Challenges, Trends Among ACO Home-Based Care Initiatives

Home-based care initiatives were common among accountable care organizations (ACOs), but ACO leaders cited the lack of return on investment as a barrier to expanding these services, according to a study published in the American Journal of Managed Care.

Home-based care can help improve care for high-need, high-cost individuals with multiple chronic conditions, functional limitations, and complex social needs.

Providers can leverage several home-based care models, including home-based primary care, hospital at home, post-discharge transitional care, and care coordination services. ACOs are common providers of home-based care services.

Researchers surveyed 150 ACOs participating in the Medicare Shared Savings Program (MSSP) or Next Generation ACO model as of July 1, 2019, to assess the prevalence of home-based initiatives.

Respondents were larger ACOs and more likely to be affiliated with a health system. Two-thirds of respondents reported some home-visit activity, while 25 percent had formal programs, 25 percent provided occasional home visits, and 17 percent were actively developing programs.

The study focused on the 40 ACOs that had formal home-visit initiatives in place. Over half of these ACOs (58 percent) participated in a Medicare ACO arrangement with downside risk.

There were 49 home-based initiatives reported among the ACOs. The most common initiatives focused on home-based primary care (37 percent) and care coordination (24 percent). Between 11 and 13 percent of ACOs had initiatives focused on care transitions support, addressing social needs, and acute hospital-level services.

Many respondents reported using other services to supplement their program’s primary function, including care coordination, addressing social determinants of health, palliative care, and acute urgent care services.

Most of the ACOs leveraged multidisciplinary teams for their home-based programs. Nearly half of the programs included physicians, 65 percent used nurse practitioners, 85 percent used registered nurses, and 70 percent had social workers.

While these programs can help improve care for vulnerable populations, their sustainability requires funding, posing a barrier for some ACOs.

Around half of the programs received funding from billed services (54 percent) and shared savings from value-based contracts (52 percent). Forty-six percent of programs received funding from institutional support, 15 percent had grant funding, and 7 percent received direct support from health plans.

The most common major factor significantly challenging ACOs considering home-based care programs was demonstrating return on investment (ROI), with 45 percent of ACOs expressing concern about it, the report found. Three in ten ACOs cited engaging physicians to refer patients for home-based services as a major challenge.

The lack of ROI may dissuade ACOs from implementing home-based programs or expanding their current programs, researchers said. Forty percent of respondents said they plan to expand their home-based programs, while 38 percent reported they would expand only if the program demonstrated a positive ROI.

“This is critical because many organizations are reluctant to invest in new programs designed for cost savings rather than revenue generation,” the report stated.

Shared savings models, like MSSP, make it complicated to measure ROI because ACOs will not benefit from home-based program savings unless they see sufficient overall savings. ACOs that earn shared savings under MSSP do not see the payments until nine months after the performance year ends, leaving ACOs to fund new programs with their own capital.

Under Medicare’s ACO REACH model, providers can choose to receive prospective monthly payments per beneficiary, which may help ensure positive ROI.

Researchers recommended several other policy changes that could help strengthen the financial viability of home-based programs for ACOs.

Policymakers should extend home-visit waivers to MSSP ACOs taking downside risk, expand hospital at home waivers to independent medical groups, and solidify Medicare coverage for telehealth services to improve ACO participation in home-based programs, researchers concluded.