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How Direct Contracting Transforms Home-Based Primary Care

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How Direct Contracting Transforms Home-Based Primary Care

Home-based primary care has historically been a high-value but low-volume service due to logistical hurdles such as drive time and patient complexity. The resulting low fee-for-service revenue made scaling difficult. This year, with the introduction of its direct contracting model—made possible by creating direct contracting entities (DCEs)—CMS has created an economic engine to fuel the expansion of home-based primary care.

Alignment with Value-Base Primary Care

Building on earlier Medicare Advantage Plans and Medicare Shared Savings Programs, including the NextGen Accountable Care Organization (ACO), direct contracting aims to improve outcomes for beneficiaries with chronic health conditions while lowering healthcare costs.

Primary care providers who elect to become participant providers in the program are compensated based on outcomes instead of volume associated fee-for-service revenue. A fixed amount paid monthly per patient gives participant providers a reliable revenue stream that grows with each patient they add under the program.

Beneficiaries who choose direct contracting enjoy greater access to enhanced services, including at-home care, at no additional cost and without losing any of their coverage privileges and benefits.

More Flexibility for Primary Care Providers

DCE lifts restrictions and puts decision-making into the hands of primary care providers, enabling them to optimize treatment plans and decide how and where medical care is provided, including at home. Plus, participant providers can reduce their administrative burden by aligning with DCEs that take this on. This allows them to spend time with patients and develop innovative, individualized treatment plans that help manage disease and improve quality of life.

DCE Benefit: Reduction in Hospital Stays, Increase in DCE Revenue

Home-based primary care providers know the sickest patients benefit from home care. For instance, 65% of patients are hospitalized in the last 90 days of life, and 29% are in the ICU in the last 30 days, which increases risks and costs. With improved access to home care, we have found that only 37% are admitted to the hospital, and 5% are in the ICU, with the rest remaining at home where they most want to be, according to studies.1

For example, in a population of 10,000 DCE lives, 5% (500 patients) of the sickest patients would be targeted for home-based primary care. These 500 patients under Medicare fee-for-service could potentially generate an estimated annual revenue of $1.2 million compared to $16.3 million with direct contracting. The $16.3 million covers all costs, including but not limited to hospital stays, rehab, home health and hospice, primary care, specialists, and ancillaries.

Choosing the Right DCE

The future looks bright for home-based primary care, but participant providers must wisely choose the DCE they align with. Although CMS describes direct contracting as a risk-sharing arrangement, there’s virtually no risk for participant providers aligned with a top-tier DCE such as VillageMD, which assumes up to 100% of the risk and is capable of managing costs within their allotted CMS budget.

When evaluating DCEs, I recommend you look for one experienced in contracting with CMS, and that leverages advanced technology to provide the patient-level data and tools required to successfully meet the needs of medically complex patients. Additionally, a DCE must be knowledgeable about benefit waivers, including waiver of the homebound requirement for home health to preferred networks, and contract with private duty home aid companies and other healthcare specialists to support their participant provider’s decisions for specialized care. Choosing the right DCE will help ensure success for everyone involved.

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By Thomas Cornwell, MD
Senior Medical Director of Village Medical at Home

1Teno; Site of Death, Place of Care, and Health Care Transitions Among US Medicare Beneficiaries, JAMA 2018

Reclaiming Chronic Wound Care: Understand and Address the Barriers to Wound Healing

Reclaiming Chronic Wound Care: Understand and Address the Barriers to Wound Healing

The statistics are staggering. Chronic wounds are a burden to patients, caregivers, care providers, and our healthcare system. Approximately 6.5 million people, or about 1 in 38 adults, are affected by chronic wounds each year in the US1,2. Annual cost estimates for managing chronic wounds range from $28.1 to $96.8 billion3. Three million people worldwide experience venous leg ulcers4. In 2019 alone it was estimated that 463 million people were living with diabetes worldwide, and up to 15% of patients with diabetes have a foot ulcer at some stage5,6. Devastatingly, every 20 seconds of every day someone, somewhere, loses a leg because of diabetes6.

