By BETTY OLT //
When the New York City area became the epicenter of the COVID-19 pandemic in March 2020, the Northwell Health House Calls program – which treats chronically ill, frail seniors at home – needed to quickly pivot to provide specific care to this at-risk population.
While the pandemic tested House Calls clinicians, who continued to provide the highest quality of care to homebound patients, the program was also recognized for the sixth consecutive year by the U.S. Centers for Medicare & Medicaid Services for its success in managing chronically ill seniors through home-based primary care.
The program is part of a federal demonstration project known as Independence at Home, established in 2012 as part of the Affordable Care Act. The CMS analyzed program performance data from January-December 2019, the most recent time period for which data is available, in honoring Northwell for the sixth straight year.
“During the pandemic, our priority was to keep our House Calls patients connected and provide uninterrupted medical care,” said Zenobia Brown, medical director and vice president of population healthcare management at Northwell Health Solutions.
“We were able to offer patients Northwell’s telemedicine services in their homes, with the help of family and staff,” Brown added. “Through careful planning and mapping, House Calls clinicians offered lifesaving COVID-19 vaccines to its more than 1,500 patients enrolled in the program.”
In addition to improving health outcomes in older patients with complex health needs, Northwell clinicians reduced costs during the program’s sixth year by $12,636 per patient per year, representing 22.1 percent total cost of care reduction, for an overall saving to Medicare of more than $4.7 million.
During the sixth year of the demonstration project, House Calls provided care through its IAH program to 554 patients in Manhattan, Nassau, Suffolk and Queens. Through a highly responsive clinical model that includes continuous access, same-day appointments and a community paramedic program, House Calls reduced cost of care to $3,719 per month.
Northwell had the highest savings performance among the nine demonstration sites nationwide. After accounting for Medicare withholds, Northwell earned more than $2.9 million in incentive payments – the only program in New York State to receive CMS incentive payments. CMS awarded a total of $11.2 million in incentive payments to nine of the 11 participating practices nationwide that succeeded in reducing Medicare costs and met quality goals.
“Our patients who are older with multiple chronic illnesses are unable to receive medical care elsewhere and have made a decision to remain at home as long as safely as possible,” said Konstantinos Deligiannidis, House Calls’ newly appointed medical director. “We partner with patients and caregivers to develop an individualized treatment plan so they can live in accordance with their wishes.
Betty Olt: Home team.
“Our staff is passionate about the care it provides,” Deligiannidis added. “Programs like Independence at Home are only successful because they involve a large multidisciplinary team working together to deliver high-quality care, at the right level, at the right time and in the right place of care.”
Patients enrolled in the House Calls program receive coordinated care, similar to treatment and referrals they would receive from a primary-care physician, such as ultrasounds, radiology, electrocardiograms, lab work, physical exams, occupational and speech therapy, social work services and prescription refills.
Physicians, nurse practitioners and other clinicians are available for urgent, same-day visits. The team is accessible 24/7 to answer clinical questions from patients and caregivers.
In addition, Northwell’s Center for Emergency Medical Services works with the program to bringing highly trained community paramedics to patients’ homes to assess and treat them.
Cost savings achieved in the federal project will be reinvested to expand House Calls’ services to more patients in need, including recruiting additional physicians and increasing telehealth services.
Deligiannidis noted that House Calls’ top performance in the demonstration project was achieved through collaboration with key programs across the Northwell system, including its Clinical Call Center, Center for Emergency Medical Services, Health at Home agency and hospice services.
Participating IAH practices must meet the performance measures for at least three of the six quality measures in order to qualify for the incentive payments. House Calls achieved all six in 2019: follow-up contact within 48 hours of a hospital admission, hospital discharge or emergency department visit; medication reconciliation in the home within 48 hours of a hospital discharge or emergency department visit; annual documentation of patient preferences; hospital readmissions within 30 days; hospital admissions for ambulatory care sensitive conditions; and emergency department visits for ambulatory care-sensitive conditions.
More information about the federal IAH program is available here.
“Our team is focused on delivering patient-centered care that improves outcomes, reduces costs and alleviates pain and suffering for patients in the community,” Deligiannidis said, “by preventing unnecessary emergency department visits or hospitalizations.”
Betty Olt, LMSW, is the director of public relations for Northwell Health.
