Bringing comprehensive care to patients in their homes

When people are living with multiple serious health conditions and dealing with limited – or no – mobility, getting the health care they need can be a major obstacle. That’s where home-based care can make a difference in their quality of life as well as their health.

“These individuals can’t access the health care system, so we are bringing it to them,” said Melissa Steffan, president of Evernorth Home-Based Care. “Without access to care, they just get sicker and sicker. We’re coming in and providing a care model that is designed to take care of these patients vs. having them try to navigate the traditional health care system, because that doesn’t work for them.”

Melissa Steffan

Jack’s story

Home-based care can make a tremendous difference in a family’s quality of life. “There are many examples, but one that stays with me is Jack, a patient with COPD,” Steffan said. “Over the four months before he enrolled in home-based care, he saw his primary care physician only once – and he was hospitalized 11 times. If he had to leave his house, he needed to be transported by ambulance.”

Patients like Jack who are suffering from chronic obstructive pulmonary disease have damaged airways, which makes breathing difficult. Jack needed to be on oxygen around the clock, but his oxygen tank held only a two-hour supply. In addition to his lack of mobility, his fear of running out of oxygen kept him homebound. He also was unable to read medicine labels and had a poor understanding of how his medicines worked and when he needed to take them. The cost of his care was another hurdle.

After Jack enrolled in Evernorth Home-Based Care, his new primary care physician and nurse practitioner visited regularly, making 19 visits to his home in the first eight months. They got to know Jack and his wife and were able to identify and address numerous barriers to optimal health. 

“He was still very ill, yet he was hospitalized just five times over those months, a reduction in frequency of about 75%,” Steffan said.

When the team learned that Jack faced literacy challenges, they color-coded his medications according to the time of day he needed to take them. They brought him an oxygen tank that lasted six hours, easing his mind when he needed to leave the house. Jack told them that he had sometimes delayed care due to costs, so they identified and implemented affordable alternatives. 

“Our teams have a passion for improving people’s lives,” Steffan said. “There is an intense bond between our patients and our teams.”

How Evernorth Home-Based Care works

The organization partners with numerous clients – including health plans, provider groups, and accountable care organizations – to provide home-based care to their patients with multiple chronic conditions. Evernorth Home-Based Care operates in seven states with plans to expand, Steffan said, and employs about 800 people.

Clients identify which of their members could benefit from home-based primary care. Each patient is dealing with three or more chronic conditions, such as congestive heart failure, diabetes, dementia, hypertension, and kidney disease. Many – like Jack – are also dealing with adverse social determinants of health (SDOH).

Our interdisciplinary care teams include primary care physicians, nurse practitioners, nurses, social workers, and behavioral health providers. Team members work in tandem to address their patients’ medical needs. This includes monitoring chronic conditions, providing wellness and preventative care, and prescribing medications and other treatments, such as physical therapy.

“We are delivering primary care to people in their homes,” Steffan said. “Our patients can’t go to a clinic because they’re so sick – so we go to them. If a patient needs to see their primary care doctor every two weeks because that’s how ill they are, that’s what we do.”

Beyond that, home-based care allows the team to see the full picture. “If a home lacks heat or food, we can step in to help identify resources. We can help find transportation or make connections, such as arranging for food deliveries from Meals on Wheels. When someone would benefit from physical therapy, we coordinate that care in their home,” she said. “There’s an intensive bond between patients, caregivers, and the care team.” 

The growing need for home-based health care

Older Americans are more likely to remain in their homes, including in retirement communities and senior housing, while they are less likely to live in nursing homes or utilize other types of residential care. Among people 72 or older, 87.5% live in traditional community settings, up from 84.2% 10 years earlier.

At the same time, the American population’s average age is higher than ever, and that trend is predicted to continue over the next 25 years. By 2050, almost 1 in 4 Americans will be 65 or older, compared with less than 1 in 5 today, according to the 
U.S. Census Bureau.

These two trends converge in a third: the rise of polychronic health conditions. By 2030, an estimated 83 million Americans will have been diagnosed with three or more chronic conditions – up sharply from 30.8 million in 2015.

As the prevalence of chronic conditions escalates, so do costs to the U.S. health care ecosystem. The average health care costs of a patient living with one chronic disease is $6,032 annually. Health care expenditures for people with chronic conditions add up to $4.5 trillion annually, which represents 90% of total health care costs.  

“Addressing the needs of this population requires new approaches,” Steffan said. “Home-based care is effective and efficient, especially for medically complex patients with multiple chronic conditions.”