However, let us not only consider the statistics. Chronic wounds can have a significant impact on individuals’ lives. Diabetic Foot Ulcers (DFU), for example, can be painful and limit social activities, leading to reduced Quality of Life (QoL)7. Goodridge et. al., compared QoL parameters in 104 patients with healed and unhealed DFUs (presence ≥6 months considered unhealed) and found that the impact an unhealed DFU can have on QoL is comparable to that of myocardial infarction, breast cancer, or chronic obstructive pulmonary disease7. Because of this, Smith+Nephew’s aim is to assist clinicians in creating effective and efficient paths to help prevent wounds and prevent delays in wound healing.

With over 160 years of experience in the medical industry, Smith+Nephew offers customized education in wound prevention, assessment, and treatment across the care continuum. Come join Smith+Nephew on October 28th for an interactive session exploring The T.I.M.E Principles of Wound Bed Preparation and its application in the management of two of the most challenging types of chronic wounds: DFUs and Venous Leg Ulcers (VLU). The concept of T.I.M.E was first introduced in the Journal of Wound Repair and Regeneration in 2003 by an international panel of wound care experts which included physicians, nurses and researchers8. The panel identified 4 major barriers to wound healing and used the T.I.M.E acronym as an easy reminder of those barriers: Tissue nonviable or deficient, Infection or inflammation, Moisture imbalance, Edge of wound non- advancing8.

Join us October 28th for a pre-conference session titled Wound Care for My Home-based Patients – HELP! Engage in this case-based discussion on applying the validated T.I.M.E Principles of Wound Bed Preparation to your clinical practice.

SmithNephew logo

Bridget Carey MSN, RN, CWCN
Mandy Spitzer MBA, RN, CWOCN, CFCN
Smith+Nephew Medical Education

For over 160 years, Smith+Nephew has taken a pioneering approach to product design and services. Alongside our customers we won’t settle until we’ve solved the challenges of preventing and healing wounds, because they hold back too many lives.


  1. Järbrink K, et al. Syst Rev. 2016;5:152.
  2. National Population by Characteristics: 2010-2017. United States Census Bureau Web site. Accessed January 9, 2018.
  3. Nussbaum, Samuel & Carter, Marissa & Fife, Caroline & DaVanzo, Joan & Haught, Randall & Nusgart, Marcia & Cartwright, Donna. (2017). An Economic Evaluation of the Impact, Cost, and Medicare Policy Implications of Chronic Nonhealing Wounds. Value in Health. 21. 10.1016/j.jval.2017.07.007.).
  4. Johnson J, Yates S & Burgess J. Venous insufficiency, venous ulcers and lymphedema. In Doughty D & McNichol L (Eds.). Wound, Ostomy and Continence Nurses Society Core Curriculum: Wound Management. 2016: 385-419. Philadelphia: Wolters Kluwer.
  5. International Diabetes Federation. IDF Clinical Practice Recommendations on the Diabetic Foot 2019.
  6. Adiewere P, Gillis RB, Imran Jiwani S, Meal A, Shaw I, Adams GG. A systematic review and meta-analysis of patient education in preventing and reducing the incidence or recurrence of adult diabetes foot ulcers (DFU). Heliyon. 2018;4(5):e00614. Published 2018 May 2. doi:10.1016/j.heliyon.2018.e00614
  7. Goodridge D, et al. Quality of life of adults with unhealed and healed diabetic foot ulcers. Foot Ankle Int. 2006;27(4):274–280. (n=57 unhealed DFU ; n=47 healed DFU).
  8. Leaper D, et al. Extending the TIME concept: What have we learned in the past 10 years? Int Wound J 2012; 9 (Suppl. 2):1–19.).

Preventative Services As A Lens Into The Home

doctor using computer with tech graphics

While there are many benefits to quality preventative healthcare for the general population, such as averting disease before it occurs and intervening at the earliest stage, this care is arguably more consequential to the 4 in 10 adults who already have two or more chronic conditions. For this patient population, many of whom are older adults, tertiary preventative care can drastically improve their quality of life and determine whether they can comfortably and safely remain in their home or not.

Of course, traditional care delivery has its limits. Patients must physically travel to receive it, which can be difficult and time-consuming for seniors with chronic conditions. Traditional in-office care has other, non-physical limits too. One of the most important elements of preventative care is educating patients about their condition and treatment options, which should be tailored to their personal lifestyle, preferences, and challenges. When discussed in a traditional office setting, often these factors can be clouded by the patient’s potentially inaccurate representation of their life.

