iac learning collabortive


Home-Based Care for High-Need, High-Cost Patients

The Institute for Accountable Care and NAACOS supported twelve ACOs through a learning collaborative focusing on developing, implementing and enhancing home visit programs designed to improve care for high-need, high-cost patients. Participating ACOs worked on a diverse range of programs including Hospital at Home; Home-Based Primary Care; Care Transition Home Visits; Community Paramedicine and Community Volunteers. A major issue facing all participants was evaluating the financial implications of their home visit programs. To assist in this process, we developed a return-on-investment (ROI) calculator specifically designed for ACOs based on an extensive review of the literature to identify the range of potential savings achieved by prior programs.

The collaborative was made possible by the generous support of The Commonwealth FundThe SCAN FoundationThe Robert Wood Johnson Foundation, and the John A. Hartford Foundation.

Below we provide selected content from the collaborative from expert faculty and collaborative participants.

Home-Based Care Return on Investment Calculator for ACOs

Click here to access the home-visit ROI tool and instructions.

Home-Based Care Learning Sessions

Maximizing Home-Based Primary Care Value and Reimbursement
Presenters: Thomas Cornwell, MD and Brianna Plencner, Home Centered Care Institute
Date: January 21, 2020
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Addressing Behavioral Health with Home Visiting Programs
Presenter: Lauren Hardin, MSN and Jason Turi, MPH, RN
Date: February 18, 2020
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Care in the Home Healthcare’s Next Frontier
Presenters: Rob Mechanic MBA, Bruce Leff MD, Susan Erickson RN, MPH, Dianne Schultz, NP
Date: June 17, 2020
Download Presentation (Scripps)
Download Presentation (IAC-Johns Hopkins)
Download Presentation (Unity Point)
Watch the Video: NAACOS Virtual Spring Conference

Integrating Telehealth Technology into Home-Based Care
Presenter: Karen Abrashkin, MD, Northwell Health
Date: September 15, 2020
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A Practical Guide to Expanding Home-Based Primary Care with Telehealth
Telehealth and Home-Based Primary Care Workflows

Addressing Palliative Care Needs Through Home Visits

Presenter: Allison Silvers, Center to Advance Palliative Care, Mount Sinai School of Medicine
Date: October 6, 2020
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Dr. Atul Gawande Video: How to Talk End-of-Life Care with a Dying Patient

Starting Up a Hospital at Home Program: Addressing Common Barriers
Presenter: Linda DeCherri MD, Mount Sinai Health System
Date: October 27, 2020
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Starting Up a Hospital at Home Program: Facilitators and Barriers to Implementation
Hospital at Home-Plus: A Platform of Facility-Based Care

Reimagining Emergency Medical Services to Improve Care for High-Need, High-Cost Patients
Presenter: Matt Zadavasky
Date: November 17, 2020
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Using Community Paramedicine to Address Social Determinants of Health
Presenter: Amy Russell MD, Mission Health Partners
Date: March 5, 2021
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Improving Care for High-Need Elders through the Community Aging In Place Advancing Better Living for Elders (CAPABLE) Model.
Presenter: Alice Bonner, Title, Johns Hopkins University
Date: May 25, 2021
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Integra Community Care: Integration of Community Paramedicine with Hospital at Home
Presenters: Dr. Ana Fulton and Ruth Scott
Date: July 13, 2021
Presentation Coming Soon

Home Visit Literature Summary

Download Home Visit Literature Summary