There are many patients who struggle to navigate the traditional healthcare system and end up falling through the cracks. These patients, often with complex care needs, will frequently end up in the emergency department, resulting in unplanned hospitalizations.
Connecting these patients with healthcare resources from the convenience of their homes can be key to keeping them healthy and addressing social or mental health needs.
Equality Health, a company that aims to improve access to value-based care for underserved populations, launched a new program to provide staff for home-based care, delivered in-person and virtually, to patients facing complex medical issues.
The company, based in Phoenix, launched eight years ago to help independent practices adopt and deliver value-based care for diverse communities. Equality Health works with managed care plans and health systems to engage diverse members through customized, culturally competent provider networks, mobile-based patient engagement platforms and proprietary cultural care pathways.
The company's care model is Medicaid-first in design, according to executives, and primary care providers in its network gain access to value-based care contracts, risk-bearing financial incentives and an advanced practice technology platform. Through its proprietary software, primary care providers in the Equality Health network benefit from resources like predictive modeling and advanced care tracking tools to streamline value-based administration.
The population health risk management company has been quietly and steadily growing. It now partners with over 3,200 primary care providers serving about 750,000 patients across Arizona, Texas and Tennessee.
The company's new Health at Home service provides community health workers and nurse practitioners that come into patients' homes to provide "concierge-like" services such as creating custom care plans, driving care plan adherence, helping them navigate the healthcare system and gaining access to community services for social needs.
Equality Health's field-based staff act as "extensions of the patient's PCP in the home" to address both medical, behavioral and social determinants of health needs, according to Mark Stephan, M.D., Equality Health's chief medical officer.
"Through our provider network and member data, we have learned that many patients require additional support to improve their health outcomes. By evaluating patients in their home environment, we are able to better understand any barriers they are experiencing and get the appropriate support in place," he said in an interview.
These field-based teams often include community leaders such as chaplains.
"We have learned from six years of surveying members about their health that there is a spiritual component for many. We support whole health across cultures, religions and diverse communities. Chaplains are not just spiritual counselors; they facilitate open discussion of behavioral health needs and empower patients to advocate for themselves," Stephan said.
The Health at Home program aims to set patients up for success and bridge them back to the PCP for continuity of care, rather than replace their primary care doctor. The program generally runs for three months.
"Over the course of the 12-week program, Equality Health will create a care plan which addresses all aspects of the patient’s wellbeing. We get patients back on track with their medical needs such as medication adherence, infection prevention, labs and screenings, specialist appointments, and durable medical equipment. Once all of that is in place, typically around the 12-week mark, our team will connect with the patient’s PCP in our network to transition care," Stephan said.
Twelve weeks is generally enough time for the field-based team to address barriers to care and establish a mutually agreed upon care plan with the patient and family, which is then shared with the primary care doctor.
"Though medical needs and care gaps are readily identified by the nurse practitioner, we first assess and address SDOH barriers to care such as transportation, food and finances. The community health worker leads the engagement," he noted.
The company is initially launching the program in Arizona. Eligible patients are Equality Health members 18 years of age or older and assigned to a primary care provider within the Equality Health network.
Patients who are high-risk or patients with acute needs can be flagged for the program in two ways, Stephan noted. A provider may refer a member to Equality Health at Home directly, or the patient will be identified in CareEmpower, the company's proprietary technology that can flag members at risk for unplanned hospitalizations, are disconnected from a usual source of primary care and have open care gaps.
Equality Health was founded by serial entrepreneur Hugh Lytle who previously co-founded Univita Health, a home-based care management business. He also was the president and co-founder of population health management company Axia Health Management. Axia’s flagship product, the SilverSneakers Fitness Program, grew into the nation’s leading fitness program designed exclusively for active older adults.
Lytle and the Equality Health management team built the company to offer culturally tailored care to break through barriers, creating a connected pathway to good health that builds bridges of trust, respect and compassion across the continuum of care and health insurance coverage. As primary care providers are considered the "quarterback" of the healthcare team, Equality Health focuses on providing stepping stones for practices to shift from fee-for-service to value-based care and payment models.
The company's in-home services can help close gaps in care and support patients which then helps independent primary care practices succeed in value-based care and payment arrangements, executives said.
Stephan said Equality Health focuses on low-income and socially disadvantaged Medicaid and Medicare adults who typically have low healthcare literacy.
"Regardless of age, common themes emerge such as difficulty managing activities of daily living, in and out of the home. This is often a mix of physical, psychological and cognitive challenges. Chronic conditions such as diabetes, heart failure, kidney and liver disease frequently coexist. Unplanned hospitalizations and emergency department visits are common," he noted.
The company's community health workers and nurse practitioners work with the patient, family and providers to control chronic conditions, reduce risk of infection and promote self-care.
"This involves addressing the root causes of medication non-adherence and non-healing wounds, as examples. The community health workers, the nurse practitioner and the chaplain all set priorities and plans of care together with the member and family or caregiver. Finally, we step back once the situation is stabilized and a plan of care is in place, but we don’t go away," Stephan said. "These individuals can and do call us back when barriers again emerge because we work to build trust."