Through virtual care and technology like telehealth and remote patient monitoring, primary care physicians can work more closely with boots-on-the-ground homecare providers to efficiently and effectively address these social determinants of health. Below are three important but often overlooked indicators of a patient’s health that typically fall within care gaps. With a combination of home care and virtual care, providers can better address these challenges and incorporate adaptations into the patients’ care plans.

  1. apple-food-icon The Food In Their Fridge - This is not necessarily a traditional screening question, and even when a physician does ask there is no guarantee the patient will relay that information accurately. This is crucial, however, because generally understanding what a patient is eating can be an important indicator of their overall health. A 2020 report found that 7.3% of the senior population was food insecure — a problem that was likely exacerbated by COVID-19. If a home care physician sees indicators of an unhealthy diet and alerts other members of the care team, they may consider deploying an RPM tool like VAL’s glucometer to monitor the patient’s blood sugar more regularly or engage family members in a telehealth visit to discuss ways to ensure access to healthy foods. This narrow lens into a patient’s life (and refrigerator) can provide insight on how to better manage a patient’s diabetes, cholesterol, or other chronic conditions.
  2. bed-icon Where They Sleep - Non-traditional preventative home care can also offer a lens into where/how a patient generally sleeps. Sleep quality can be an important two-way factor in a patient’s health -- it can be both the cause of health challenges and an indicator of existing conditions worsening. According to the Sleep Foundation, poor sleep may be an indicator of depression, anxiety, heart disease, diabetes, arthritis, and more. Poor sleep quality also has negative effects on a patient’s health, resulting in memory issues, mood changes, weight gain, and increased risk of diabetes and heart disease. Highly sensitive bedpost smart pads, like those by UDP Labs, can collect data on a patient’s sleep as high-quality as an EKG. This can alert the care team to any anomalies like excessive or insufficient sleep and dispatch assistance accordingly.

  3. apple-food-icon Their General Surroundings - Whether there are clear concerns, like hoarding or keeping piles of untouched medication bottles on the counter, or more subtle indicators, like a steep staircase or an answering machine full of un-listened-to messages, observing a patient’s general surroundings may be one of the most important ways that home healthcare can support and inform their greater care plan. These observations can relay information about medication adherence, risks of falls in the home, or possible mental health or mobility challenges that prevent them from responding to phone calls. Subtle observations by a home care provider can bridge these gaps in care and connect patients with services like MyndYou’s AI-enabled voicebot, which detects cognitive and mental health decline.

The insight at-home preventive care provides, combined with new and exciting advances in virtual care, can go a long way towards addressing a patient’s social determinants of health and providing more effective preventative care. This hybrid model has the potential to vastly improve home care, allowing patients to age at home safely and comfortably.

David Hunt
Founder & Chief Marketing Officer
Cosán Group

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Learn more about Cosán Group here.


Give Your Home-Based Care Program a Leading Edge with the Right Technology

doctor using computer with tech graphics

If you have implemented a home care medical model or are moving your practice in that direction, your profitability depends on having effective systems and high-level insights. You need technology solutions that improve your ability to manage care without adding administrative burden to your staff. In this article, edited from an earlier one published on Acclivity Health Solutions’ website on June 8, 2021, we review five important ways that technology can help you track your patients’ health status, monitor and schedule care appropriately, and utilize your resources efficiently.

ai-icon  1. Predictive Analytics Help Ensure Proper Level of Care

One of your primary goals is to match the level of home care with the changing physical, emotional and social needs of your patients and their families. This can be difficult when you rely solely on feedback from these individuals.

Predictive analytics is an important development in advanced care management, working to solve the knowledge gap. Specialized tooling that combines claims and real-time patient data, Artificial Intelligence, and machine learning can help you determine the current care needs of patients with advanced illnesses and predict when they may need a higher or different level of care.

There are multiple benefits to a technology platform that includes predictive analytics. Most importantly, it can be used to identify patients in your community who can benefit from palliative or hospice care sooner. It can also help you anticipate changing staffing and equipment requirements and schedule staff and other resources in a more consistent way that reduces staff burnout and improves quality scores for value-based care contracts.

real-time remote monitoring icon2. Real-Time Remote Monitoring Creates More Connected Healthcare Ecosystem

Use technology to assess a patient’s condition remotely and alert you when indicators predict a patient needs additional care. A real-time monitoring system should enable the patient, their proxies, and/or your staff to complete data entry at the point of care. It may include the ability to track symptoms and vital statistics so you can assess a patient’s current condition and pinpoint whether they are stable, need more monitoring, or are nearing the end of life. When your data lives on a shared platform that everyone can access, you empower the entire care team to work together to improve care coordination and communication.

