In its eighth year in a demonstration program through the U.S. Centers for Medicare & Medicaid services, Northwell Health’s House Calls program was awarded $5.7 million in federal incentives based on its superior home-based primary care to chronically ill and frail seniors at home.
Known as Independence at Home (IAH), the federal pilot program, as part of the Affordable Care Act, was established in 2012 with 19 programs. CMS analyzed program performance data from Jan. 1, 2021, to Dec., 31, 2021, the most recent time period for which data is available.
According to Dr. Zenobia Brown, associate chief medical officer and senior vice president of Population Health Care Management at Northwell Health Solutions, “Northwell led the nation for quality and cost savings, which are core to our House Calls program. It delivers patient-centered care effectively with a specialized multidisciplinary team working together to reduce unnecessary emergency department and hospital visits that are inherently costly and unwanted by the patient if their care can be effectively delivered at home.”
While many patients and families enrolled in Northwell’s program were already accustomed to using remote technologies including telemedicine, this was accelerated by the COVID pandemic, Brown noted.
“With an otherwise totally disrupted healthcare system and communities being urged to ‘stay at home,’ our House Calls program was able to keep fully connected with our patients and address clinical and social needs during the pandemic, including implementing a homebound vaccination program in order to reduce the risk of patients contracting and later being hospitalized with COVID,” said DBrown.
In addition to improving health outcomes in older patients with complex health needs, Northwell’s clinicians reduced costs during the program’s eighth year to $44,820 per patient per year – a 33 percent total cost of care reduction.
That represents an overall savings to Medicare of more than $8.5 million. During the most recent year of the demonstration project, Northwell’s House Calls practice provided care through its IAH program to 582 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 $3,735 per month.
Northwell had the highest savings performance among the seven demonstration sites nationwide.
After accounting for Medicare withholds, Northwell earned more than $5.7 million in incentive payments. CMS awarded a total of $12.4 million in incentive payments to all seven of the participating practices nationwide that succeeded in reducing Medicare costs and met quality goals.
Currently, Northwell serves approximately 2,000 homebound patients, having increased over 30 percent in the last year fueled by need and partly geography, with plans for expansion. Patients are served in Staten Island, Brooklyn, Westchester, Queens, Manhattan and Long Island.
To date, Northwell’s House Calls program has been awarded a total of $21.5 million in incentive payments while realizing a total cost savings of $35 million to CMS. All federal incentives received are reinvested back into the House Calls program.
“We partner with patients and caregivers to develop individualized treatment plans so they can live in accordance with their wishes,” said Dr. Konstantinos Deligiannidis,, Northwell’s House Call’s medical director. “The pandemic tested us, but with our creative and resilient team, we were able to provide an intense level of service to vulnerable patients. Programs like Independence at Home are only successful because they involve integrated teams of health care professionals working in concert 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, such as ultrasounds, radiology, electrocardiogram, 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 during the week. The team is also 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 bring highly trained community paramedics to patients’ homes to assess and treat them, helping to avoid unnecessary emergency department visits or hospitalizations.
Deligiannidis noted that House Calls’ top performance in IAH was achieved through collaboration with key programs across Northwell, including its Nurse Clinical Call Center, Center for Emergency Medical Services, Home Health Care Agency and Hospice.
“House Calls’ high-touch model addresses acute and chronic medical issues quicker; we intervene early to reduce exacerbations of chronic medical conditions and reduce hospitalizations and ED visits through proactive action in a systematized way – this is built into our DNA. We guide patients and their loved ones throughout their health care journey,” said Deligiannidis.
To qualify for incentive payments, IAH practices must meet three of six performance measures; Northwell’s House Calls achieved all six quality measures. They include follow up contact within 48 hours of a hospital admission, hospital discharge or emergency department visit as well as medication reconciliation upon returning home; documentation of patient preferences; hospital readmissions within 30 days for ambulatory care sensitive conditions; and emergency department visits for ambulatory care sensitive conditions.
For more information about the federal Independence at Home program, visit:
https://innovation.cms.gov/innovation-models/independence-at-home