Home Health’s Next Frontier: Complex Patient Management

Partnering with Medical Homes to Manage High-Risk Patients

Topics: Post-Acute Care, Service Lines, Referral Management, Physician Issues, Physician Engagement, Care Management, Methodologies, Performance Improvement

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By reading this study, members will learn:

  • How your home health agency can use existing core competencies to meet emerging physician group needs
  • What benefits a physician group partnership may hold for your organization
  • Why home health providers are poised to serve as a complex patient managers
  • Three opportunities that allow home health providers to expand their role, securing greater referrals and new revenue streams

Executive Summary

The health care industry is embracing a preventive approach to patient care to reduce costs and improve patient well-being. Central to this shift is the transition of traditional primary care practices to the patient-centered medical home (PCMH) model—a team-based approach to primary care delivery emphasizing longitudinal patient care. These medical homes are run by primary care physician offices. While these groups are well-equipped to manage overall care for most patients, they may struggle to provide and coordinate care for complex patients. Further underscoring this transformation is the development of accountable care organizations (ACOs), assuming responsibility for total patient health (and cost)—leveraging the PCMH model as a cornerstone of their infrastructure.

Home health's opportunity

Home health agencies have significant experience caring for complex patients, and can partner with physician groups to provide support in the form of transitional care, telehealth, patient education, and even care planning consultation. These partnerships give home health agencies the chance to create a new and exciting role as the complex patient manager, adopting an expanded patient population, a greater presence in preventive care, and even assuming financial risk for patient outcomes. This study explores three main areas of opportunity home health providers have to strengthen complex patient management:

  • Hardwiring physician engagement
  • Developing high-risk patient management services
  • Serving as care planning resources

Benefits to partnership

Home health agencies that partner with physician groups can use the relationship as a foundation to develop stronger communication, new service lines, and a broader role in patient care. These changes produce many benefits for the home health provider, including a greater voice in physician decisions, increased referrals, access to new patient populations, and the chance to enter into risk-based contracts. Physician group partnerships provide an exciting new opportunity for home health agencies to expand their reach.

The Need for A Complex Patient Expert