A mixed methods study explored the effectiveness of five different home visiting programs on reducing hospitalizations, ED visits, and expenditures among Medicare beneficiaries. These programs use care teams comprised of registered nurses or lay health workers as lead staff on home visits. Together, the five programs addressed six categories: care coordination, beneficiary or caregiver education, referrals, disease management, advance care planning, and environmental assessment.
When compared to matched control groups, participants in four out of the five programs demonstrated significant improvements on one or more outcomes over a two to three year period. The Community Aging in Place, Advancing Better Living for Elders (CAPABLE) program and the Advanced Illness Management (AIM) program saved Medicare $2,765 and $5,985 per quarter per patient respectively. AIM demonstrated 76 fewer hospitalizations per quarter per 1000 patients. The Stroke Mobile program demonstrated 52 fewer hospitalizations per quarter, and the Doctors Assisting Seniors at Home (DASH) program demonstrated 17 fewer hospitalizations and 24 fewer ED visits per quarter per 1000 patients.
This study also included a qualitative component, which helps to explain how these programs actually work in achieving good outcomes. Participants reported increased confidence and self-management, and participants from most programs reported improved self-management of health behavior, improved physician communication, and reduced caregiver burden.
It should come as no surprise to those working in direct patient care that an intervention which builds a trusting relationship between the patient and the care provider would be effective in improving health. Historically, successful home visiting programs have fallen under the purview of nurses. Visiting midwives in Londons east end in the 1960s contributed to a significant decline in infant and maternal mortality rates; David Olds Nurse Family Partnership, which provides nurse home visits to poor mothers and their infants, has demonstrated increased prenatal health, fewer childhood injuries, increased maternal employment, and improved school readiness. The policy prescription is clear. Uphold provisions under the ACA that support evidence based home visitingand keep on providing the evidence.
commentary by Megan Doede
While studies of home-based care delivered by teams led by primary care providers have shown cost savings, little is known about outcomes when practice-extender teams-that is, teams led by registered nurses or lay health workers-provide home visits with similar components (for example, care coordination and education). We evaluated findings from five models funded by Health Care Innovation Awards of the Centers for Medicare and Medicaid Services. Each model used a mix of different components to strengthen connections to primary care among fee-for-service Medicare beneficiaries with multiple chronic conditions; these connections included practice-extender home visits. Two models achieved significant reductions in Medicare expenditures, and three models reduced utilization in the form of emergency department visits, hospitalizations, or both for beneficiaries relative to comparators. These findings present a strong case for the potential value of home visits by practice-extender teams to reduce Medicare expenditures and service use in a particularly vulnerable and costly segment of the Medicare population.