Can Home‐Based Primary Care Drive Integration of Medical and Social Care for Complex Older Adults?

Caring for community-dwelling, frail, medically complex older adults is a topic of intense interest among payers (government and private), health systems, and healthcare providers, not to mention such older adults themselves and their caregivers. Many are homebound with multiple chronic conditions, functional impairments, and limited social capital. They constitute a high-need, high-cost, often invisible population. Their needs are rarely addressed in an adequate fashion by a medical system and culture that continues to focus on facility and disease-based care. Attending to the social and functional needs of frail older adults by integrating their medical care and social care is advantageous for multiple stakeholders. Medicare beneficiaries with impaired function experience twice the costs of care when compared to similar beneficiaries with intact function. Data examining healthcare and social spending in Organization for Economic Cooperation and Development countries, where social and medical care expenditures are more balanced, demonstrate better healthcare outcomes than in the United States, where medical expenditures far exceed social expenditures. In the United States, medical care usually occurs in parallel with long-term services and supports (LTSS), often in the form of Medicaid homeand community-based services (HCBS) 1915c waiver programs that typically do not integrate with traditional medical care. LTSS services encompass paid and unpaid medical and personal care assistance that people need when they experience difficulty completing self-care tasks as a result of aging, chronic illness, or disability. Services may include caregiver support (eg, respite care), mental health and behavioral services, health services (eg, medication assessment or management), skilled therapies, financial management, nutrition support (eg, Meals on Wheels), transportation, and others. Care models that integrate LTSS with traditional medical care produce better outcomes. Managed Medicaid that integrates social and medical care experiences better care quality. People participating in the Program of All-Inclusive Care for the Elderly for dually eligible Medicare-Medicaid beneficiaries have lower rates of conversion to long-term institutional (LTI) care compared to traditional HCBS enrollees. In this context, we consider the work in this issue of the Journal of the American Geriatrics Society by Valluru and colleagues, in stitching together various data sources to evaluate outcomes associated with integrating medical and social care for enrollees in the Center for Medicare and Medicaid Innovation (CMMI) Independence at Home (IAH) demonstration. IAH, developed by leaders of the American Academy of Home Care Medicine, tests effectiveness of delivering comprehensive primary care services at home with homebased primary care (HBPC). Using a shared savings model, it seeks to improve care quality while simultaneously reducing healthcare costs and utilization. HBPC delivers medical care to people who find it difficult to get to a physician’s office. IAH specifically targets high-need, high-cost Medicare fee-for-service beneficiaries with multiple chronic conditions, functional impairment, and high-cost utilization. IAH has been one of CMMI’s most successful demonstration projects; high-quality care has been delivered to a complex population, with first-year savings 10 times as great as those of pioneer accountable care organizations (ACOs), with projections for billions in savings were the program to be scaled nationally. The magnitude of cost savings associated with IAH is not surprising given the target population and the nature of the IAH care delivery intervention. While much has been written on the concentration of healthcare costs among a small proportion of the population, it is critical to remember that high costs are not the same as preventable costs—one can only save money on people who cost money and have preventable healthcare costs. A recent analysis found that while frail older adults comprise only 4% of the Medicare population, they account for nearly half the preventable costs in all of Medicare; most preventable costs in this group are from preventable hospitalizations. In a real-world example of this principle, the only HBPC-only ACO in the United States was the fourth most successful ACO in terms of cost savings in 2016. The observational study by Valluru et al evaluated whether HBPC, provided in the context of IAH and integrated with home and community-based LTSS, would lower LTI care and costs of LTSS compared to local LTI care and HCBS benchmarks. The study compared LTI rates for patients receiving HBPC via an IAH practice integrated with LTSS to: (a) IAH-qualified beneficiaries not receiving HBPC DOI: 10.1111/jgs.15969