Improving Outcomes for Vulnerable Patients With Comprehensive At-Home Care

By Matt Phillion

If the healthcare has learned anything over the past few years, it’s the need for change and improvement to systems and processes, particularly those related to care delivery for vulnerable populations.

Organizations like Emcara Health were already working toward more interconnected, at-home delivery of care even before the COVID-19 pandemic, and over the past few years they saw the concept become top of mind for the industry.

“Truly, patient-centered medical care at home is the most effective way to overcome significant challenges people face to living the healthiest life possible. One of the silver linings of the pandemic, if there is one, is that it accelerated people’s openness and awareness of the value of care in the home,” says Chris Dodd, MD, chief medical officer with Emcara Health. “Both from a personal perspective—where if you can have a doctor or nurse come to you and you don’t have to go to a brick-and-mortar setting, that’s a win—but also from the provider and payer perspective.”

One of the unfortunate consequences of the pandemic was a rise in patients delaying preventive care or management for chronic conditions to avoid the risk of going into a hospital. But Emcara Health has the tools to meet patients where they are.

“We’ve been delivering care in the home long before it became a trend,” says Dodd. Emcara Health had already established at-home care in rural and urban settings, with high satisfaction scores showing their patients’ appreciation.

A unified front for care

Patient-centric care in the home offers a solution to one of the more common challenges for healthcare in general: the siloing and fragmentation of services.

“If you look at the healthcare delivery system on a macro level, it doesn’t look very organized—it’s fragmented and chaotic,” says Dodd. “Picture a Jackson Pollock painting. Over the last number of years, the industry has been developing point solutions, where one company will take care of your kidney [and] another handles behavioral health. And while there’s some value to those solutions, it’s unfortunately increased the complexity and fragmentation, which has increased the administrative burden.” This is overwhelming for patients, but especially overwhelming for the most vulnerable of patients.

“The reality is that the industry is not achieving the outcomes we know it can achieve, and it’s not making healthcare more affordable,” says Dodd.

To rectify the pitfalls of a fragmented delivery system, Emcara Health believes in “the delivery of advanced primary care with a foundation in the home,” Dodd says. “We want to bring as much of the continuum of care under our umbrella as we can so that we have the ability to provide a more coordinated, focused, unified delivery of care so it’s much simpler for patients and family and caregivers.”

This concept of a coordinated continuum of care has the effect of reducing fragmentation, duplication of services, and overall costs while enhancing the care received.

“Tinkering with the current system is not really working,” says Dodd. “Costs keep going up; we’re not getting outcomes we want; inequities in terms of population health are increasing. What we’ve demonstrated is by radically transforming the delivery model, we’re able to generate better outcomes.”

Advanced primary care

The advanced primary care model brings a spectrum of roles to the team, from physicians, nurse practitioners, and physician assistants to case managers, behavioral health professionals, and even pharmacists.

“It’s the ability to have a ‘Batphone’ to someone who is going to pick up,” says Dodd. “A lot of people, if they call their PCP after hours, they end up being sent to urgent care. Our team understands their situation and can provide counsel to help keep them healthy, home, and out of the hospital.”

The payment methodology is also important with this type of delivery method, says Dodd. “For it to work, it has to be paid for in the right way,” he says. “It can’t be a traditional fee-for-service model where you get paid to do more.” So, all of Emcara Health’s partnerships are value-based. “If we do it well, there’s savings opportunities.”

One partnership, a large regional health plan, was value-based, but the plan had found that its most in-need population segment wasn’t getting the healthy outcomes that should have occurred given the plan’s quality of care.

“They invited us to partner with them and their network as a provider for advanced primary care, but we did it in partnership with their patients’ PCPs based in the community,” says Dodd. “Almost all of them were based in brick-and-mortar settings. We were able to wrap around the delivery network, specifically the persistently high-cost population, those patients on a lot of medications who are managing multiple chronic conditions, and so on.” Together, they were able, through home-based health, to reduce ER visits and hospitalizations among those at-risk populations.

There’s a lot of gamesmanship in the value-based system, Dodd notes. Organizations take on risk but benefit from “regression to mean” with patients who were going to get better anyhow.

“We focus on caring for the people most in need, most in crisis, who are not going to get better if you do nothing,” says Dodd. “When we show up there’s sometimes a little hesitation, but when providers see these are the patients we’re here to help, their shoulders go down. These are patients who aren’t getting better, and it’s frustrating, and that’s not because the PCPs aren’t doing great work. But within the existing system, there’s a lot of hoops people have to jump through, and it makes it difficult for vulnerable populations to access care. So we’re taking a lot of barriers away.”

Health workers in the community

Advanced primary care in the home addresses one of the specific hurdles for at-risk patients—the social determinants of health that get in the way of seeking out basic care. “You can have the best plan for their heart condition, but if you don’t address the social barriers, forget about it,” says Dodd.

To this end, Emcara Health has prioritized scaling its community health worker role: laypeople who are natural helpers or community leaders. These workers identify and focus on social barriers, working with patients, families, and community-based organizations to overcome them.

“Often that’s the first thing we do: building time to build those relationships and identify what’s most important to people,” says Dodd. “If you overcome those social barriers to health, then you can get to figuring out an insulin regimen they need to be on.”

These community health workers receive training and knowledge enhancement to better their skills, but they start with something that can’t really be taught, Dodd says. “A common saying at Emcara Health is we hire for the heart and train the brain,” he says.

Telehealth versus in the home

Another transformative part of the pandemic was the growth of telehealth, which Dodd says is a two-sided coin.

“Yes, there’s value, but for vulnerable populations, it won’t solve the quality/safety/cost conundrum,” he says. “But on the flip side, when caring for patients who live in more isolated areas, the ability to scale a community health worker role where they can be with the patient while getting a physician or nurse practitioner to do a consult remotely makes a big difference.”

This type of care can help get ahead of the game for patients who are “low cost today but high cost tomorrow,” says Dodd. “If we can get into the home and see what’s really going on, and combine those insights with the right care, right place, right time … I really can’t say enough about being in the home. With a senior, for example, you can spot all the fall risks. A bathroom that isn’t equipped for a frail individual. Food insecurities for diabetic patients.”

All of this personal, on-the-ground knowledge can benefit the bottom line as well.

“At a macro level, you might look at population health management and think things are going really well, but if you segment out the portion of the population that is really responsible for driving the costs, that population needs, and is sort of demanding, a radically different care delivery model,” says Dodd. “Providers are increasingly seeing a need to partner with groups for house calls for those vulnerable populations to get better results and close that continuity chasm. Payers are seeing that too. There’s a recognition that there’s a different path forward to manage this population most in need.”

Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at