independence at home

Introduction

Maintaining mobility is directly related to successful living in the community.

A demonstration program created under the Affordable Care Act.

Indications

patient eligibility

• 2 of 9 modifiable chronic conditions
• pattern of high-cost use of medical recources, including hospitialization & postacute services
• functional impairment in >= 2 basic activities of daily living

Procedure

• identifies 5-10% of Medicare patients that account for 50% of Medicare costs
• home-based primary care provided to these patients
• interdisciplinary team led by physician or nurse practitioner
• focus is on home-based primary care, but team's responsibility extends across all health care settings

Notes

• billable services are covered by fee-for-service payments under Medicare
• additional case management services are also supported through a shared savings formula using the expected vs actual costs for care of the patient
• health care agencies may participate

More general terms

• medical organizational structure