How to integrate direct primary care at home

Homebound patients often struggle with complex medical conditions that are among the costliest in healthcare. A recent analysis concluded that homebound people ages 70 and older accounted for 11% of Medicare spending in 2015, even though they made up only 5.7% of Medicare’s fee-for-service population.

In addition to older Americans, research shows that homebound populations have more chronic conditions on average and are more likely to have been hospitalized in the past 12 months. Additionally, homebound Americans also often face health equity issues related to social determinants of health (SDoH), such as lack of reliable transportation, making it difficult or impossible for them to go to a clinic, hospital or doctor’s office for assessment and treatment. As a result, their chronic illnesses may worsen, leading to poorer health outcomes and higher healthcare costs.

Fortunately, healthcare organizations, patient advocacy groups and policy makers are increasingly recognizing that patients tend to be happier and healthier when they are at home. “The home environment is the most authentic place a person can receive care,” said Monique Reese, senior vice president of Highmark Health. “It’s where people live, raise families, dine and make tough decisions.”

The growing number of homebound Americans and growing awareness that patients fare better at home are fueling a shift toward home-based primary care. McKinsey estimates that up to $265 billion in care services (representing up to 25% of total care costs) for Medicare and Medicare Advantage fee-for-service beneficiaries could move from traditional facilities to the home by 2025.

Delivering basic health services and providing assistance with daily activities requires a team approach to primary care that includes non-traditional providers such as community-based organizations (CBOs) and social service agencies. This means that a primary care provider may visit selected patients in their homes two or three times a year, with allied and affiliated care providers providing other services as needed by the patient, such as wellness visits. being, nutritious meals, errands and assistance with daily activities. .

Having trained nurses, social workers, lab technicians and other ancillary service providers in the environment where patients are most comfortable — their homes — allows housebound Americans to be monitored. more closely and develop trusting relationships with primary care providers and members of the care team. Such a coordinated approach helps reduce a patient’s social isolation, a condition that can negatively impact the mental and physical health of homebound populations.

Benefits of Direct Primary Care

A big part of a homebound patient’s success in managing their own care as much as possible is having a trusting relationship with a primary care provider. For this reason, direct primary care (DPC) – an alternative payment system that eliminates fee-for-service payments and third-party billing – is becoming an increasingly popular model of care delivery for patients concerned about cancer. rising health care costs and providers wanting to reduce administrative costs. burdens. DPC builds on and enhances these critically and clinically important patient/primary care provider relationships.

A recent study analyzing the impact of DPC on health outcomes and costs found that DPC members had 25.5% fewer hospital admissions, while the cost of emergency room claims was reduced by 53.6%. The improved outcomes, better patient experience, reduced paperwork and lower costs generated by DPC payment models can help small practices stay independent.

So too are the strong working relationships with CBOs, allowing small practices to thrive while ensuring patients’ needs are met where they are. To successfully integrate CBOs into a care network, providers must deploy technologies that provide support for onboarding, data capture, digitization, and exchange. These technologies must also support SDoH, quality reporting, and other use cases.

Although many smaller providers have digital infrastructures, they are unlikely to offer the support to enable the complex many-to-many relationships between different entities needed for coordinated care of patients at home. Integrating CBOs into a care network requires:

  1. A cloud-based digital health data infrastructure that powers real-time clinical decision-making, information sharing, and analysis. Besides digitizing data, such an infrastructure can integrate with existing systems and provide a unified view of datasets for better decision-making.
  2. Realignment of downstream reimbursement to include both medical and non-medical providers (behavioral health services, nutritionists, etc.)
  3. Integration of SDoH resources and CBOs


Homebound Americans are among our most vulnerable populations. As more primary care is delivered in the home through CPD and more traditional models of care, a team-based, collaborative approach involving multiple disciplines and services is essential to improving health equity. for those who need it most. A scalable, cloud-based digital infrastructure can enable independent providers and community organizations to coordinate care, services and reimbursements.