Real-time remote patient monitoring not only keeps clinicians connected with patients and their families between visits, it can also be used to assess for signs of caregiver breakdown and determine when to intervene and provide caregiver support.

phone alert icon3. Event Notification Helps Contain Costs

Most value-based care contracts penalize you for over-utilization of treatments and services. In order to prevent unnecessary hospital utilization or readmissions, you can use technology to ensure that your patients or caregivers call you first when they require care for an emergency that can be handled at home.  

There will be times when patients panic and call 911. With an electronic alert system in place, you can ensure you remain their primary care provider by being notified in real-time when a patient of yours enters or is discharged from an Emergency Department or hospital or transitions between levels of care.

telemedicine phone doc icon4. Telemedicine Connects Patients with Clinicians

The COVID-19 pandemic accelerated the use of telemedicine across the care continuum. Telemedicine has allowed home care medicine doctors and staff to stay in frequent contact with patients and families securely and safely. As the pandemic wanes, telemedicine will likely remain an effective way for clinicians and patients to interact. While renumeration for telemedicine visits post-COVID is still uncertain, CMS has acknowledged it will most likely continue to support it.

Offering telemedicine options may require additional education for both staff and patients who are not familiar with the technology. You can minimize the amount of training required by investing in programs that are intuitive and offer step-by-step guidance.

doctor on computer screen icon5. Family And Caregiver Education

Patients with advanced illness may be facing a terminal prognosis that qualifies them for palliative care or hospice.  The success of hospice depends on how well patients and their families accept their prognosis and understand the way hospice care works. Video and audio programs as well as interactive education modules can help you guide them through the process associated with the end-of-life journey — from diagnosis to defining goals of care to options for end-of-life care. Remote learning can also help caregivers learn the triggers and indicators to report so your staff gets a more accurate view of the patient’s condition.
Now is the time to implement technology to assist with care monitoring and management, scheduling, staffing, communications, patient education, and cost control. With the right technology, your organization can position itself to operate more efficiently and remain profitable.

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Learn more about Acclivity Health here.

Patient Education: Education for the individual with multiple chronic illnesses on medication adherence and management

It is common for individuals with COPD to have multiple comorbidities. Along with this comes the necessity, in most cases, to see numerous physicians. The opportunity for mismanagement of the individual described here is great. One physician may focus solely on glucose levels and insulin or diabetes medication to prescribe or change. Another physician could be focused on blood pressure and manipulating the dosage of the medication used to treat this disease. This myopic focus can lead to mismanagement of the individual as a whole.

So, what is the solution? Or rather, how can we minimize the risk of such medication errors or mismanagement? We can educate these individuals with best-practice tools and resources. This is a vital part of patient engagement.

doctor and patient reviewing charts

Some of the chronic diseases which are of highest risk for medication error are, but not limited to:

  • COPD
  • Congestive Heart Failure
  • Diabetes
  • Hypertension
  • Depression and/or Anxiety
  • Chronic Kidney Disease
  • Heart Disease
  • Osteoporosis
  • Osteopenia

Educate patients to use these best practices

  • Work with the primary doctor to decide what matters most when it comes to care. Remember that patients can choose which treatments they want and don’t want. Think about these questions and talk to the doctor about:
    • Which health problems are the most bothersome? Which one should be focused on first?
    • What matters most: living a long time, staying independent, or having the least amount of pain or other symptoms?
    • Are any of the treatments causing side effects or problems?

  • Plan for doctor visits ahead of time. When seeing the doctor, make a plan for what to discuss and come prepared with notes or questions. Do not try to do too much at once. If necessary, make more than one appointment.
  • Make sure the primary doctor, and any other doctor or nurse who prescribes medicines, knows about all of the medicines taken. This includes any over-the-counter or herbal medications used on a regular basis. It is helpful to take the actual bottles of pills to each visit, so the doctors or nurses can review them. Ask the main doctor or nurse to go over all medicines at least once a year.
  • Keep a list of all the medicines taken regularly that includes the dose taken, the reason for taking it, and the doctor or nurse who prescribed it. Keep this list on hand and take it to all medical appointments.
  • Ask the doctors and nurses which, if any diet or lifestyle changes would improve your health problems. Some of these changes may reduce the risks and side effects of some medicines or treatments.

