Palliative care improves the quality of life of patients with serious illness through symptom management, caregiver support, and care coordination. Homebound individuals, however, often find it difficult to access these services and as a result, may forego palliative care treatment. Without a source for ongoing, coordinated care, these individuals often experience fragmented care and are more likely to need costly hospital and emergency care. Housecall Providers, a non-profit medical provider serving Portland, Oregon, aims to disrupt this pattern by offering comprehensive home- and community-based programs that incorporate palliative care services and provide patient-driven, high-touch support wherever patients call home.

Intervention

Housecall Providers offers palliative care services through two distinct programs. Their flagship Primary Care program, which started in 1995, serves patients from a diverse payer mix and integrates palliative care within primary care services. The Advanced Illness Care (AIC) program, developed during CareOregon’s acquisition of Housecall Providers in 2017, serves Medicaid enrollees and offers standalone community-based palliative care services. The Primary Care program serves 1,500 to 1,600 patients, while the AIC program serves roughly 130 patients at any given time.

Both programs use an interdisciplinary care team including a physician, nurse, and social worker. Team members are trained in advanced care planning and patient goal setting. In the AIC program, an additional outreach specialist helps coordinate services for housing, transportation, and food since many patients experience housing insecurity and have other complex social needs. Although the two programs are standalone, Chief Executive Officer, Rebecca Ramsay shares that, “The safety net focus and expertise of our Advanced Illness Care program has helped infuse the Primary Care program with more of the skills, resources, and understanding to address health-related social needs.” Through this knowledge sharing, Housecall Providers Primary Care program is better equipped to provide services for the 35 percent of their patients that are Medicaid eligible or dually eligible for Medicare and Medicaid.

Implementation

Patients come to Housecall Providers through a variety of referral mechanisms. At the root of these referrals are strong community relationships and trust. Most frequently, referrals come from adult care home programs in the area. Ramsay reflects, “They know us because we have seen their residents for over 25 years, so we’ve developed really deep relationships with those adult care homes.” Referrals also come from community providers whose patients are not able to come into their clinics and need the extra support of a home-based model. And finally, some patients are referred to Housecall Providers through payer case management programs and state case manager referrals.

To determine what type of care and the frequency of visits patients need, Housecall Providers uses a stratification tool adapted from the Minnesota Complexity Assessment Method. This tool allows them to strategically map patients to services based on medical need. Every six months, or whenever a major health status change occurs, patients are reassessed using this tool and appropriate care is adjusted accordingly. The frequency of patient visits depends on patient needs, but almost all patients receive a visit from a provider at least once every six weeks.

In implementing home-based services, the move toward capitated payments has provided more flexibility for Housecall Providers to best serve its patient population. The traditional fee-for-service model, which is still the dominant payment structure for home-based services, offers very little room for creativity and limits their capacity to address health-related social needs. Housecall Providers’ success has been in large part due to the value-based arrangements they have been able to participate in because they allow the care team to provide more wrap-around services to meet patient needs. There is still, however, a strong administrative burden when it comes to managing multiple contracts for the different services they offer. Looking to the future, Housecall Providers is hopeful that payers and providers will enter singular blended payment models that are centered on patient needs rather than multiple contracts based on individual service line agreements.

Impact

For Housecall Providers, treating homebound patients in the Portland community has increased patient comfort, improved health outcomes, and reduced their overall health care costs. Since 2012, Housecall Providers has saved Medicare millions through their Independence at Home demonstration by keeping patients out of the hospital and treating them in the home. A major impact of the Housecall Providers’ palliative care model is their ability to ensure that patients and caregivers feel empowered and heard during the course of their care. Over 95 percent of their patients have either been satisfied or highly satisfied with the care they’ve received. “Our philosophy throughout the entire organization is heavily invested in the demedicalization of care and making it really accessible for patients and caregivers to understand,” says Ramsay.

_{*Patient name changed to protect privacy.}

Insights

Below are some lessons from Ramsay on what makes the model successful and what other organizations interested in offering home- and community-based palliative care services should consider as they develop their programs:

• Developing and maintaining your workforce is the most important thing for the success of the model. Burnout and turnover are prevalent in this field and replacing valuable care team members takes time and resources. Hiring the right interdisciplinary team can help spread workload burden and coordinate care across the appropriate team members. Additionally, because of the population Housecall Providers serves, hiring providers that have experience with health-related social needs, behavioral health complexities, and understand the impacts that poverty and resource poor environments have on health has been instrumental in the programs’ success.
• The traditional fee-for-service payment model doesn’t work for people with serious illness. Per Ramsay, Housecall Providers wouldn’t be nearly as successful as it is today without alternative payment models and value-based arrangements. For example, the AIC program is a fully capitated per member per month payment model. This arrangement allows Housecall Providers to allocate resources so that caregivers can spend the appropriate amount of time with patients to improve their outcomes. A capitated rate allows Housecall Providers to build a robust interdisciplinary team because revenue isn’t dependent on a physician-centric fee-for-service billing structure.
• Optimizing the use of technology can improve program efficiency. To reduce the amount of time providers are behind the wheel, Housecall Providers uses technology that integrates GIS mapping with scheduling functionality. They have also been able to strategically use telehealth to communicate with patients when an in-person visit isn’t necessary. For Housecall Providers, it’s important to strike the right balance between using technology to improve efficiency, while also retaining the core of their services — face-to-face care.

Acknowledgements

Thank you to Rebecca Ramsay, MPH, BSN, Chief Executive Officer of Housecall Providers for participating in an interview to inform this profile.

Related Collection

• Home- and Community-Based Palliative Care