Navigating the Shift to Home-Based Care: 4 Strategies for Success

By Ashish V. Shah, CEO, Dina

First came the rise of telehealth. Now home-based care is gaining traction with Accountable Care Organizations (ACOs) as care delivery continues to move outside of the hospital and into the home and community.

Evidence of this shift is present in recent data from The Institute of Accountable Care (IAC), showing an increase in home-based care among ACOs. In fact, half of the home-based care programs developed by ACOs were formed between 2017 and 2019 – almost double the 26% formed between 2014 and 2016, according to the same study.

Furthermore, two of the largest payers – Humana and UnitedHealth Group – recently acquired leading home health companies to solidify their commitment to home-based solutions that improve patient outcomes and deliver value.

Add in growing consumer demand, and you have a healthcare environment more willing than ever to modify authorization rules and health plan design to enable a shift to in-home care. 

Today’s ACOs need to position themselves for success in this changing landscape. But where do you start? Here are four strategies to help navigate the shift to home-based care.

1.              Improve PAC visibility

Most ACOs perform some level of tracking, monitoring, and trending into post-acute care (PAC) facility utilization. But one-way visibility is not enough. To optimize care, you need to know not only when patients have moved to a post-acute facility, but what’s happening once they are there. 

The first step is to establish a preferred network of post-acute providers and embed those partners in the care planning process. Once you develop a shared set of expectations, care teams can work together to recognize–and address–changes in patient conditions that can reduce ED visits and prevent hospital admissions and readmissions.

Electronic, real-time communication and coordination help facilitate proactive care planning. A bi-directional exchange of information can help providers evaluate projected length of stay and identify candidates who can safely be cared for in the home setting. Collectively, these efforts can optimize patient satisfaction and outcomes while reducing costs.

2.              Build a preferred home-based provider network

An effective care-at-home strategy also requires building new partnerships with service providers, including DME, transportation, meal delivery, courier services, and more. Identifying and establishing connectivity with these services can be challenging. Many home-based providers aren’t licensed or rated by the Centers for Medicare and Medicaid Services (CMS) and aren’t owned or operated by large healthcare organizations. Cloud-based technologies can be helpful to evaluate these new types of partners, including assessing their suites of capabilities, service areas, capacity and turnaround time. Working with organizations that can engage with you in a digital manner will be critical.

3.              Drive timely interventions with direct patient connections

Many ACOs leverage a variety of remote patient monitoring (RPM) tools to connect directly to patients and proactively track their health status. Unfortunately, these tools are often used only to monitor people with chronic conditions, who represent a small segment of the overall need. 

And the data captured by these devices only tells part of the patient story. While these tools may relay a patient’s A1C reading, for example, they don’t tell the provider if there is healthy food in the refrigerator or if they can prepare themselves a meal. 

Truly effective remote engagement needs to combine vital sign data with an engaged care team plus the patients themselves to understand the conditions that may impact someone’s health. 

The goal is to help people become active participants in their own care, not just when they are recovering from an illness, but to maintain wellness. Participation is most successful when it is easy for the patient. For example, automated check-ins via widely accessible mobile technologies are easier to access than hospital portals that require patients to log in and initiate the interaction.

4.              Use technology to manage by exception

Healthcare organizations across the country are struggling with staff shortages and burnout. To effectively navigate the shift to home-based care, ACOs need to find ways to extend their reach into the home without causing staff to feel overburdened or pushed beyond capacity.

Technology is one way to make an impact. We expect to see more providers establish “care traffic control” centers to remotely monitor people at scale, and use home-based insights to identify risks and inform care plans.Text-based patient check-ins, for example, are one way to receive feedback in real time and manage by exception to help people stay home safely.

During the height of Covid-19, our client Jefferson Health found that 75% of their Covid-positive patients responded to automated text-based check-ins, and remained engaged throughout their recovery at home. Conversely, only 3% to 7% of respondents required escalation, and they were evaluated by a care coordinator to determine next steps. This approach allowed care teams to focus their attention on those patients who needed their support the most, and intervene if conditions escalated.

By leveraging technology to enhance connectivity and visibility, providers can make care adjustments mid-stream – incorporating home-based care where appropriate – and ultimately ensure more successful patient outcomes.

Ashish V. Shah is CEO of Dina ( and leads the Dina team on its mission to power the healthcare industry’s transition to virtual and in-home care. He founded the company in 2015 and remains passionate about empowering care teams with the tools they need to help people age in place. A recognized thought leader, Shah previously served as CTO at Medicity, the market leader for vendor-neutral Health Information Exchange solutions (acquired by Aetna in 2011). 

Attending FLAACOS 2022? Join Ashish V. Shah for the presentation: “No place like home. Evolving trends to move care to the home” October 19, 10:45 am.

Related Posts