There are things that all people can do to improve their health. Here are some examples:

senior man exercising on patio
  • Choose a diet rich in fruits, vegetables, and low-fat dairy products that is low in sweets and processed flours. For example, choose whole-grain bread and whole-grain pasta over white bread or regular pasta.
  • Do some sort of physical activity most days of the week, and build the activity level slowly. Even small amounts of activity done several times a day can help build strength.
  • Try to get enough sleep. For trouble sleeping, talk to the doctor or nurse about possible solutions.
  • For feelings of depression and anxiety, talk to the doctor or nurse. Depression and anxiety can make other health problems hard to manage.
  • Plan activities with other people, to avoid being stuck at home and alone for days. If friends and family are not around, look at the local paper for ways to meet new people through senior centers, religious groups, libraries, garden clubs, or other activity groups.

Patient Education for the Approaching Travel Season

As we approach warmer temperatures and a time when our patients are doing more travel, we can provide some best practice tips to ensure they have the knowledge needed to stay healthy. The following tips may minimize the risk of infections, sickness, and exacerbations while they are trekking through airports, tourist venues, and exposing themselves to unfamiliar airborne germs.

What if I am traveling internationally? Those traveling to Asia, Africa, South America, or Eastern Europe, should make an appointment at a travel clinic. The doctors and nurses there can help prepare for the trip. Depending on the destination, there might be a need to:

  • Have one or more vaccines, weeks, or months before the trip. For example, if traveling to parts of Africa or South America, a vaccine against yellow fever may be indicated.
  • Avoid ice, tap water, and certain foods or parts of foods that can carry germs. Drinking untreated water or eating certain foods may result in an infection that causes diarrhea, vomiting, or other problems.
  • Treat water, to make sure it has no germs that could cause infection. To get rid of bacteria, boil water for three minutes and then let it cool. Another way to eliminate germs is to take two quarts of water, add two drops of 5% bleach, and wait 30 minutes.
  • Use bug spray containing DEET or a chemical called picaridin. Wear clothes that protect from insect bites. Plus, check yourself for insects and remove them if found. Insects carry germs, and may cause infection when they bite or sting.
  • Take medicines before and during the trip to prevent infections such as malaria.
  • Wear shoes that cover the feet entirely if walking anywhere that dog or human waste may be present in the sand or soil. Places that do not have adequate plumbing or that do not treat toilet water before dumping it, result in contaminated soil. If walking barefoot in situations like these, it's possible to acquire a worm infection.

What if I have a health condition, but I want to travel? If you have an ongoing health problem, such as diabetes or heart disease, ask your doctor or nurse how to plan for your trip.

Many people with health concerns can travel without any problems. The key is to form a plan. Make sure to have all the needed medicines and supplies. It is essential to make a list of all the prescribed medications, the doses, and reason or associated diagnosis.

Here are some examples of individual travel needs:

elderly couple dancing on holiday
  • Some people with diabetes must carry pills, insulin, and syringes when they fly. They usually have a letter from their doctor explaining their needs.
  • Some people with lung or heart disease need extra oxygen when they fly. Because oxygen content in a pressurized aircraft contains less oxygen than room air at sea level, supplemental oxygen may be required by those with pulmonary issues. People who need oxygen on the flight must arrange it with the airline before they fly. A copy of the oxygen prescription should be kept on hand while traveling. Also, pre-planning with the HME provider is needed to ensure the availability of the necessary equipment required for travel.
  • Some people with blood clotting problems or bad veins need to stand up and move around if they are on a long flight. Otherwise, they can develop blood clots. They might also need to wear special stockings that improve blood flow in the legs.

Tongue Fat Volume and OSA

Obese patients with obstructive sleep apnea (OSA) are encouraged to lose weight, but the mechanism for improvement in OSA is unknown.

A recent prospective observational study of 67 obese patients with OSA compared the MRI of the upper airway before and after weight loss. The MRI measured airway size and tongue, pterygoid, lateral pharyngeal wall, and abdominal fat volumes. In the study, reduced tongue fat volumes was the primary mediator associated with an improved apnea-hypopnea index leading to the hypothesis that reduction in tongue fat volume may be a potential treatment strategy for patients with obesity and OSA.

Learn more about Incremedical here.