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Roundtable takeaways: home- and community-based care, and new care models

CarePort recently hosted a virtual executive roundtable with Dr. Lissy Hu, CarePort CEO and founder, Mike Ipekdjian, Manager of Clinical and Solution Architects, and Mark Heron, Vice President. Alongside attendees from the healthcare industry, Lissy, Mike, and Mark held an interactive discussion centered around the current state of care coordination amidst a backdrop of COVID-19, evolving value-based care programs, and increasing interoperability. Below, we share key themes and takeaways from the roundtable.

The shift to home- and community-based care

Spurred by the COVID-19 pandemic, the industry has experienced a marked shift to home health care. SNF referrals, which dropped 34 percentage points in March and April 2020, have yet to recover to pre-pandemic levels.

In talking with case management teams, Dr. Lissy Hu has found that discharging patients home can be more challenging than sending them to a SNF. Case management teams must take several steps when discharging a patient from the hospital to his or her own home, including coordinating dialysis and other care services, securing transportation or meals, or even determining whether the patient’s home is a safe space for recovery. However, in an institutional post-acute care setting, case management teams don’t necessarily need to organize all of these resources to ensure continuity of care.

Roundtable attendees agreed with this sentiment, citing the following challenges associated with the shift to home-based care:

  • Patients now being discharged to home-based care are more acute and medically complex, and securing the necessary resources from home health agencies can be challenging
  • With more patients opting for home-based care, especially due to COVID-19, home health agencies are facing widespread staffing shortages
  • Rural patient populations may not have access to home health providers


If patients are discharged home with the intent of receiving home health services that are never provided – or aren’t provided in a timely manner – this can result in adverse and costly outcomes, such as readmissions, for the hospital. In fact, CarePort data has found that the risk of hospital readmission rises by 3% each day a patient is not seen by a home health provider.

New models of care in the home and community

There has been a push by CMS and payers toward new models of care, including SNF and hospital at home programs.

Initially spurred by the COVID-19 pandemic, CMS introduced the Hospitals Without Walls program, providing broad regulatory flexibility to allow hospitals to provide services in locations outside of their physical organizations. Expanding upon this effort, CMS announced the Acute Hospital Care At Home program in November 2020, supporting existing, successful models of at-home hospital care across the U.S. and offering eligible hospitals unprecedented regulatory flexibilities to treat patients in their homes.

Meanwhile, SNF-at-Home programs are designed to offer patients the choice to receive post-acute medical rehabilitation in the safety and comfort of their own home.

Despite industry staffing challenges, in some circumstances this program is appealing to nurses who want to work in an acute level of care but don’t want to work 12-hour hospital shifts. In addition to staffing challenges – as hospitals often use outside vendors, particularly for complex patient cases – these programs present their own sets of challenges. Attendees say they’re still trying to figure out how to provide and manage necessary services such as DME and pharmacy at home, all while complying with all CMS and local regulations. As these programs quickly increase in popularity, it’s critical that hospitals can ensure patients can safely receive the necessary level of care within their homes.

CarePort is broadening and enhancing its referral network to support the shift to home, and is also prepared to help customers identify high-quality providers – and build effective and efficient collaborative provider networks ­– as the industry adopts new models of care.

Contact us to learn what CarePort is doing to help customers succeed.

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