robert Wood Johnson Foundation Health Policy Briefing Series discusses the importance of identifying and addressing beneficiaries’ social determinants of health, saying that “these factors can drive as much as 80 percent of health outcomes.”18 Placing a provider in the home of a beneficiary can identify previously unknown functional impairment and social care needs that can be communicated to primary care providers and/or with the health plan for coordination with community-based organizations that provide additional support.
Where Payer-Led In-Home Care Is Headed
Payers are under pressure from increased regulatory scrutiny, higher medical costs and shrinking bottom lines. For example, during the first half of 2024, several publicly traded healthcare organizations made statements in their earnings calls that medical costs have increased more than expected, partially due to increased inpatient admissions.
In-home care organizations are poised to help address these pressure points and are increasing their capabilities and the range of services provided by improving their ability to coordinate and integrate with traditional care-delivery organizations. In addition, in-home care organizations are developing strategies to create longitudinal relationships with their patients.
Actions that leading in-home organizations like Matrix Medical Network are taking to improve results include:
- Expanding the services and capabilities that can be provided in-home, such as:
— Performing whole-person care screenings to assess the physical, functional, mental, social, and environmental needs of the beneficiary
— Increasing the breadth of screenings and lab services, such as cognitive screening, retinal scans for people with diabetes, and testing required for kidney care
— Developing care coordination capabilities allowing in-home providers to become an extension of the health plan programs, such as early chronic kidney disease (“CKD”) detection, intervention, and care navigation
- Connecting beneficiaries with providers and services, such as:
— Assisting beneficiaries who need help coordinating services and support (e.g., housing, transportation, or food assistance)
— Connecting beneficiaries with a primary care provider when no relationship exists
— Scheduling primary care appointments when beneficiaries have a provider but have not seen them recently
- Integrating the patient’s in-home clinical encounter data with providers responsible for beneficiary care, including primary care providers, health systems and the payer’s care management platform
As in-home care organizations continue to improve and adapt, they will need to focus on their customers’ needs related to services provided at home and coordination among all stakeholders. This includes listening and understanding the needs of their payer and provider partners while creating valuable and efficient new services to help spur rapid member adoption.
Footnotes:
1: Center for Medicare & Medicaid Services Office of Minority Health, “CMS Framework for Health Equity 2022–2032”, CMS (2022).
2: Dr. Michael Cantor, “Analysis of internal Medicare Advantage beneficiary encounter data,” Matrix Medical Network (November 2024).
3: Ibid.
4: Freed, M., Biniak, J.F., Samico, A., Neuman, T., “Medicare Advantage in 2024: Enrollment Update and Key Trends”, KFF (August 8, 2024).
5: MedPAC, “Report to the Congress: Medicare and the Health Care Delivery System, Chapter 2: The next generation of Medicare beneficiaries”, p39, Report to the Congress: Medicare and the Health Care Delivery System (June 2015).
6: Saxon, L. MD, Ebert, R., Sobhani M., PhD, “Health Impacts of Unlimited Access to Networked Transportation in Older Adults”, The Journal of mHealth (August 13, 2019).
7: Ibid.
8: Ibid.
9: Popowitz, E., “The growing demand for at-home care”, Definitive Healthcare, December 14, 2021.
10: Freed, M., Biniak, J.F., Samico, A., Neuman, T., “Medicare Advantage in 2024: Enrollment Update and Key Trends”, KFF (August 8, 2024).
11: NCQA, “Healthcare Effectiveness Data and Information Set (HEDIS)”, U.S. Department of Health and Human Services.
12: Dr. Michael Cantor, “Analysis of internal Medicare Advantage beneficiary encounter data”, Matrix Medical Network, (November 2024).
13: Ibid.
14: Dobis, E., Krumel, T., Cromartie, J., Conley, K., Sanders, A., Oritiz, R., Rural America at a Glance, Economic Research Service, U.S. Department of Agriculture, (November 2021).
15: Dr. Michael Cantor, “Analysis of internal Medicare Advantage beneficiary encounter data”, Matrix Medical Network, (November 2024).
16: Leff, B. MD, Ritchie, C., MD, MSPH, Szanton, S., PhD, RN, Shapira. O, MS, Sutherland, A., PhD, Lynch, A., PhD, Powers, B.W., MD, MBA, Siddiqui, M., MD, MPH, MSE, and Ornstein, K.A., “Epidemiology of Homebound Population Among Beneficiaries of a Large National Medicare Advantage Plan”, Annals of Internal Medicine”, Volume 177, Number 9, (September 2024).
17: Dr. Michael Cantor, “Analysis of internal Medicare Advantage beneficiary encounter data”, Matrix Medical Network, (November 2024).
18: “Medicaid’s Role in Addressing Social Determinants of Health”, Robert Wood Johnson Foundation, BRIEFING SERIES: KEY MEDICAID ISSUES FOR NEW STATE POLICYMAKERS, Issue 5, (February 2019).
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janvier 12, 2025
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