Patient-centered medical homes are a model of primary care that is coordinated by a physician or care team. They often consist of a nurse, medical assistant, behavioral health specialist, and physician. Many states have focused on primary care medical homes (PCMHs) because they provide high-quality care, better health outcomes, and decreased healthcare costs.

Why is the medical home model necessary?

Typically, patients with multiple health concerns must consult with several different specialists and undergo a variety of medical procedures or lab tests. There can be delays or duplication in the communication between medical specialists. Repeating medical procedures or investigations means that the patient has to go through the tests again or wait a long time for the results. This also means that the medical specialists have to spend more time with the patient, which increases the costs.

Medical home changes how healthcare is coordinated for a patient. A single primary care physician (or care team) designs an appropriate care plan based on the diseases, medical investigations, at-home lab tests, procedures and health results of that patient. The medical home model has been shown to decrease healthcare costs by reducing the number of visits to the ER, the number of avoidable hospital admissions, and the overall utilization of medical services and medical staff time.

Major milestones in establishing today’s medical home model

The term “medical home” was introduced by the American Academy of Pediatrics and it described a source for all medical information about a child. In 1992, an institution released a policy statement that said the medical home is a strategy needed to deliver coordinated, continuous, comprehensive, and family-focused care for all children.

The Institute of Medicine published a report in 2001 called “Crossing the Quality Chasm” which pointed out the many ways that the American healthcare system was falling short and proposed that care be focused on the patient in the future.

Every American should have a “personal medical home” where they can get preventive, chronic and acute health services, according to the “Future of Family Medicine” project recommended by seven national family medicine organizations the next year.

A 2004 review of the project found that it was linked to improved health outcomes, lower health costs, and decreased health disparities between more and less advantaged social groups.

In 2005, the American College of Physicians developed an “advanced medical home” model. The model includes support tools for clinical decisions, easy and convenient access to care, indicators to measure the quality of care provided, information technology tailored to healthcare, and tools for collecting feedback on the model’s performance.

The model also reforms the existing payment system. The medical home model began to be intensively promoted in 2006 when the Patient-Centered Primary Care Collaborative was created as a partnership between several organizations, employers, primary care societies, national health plans, patients’ groups, and IBM. A year later, in 2007, the Joint Principles of the Patient-Centered Medical Home were released by the American College of Physicians, American Academy of Family Physicians, American Osteopathic Association and American Academy of Pediatrics.

According to these principles, the medical home care is:

• Patient-centered: medical home model assists patients in learning how to manage their care, also involving the patient’s family and caregivers in these care plans. PCMH also engages through various initiatives the patient in getting involved in policies aimed at improving health outcomes.
• Accessible: the PCMH delivers 24/7 electronic or telephone access to medical services, decreases the patients’ waiting times and eases the communication between patient and primary care physician through the use of information technology.
• Coordinated: the PCMH makes the primary care physician the coordinator of all healthcare information and services needed by a patient, including specialty procedures, hospitalizations or lab investigations.
• Comprehensive: in the medical home model, a team of caregivers is appointed to monitor and manage all the physical and behavioral health needs of a patient from prevention and wellness to diagnose and treatment of acute and chronic medical affections.
• Committed to Quality and Safety: medical home model uses health information technology (HIT) and other technology tools to support patients in making the best decisions regarding their health.

The Current State of Home and Community Care

As new technology-enabled services and modalities of care become available, the definition of home- and community-based care continues to expand. The home and community care continuum includes a variety of different types of care, such as primary care with care navigation, urgent and emergent care, acute and post-acute care, home health, behavioral health, palliative care and hospice, in-home dialysis, home infusion, virtual services and telehealth, remote monitoring, social determinant of health (SDOH) interventions, and pharmacy and medication services.

U.S. home health care spending is projected to grow by about 7% annually from $103 billion to $173 billion by 2026. The growth of the digital health market is being supported by the rapid growth of adjacent markets, such as remote patient monitoring, telemedicine, at-home diagnostics, and portable X-rays. Many solutions still only work in a small area and are only for one type of business, usually MA. As the market grows, we expect there to be a split between traditional fee-for-service solutions and innovative value-creating organizations. These organizations excel at improving care and outcomes for populations of patients, including the most complex ones, while reducing costs overall.

The following is a new, holistic platform of home- and community-based care that can be developed: a platform that serves the physical, mental, and social needs of people according to their personal care preferences. The goal is to have technology-supported care that is coordinated across providers and care settings, including communication with primary care clinicians. This would create a seamless experience for patients and optimize care delivery.

