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‘A Pathway to Value-Based Care’: Help at Home Empowering Caregivers with New Predictive Model

Help at Home is launching a new model of care, one that it believes can be centered entirely around the home instead of the doctor’s office or hospital.

The model’s goal is to capture insights from caregivers to recognize client needs and then engage the rest of the health system from there. Dubbed “HealthyMATCH,” it will give Help at Home’s caregivers digital tools to log important health information that could prevent hospitalizations or unnecessary ER visits.

“It’s very clear that care in the home is one of the most significant areas of health care that I think that we’ve underleveraged,” Dr. Stephen Friedhoff, Help at Home’s chief clinical officer, told Home Health Care News. “Individuals may see their physicians a couple times a year for a 15- or 20-minute visit, and great things happen there … but the patient spends another 364-and-a-half days of the year on their own.”

The Chicago-based Help at Home provides home care to 67,000 clients through its 169 locations spread across 13 states. It launched HealthyMATCH in August in the state of Indiana, then followed that up with a rollout in Pennsylvania in September. The plan is to have the model rolled out eventually to all of the states it delivers care in.

Through an internal analysis, Help at Home found that its caregivers – on average – spend 17 hours per week with clients over a four-year time period.

“It’s pretty clear that caregivers can often identify things that are going to arrive before anybody else can,” Friedhoff said. “If their client seems unsteady, if they are not eating well, if they seem less mobile, if they seem sad, if they’re just not getting out of the house – those are things that the caregiver can recognize. But historically, they have not been empowered to do much about those things other than to get in touch with the clients’ physician, which is sometimes successful, and sometimes not.”

Help at Home will enlist its caregivers on the front end to collect information by answering a series of questions on a regular basis, then use a proprietary algorithm to find clients where more help may be needed on the back end.

“They’re not clinicians; they can’t diagnose or do formal assessments,” Friedhoff said. “However, they can be the eyes and ears for our clients. So by providing them with a digital tool to identify potential risks for things like falls, malnutrition, polypharmacy or other medication issues, we can proactively identify risk factors before they become a problem.”

The specific digital tool does not rely on an application. Instead, it sends caregivers texts on a per visit, weekly and monthly basis, which then takes them to a secure browser where they can log information.

An additional layer of support from social workers and nurses – plus the predictive nature of the model – makes it different from other data-gathering home care initiatives, Friedhoff believes.

“This enables us to essentially have a predictive model to identify the clients that are the most at risk,” he said. “So we take this data that other organizations may or may not have and we turn it into information. Then we take it from information to something that we actually act on.”

Help at Home sees HealthyMATCH as a further shift to value-based home care.

The thinking is that, as the rest of the medical health care system moves that way, this is an avenue for home care companies like Help at Home to keep up and remain valuable to payers and partners alike.

“That’s one of the many reasons we’ll be tracking these kinds of outcomes and sharing them not only internally, but certainly with payers as well,” Friedhoff said. “Because we really believe that this is a pathway to value-based care in the home.”