Innovation and Strategy as Care Moves Home

By Matt Phillion

CMS recently released a report focusing on its strategic vision for implementing value-based care at scale and how ambulatory providers can achieve better coordination across the care continuum at lower costs. The November 2022 report, Person-Centered Innovation – An Update on the Implementation of the CMS Innovation Center’s Strategy, looks at strategic objectives to drive accountable care, advance health equity, support innovation, address affordability, and foster partnerships to drive system transformation—all topics that have been top of mind in the patient safety and quality sphere over the last few years.

“Many of the themes—driving accountable care, continuing to move toward value-based care through different models—continue to be a common thread between administrations,” says Lissy Hu, president of connected networks at WellSky. “It’s exciting to see that these areas are receiving increased interest, as stakeholders across health and community care are working hard to make elevated outcomes at a lower cost the standard.”

Policy and focus are always likely to shift as administrations change, but CMS’ latest report made it clear that we should continue to see alignment around evolved care models. “While there weren’t any surprises, it was good to get confirmation that we’ll see more of this drive to accountable care, embedding some of the pieces and solidifying around health equity,” says Hu.

CMS holds that innovation and experimentation should continue, but not at a pace that overwhelms the industry with options. “Elizabeth Fowler [the deputy administrator and director of the Center for Medicare and Medicaid Innovation] has discussed the continued need for experimentation,” says Hu. “The number of models out there for providers is a lot. A couple of things on the menu is good, but 20 is very difficult to operationalize.”

For example, if a patient is in an accountable care organization (ACO) and in a bundle, there are rules for when the bundle takes precedence over the ACO. These divisions can be confusing. “They’re an ACO patient, but once they’re in the hospital and qualifying conditions occur, they’re now in the bundle program. How does this all work?” says Hu. “All the operational parts of that are difficult.”

ACOs require alignment to achieve scale. “I don’t think the experimentation phase is over, as there’s more discussion and focus on many of these topics,” she says. “For example, let’s look at health equity. How do we bring health equity data into these value-based payment models?”

There are also calls for more physician integration of care, rather than systems. For example, how can the industry integrate specialty and primary care as a core component of care? “It’ll be interesting to see, given their focus on specialty care and primary care in general, how they try to get the ambulatory space into more value-based care,” says Hu.

In particular, there’s been discussion around kidney care choice models, specifically on methods to delay the need for dialysis and address kidney transplantation. “This has really tried to bring in that chronic care model, bringing together the primary care physicians, nephrologists, and so on,” says Hu. “What other kinds of accountable care could this extend to with conditions that require specialty care? It’ll be interesting to see what they do around specific areas such as cancer and oncology practices.”

The focus on ambulatory care

The role of ambulatory care continues to change due to the growing focus on accountable care.

“Obviously the ambulatory care setting is lower cost,” Hu says. “As we think about the shift to value-based programs, ambulatory is going to be involved as we look for ways to take care of more patients outside of an institutional setting.”

After ambulatory, the next space to watch is home-based care. “We’re going to see more of a shift to home-based care, but who is going to be managing what happens to these patients in the home?” says Hu. Is it the home health nurse, or someone else?

“For a patient in an institutional setting or skilled nurse setting, all of this is taken care of by the skilled nursing facility,” says Hu. “If they’re going home, someone’s got to do a lot of that care coordination. That’s going to be the domain of the physician in the clinic, some combination of primary care, specialty care, and those embedded within those practices.”

Hu notes that the CMS document addresses specialty integration models. One example calls out a listening session around dementia care and the challenges beneficiaries face.

“Lack of coordination with home-based care, lack of support with physicians, complexity in navigating multiple providers—including primary care, neurologists, physical therapists, psychiatrists—a lot of those themes call out a lack of coordinated home-based care,” says Hu. “These gaps have largely fallen on the health system or skilled nursing facilities. We’re now seeing it called out for specialists and primary care physicians.”

The shift to home-based care ties together all these focuses. “It’s a nexus for many of the themes CMS is saying are important,” says Hu.

Is the industry ready?

While none of the topics CMS broaches are new, there’s still a lot of work to do, and patients have made their desires clear. “The horse is out of the barn, just because of patient preference,” says Hu. “The increase in patients going to home-based care will continue to grow.”

WellSky is seeing a 120% increase in referrals to the home compared to pre-pandemic. “That’s millions of patients who are now choosing to recover at home,” says Hu.

Hu thinks we can see continued success with this transition, if we manage it smartly. “We need technology to support that work,” she says. “In the past, what we might have done to address more care coordination around home-based care is hire more people, but that’s impossible now. We have staffing shortages across the entire care continuum, and those staffing shortages are only going to get worse.”

And, of course, any new hires will still need training, which can’t be done overnight. “You can’t just hire your way out of that,” says Hu. “The only answer is technology, things you can automate. Instead of a nurse picking up the phone and calling the hospital to set something up, you have got to have technology that gives you real-time data and communicates with other caregivers. You can’t do it manually.”

Since the pandemic began, WellSky is seeing more adoption of technology due to the ongoing workforce shortages. Physicians are actively seeking this technology because they see it being leveraged in acute care settings for tasks such as sending referrals, while doctors’ offices are still often tied to phones and faxes. “They know there’s a better way and they want to get in on it,” says Hu. “With more volume and less staff, they can’t hire their way out of it.”

Much of the CMS report focuses on increasing investment in value-based program models and looking at how these funds are deployed, what’s needed to improve, and what the answer is if more staff isn’t an option.

“I think in the next year we’re going to see that focus on really delivering care coordination in the home become front and center,” says Hu. “There’s been a lot of conversation around it; we’ve seen the trends and a lot of models, but how can we scale those models?”

In the past, there have been a lot of unprofitable models, and we’re now seeing organizations look for financially viable ways to deliver care at scale. “It’s at the nexus of these trends that CMS has laid out, driving accountable care, equity, and affordability,” says Hu.

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