Home and Community Care Components

As we set out to create a home- and community-care platform that delivers superior outcomes at a lower total cost of care, we have identified critical capabilities that are necessary to effectively deliver an integrated clinical model for full-population longitudinal patient-care management that follows a patient’s journey through the health system and addresses their physical, mental, and social needs.

Patient Assessments

The first step to identifying the medical, behavioral, and social needs of your patients is to conduct an annual in-home comprehensive clinical examination. The APC identifies gaps in care and untreated conditions during this home clinical visit, and educates members on individualized wellness and disease management activities necessary to improve their health and well-being.

It is crucial to finish these initial evaluations to guarantee that a treatment plan is made specifically for the individual. Optum’s HouseCalls program demonstrates the importance of this ability. In 2021, HouseCalls closed more than 2.1 million gaps in care, generated over 600,000 referrals to follow-up care, and made over 320,000 referrals for SDOH needs. This included referrals for low-income support, transportation needs, medication affordability, and food insecurity. If clinicians and patients trust each other, the patients will be more involved in their own care, both in the short and long term.

Care Transitions

Patients who are discharged from hospitals and other care settings often find that the care they receive is fragmented and that their needs are not always met. This can lead to conflicting medications and a poor patient experience. It is important to manage a patient’s transition from an acute care facility safely so that they can recover functional skills and return to their community. Engaging the patient at discharge with clear instructions will lower the likelihood of high-cost follow-up care and readmissions.9 In fact, comprehensive transitional care programs including detailed discharge planning and 90-day home follow-up have been shown to reduce the number of readmissions, reduce deaths, and decrease health care costs.18,19 Discharge to the appropriate location, whether that be the home or a nursing facility, is a critical component to successful outcomes and lowering cost. The right balance between the cost and intensity of the location of discharge can now be determined using data.

NaviHealth, a post-acute care organization based in Nashville that is part of the Optum Home and Community platform, focuses on connecting patients to “the right care in the right setting for the right amount of time.” Using its proprietary data and technology, naviHealth has been able to improve the quality and outcomes of these care transitions. They are saving an average of 20% per episode of care and reducing the length of stays in skilled nursing facilities by 15-25%. This allows patients to go home sooner.

Partnership Ecosystem

In order to provide integrated, patient-centered care, coordination with external parties is often necessary. This means that, in order to provide home delivery of pharmacy items, pharmacies need to partner with organizations that manage pharmacy benefits. Additionally, if they want to be effective in referrals and interventions related to social determinants of health, they need to partner with networks of community-based social support services. Efficient care transitions necessitate that hospitalist groups and hospitals cooperate with one another to create a discharge plan. Even if your organization can build all of the necessary capabilities, there will always be a need for partnerships to deliver care effectively.

The Future of Home and Community Care

We need to expand access to home- and community-based care in the future so that more seniors and people with complex needs can benefit from it. This will require more funding to make it possible. At the moment, three types of plans – MA, DSNP, and CSNP – are able to provide the necessary financial support for both very intense care plans for high-risk populations, and also more general care focused on those at risk of becoming ill or who have stable conditions. States are beginning to create programs that fund home-based services through Medicaid. This presents an opportunity for those who need these services. This population typically suffers from the most challenges with health equity, so a holistic model of care for the whole person would be beneficial.

The Biden administration and Congress have been supportive of the idea of caretaking in the home. The only thing standing in the way of widespread access to home and community care is the commercial market. For people who are at a high risk for health problems in the commercial market, it is appropriate to have a model that focus on risks at home and in the community. There is a growing market for businesses that offer direct-to-consumer services that are convenient and of high quality. These services should be easy to access and offer concierge-like navigation, including virtual care in the home. Employers prefer home-based services as they result in less absenteeism. The trend of doing more at home will continue to spread into the healthcare industry, and not just for those who are sick.

As more and more people turn to home and community care solutions and platforms, it will be increasingly important for organizations to be able to differentiate themselves in order to effectively take advantage of these trends. Different organizations and local areas will have different needs, but being able to involve patients, provide support for primary care at clinics, and create a model of care that focuses on the individual’s needs will be important.

Innovations are continuing to improve care in the home and community settings. We need a health care delivery model that can provide physical, mental, and social care to people at any time and place, including in their homes.