Health Plans and ACOs

The Opportunity for Health Insurance Plans and Accountable Care Organizations

Advanced illness management is one of the few areas in healthcare where specialized clinicians can improve care for patients and their families while simultaneously lowering costs significantly. Today, over 25 percent of all Medicare costs are spent in the last year of life and costs for patients facing advanced illnesses differ significantly across geographies. Many patients often undergo unnecessary hospitalizations, skilled nursing facility visits, and ER visits in their last year of life as well as undertake treatments that not only fail to prolong their lives but are also often inconsistent with their goals of care. Patients facing a serious illness also experience severe symptoms like pain, nausea, constipation and shortness of breath that frequently go untreated, and both patients and their families often wrestle with complex emotions including fear, anxiety and grief.
At Home Support – Advanced Illness Management Program
The At Home Support Advanced Illness Management program identifies patients through a custom predictive model that targets patients suffering from serious chronic illnesses such as cancer, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), advanced dementia, and amyotrophic lateral sclerosis (ALS). The supportive care services are most appropriate for patients with advanced stages of these diseases.
The AIM services are designed to ensure that the patient receives the appropriate and necessary supportive care delivered within the comfort of the patient’s home at the time they need it most. At Home Support assigns each patient an interdisciplinary team of clinicians that include an RN case manager, a master social worker, a patient/family assistant and a core set of volunteers. This team will remain the same throughout the patient’s enrollment within the At Home Support Advanced Illness Management program. Additionally, patients and families have access to a 24/7 tele-support service and can speak with an RN in the event that you should develop an issue or need immediate assistance.
Although it can be modified to meet the needs of specific health plans and ACOs, the At Home Support service typically includes:
   • A highly effective predictive model algorithm specifically designed to identify AIM patients
   • Each patient is assigned an interdisciplinary team that includes an RN case manager, a masters social worker, a patient family assistant and a core set of volunteers.
   • The RN case manager conducting an initial comprehensive assessment that examines all aspects of a patient’s status (e.g., physical, psychosocial, emotional, spiritual)
   • This initial assessment documents all the patient’s conditions and can be used for HCC coding
   • The interdisciplinary care team then develops a comprehensive care plan for each patient based on that patient’s specific goals and needs
   • This care plan is developed in conjunction with the patient’s PCP and specialist physicians, who are also kept up-to-date on and involved in any changes to the care plan
   • The patient receives frequent home visits from the supportive care team based on the patient’s specific needs
   • At Home Support also provides 24/7 support to patients and families, including in-home visits at any time of the day or night when necessary
   • The patient’s status, care plan and progress are tracked through a comprehensive information technology system that can produce a wide variety of reports for patients, caregivers, physicians and health plans
Specific research has proven that the At Home Support Advanced Illness Management program can reduce overall medical costs by 30 to 40 percent, primarily by decreasing unnecessary and preventable ER visits, hospital admissions, and facility readmissions.


The At Home Support solution is unique in that it offers benefits to patients and families, health plans, ACOs and physicians. The benefits to each of these stakeholders are:
Patients & Families
   • Highly personalized care focused on the needs of each patient and family
   • Honest discussion with a trusted clinician throughout the course of one’s illness
   • Improved clinical outcomes
Health Plans and ACOs
   • Measureable reduction in medical expenses
   • Services count entirely against medical loss ratio (rather than administrative budget)
   • Allows health plan’s care coordinators to focus on a broader group of patients
   • Greater member satisfaction and engagement
   • Accurate HCC scoring
   • Improved clinical outcomes
PCPs & Specialist Practices
   • Creates a mechanism for PCPs and specialists to provide care to their most seriously ill patients outside of the office
   • Saves physicians time and money by providing additional supportive care to patients and their families
   • Improved information on patients’ health status when patients are out of the office
   • Improved clinical outcomes

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