Benefits of HBPC Training

SURVEY: Understanding COVID-19 in home-based care practices

Survey request

HCCI is sharing this request on behalf of our colleagues Drs. Christine Ritchie and Bruce Leff and the National Home-Based Primary Care Learning Network.

Dear Colleague,

We are researchers at Massachusetts General Hospital and Johns Hopkins University writing to alert you to a new research study supported by the National Home-Based Primary Care Learning Network.

We wish for you to take 10 minutes to help home-based primary care practices learn from each other during the COVID-19 pandemic.

This survey is being fielded to help increase our understanding of COVID-related practice challenges and the strategies used to overcome them.

The ultimate goal and benefit to you is to help home-based care practices learn from one another to navigate the current and potential future pandemics.

Our COVID-19 survey is strictly voluntary. Participation in the survey will determine consent. If particular practice leaders do not wish to complete the COVID-19 survey, they have the right to refuse without consequence. This one-time survey can be completed by anyone in your practice and should take 10 minutes or less to complete.

Please complete the survey HERE 

Please send your responses by Tuesday, June 9th 2020

Our goal is to quickly obtain and report back to you the findings from this survey so that you can use it in your practice.

Your participation in this research will make a huge difference. We thank you in advance for your help.

If you run into any technical difficulties completing this survey, please email our program manager, Naomi Gallopyn, at [email protected].

Christine Ritchie
Ken Minaker Endowed Chair in Geriatric Medicine
Research Director, Division of Palliative Care and Geriatric Medicine
Massachusetts General Hospital Mongan Institute

Bruce Leff, MD
Professor of Medicine
Johns Hopkins University of Medicine

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The Power of Three: Grant Recipients Continue to Advance Home-Based Primary Care

In the Fall of 2019, The John A. Hartford Foundation awarded a three-year, $1.6M grant entitled, Moving and Scaling Home-Based Primary Care Phase II: Quality, Training and Advocacy. The project aims to improve care for the more than two million older adults who are the “invisible homebound” with functional impairments and frailty. This phase builds on the success of the initial grant phase, with the same organizations leading three complementary grants.

While each organization has its own unique deliverables, they continue to work in close collaboration to achieve the overall goal ─ increasing access to high quality, home-based primary care that leads to improved outcomes for both patients and caregivers. Following is an overall look at the grant recipients and their respective projects:

  • The American Academy of Home Care Medicine (AAHCM) is charged with developing a home-based primary care (HBPC) national practice directory. “Our mission in phase two is to create an online Home-Based Primary Care National Practice Directory site to connect patients to practices and refer other providers to home-based primary care providers,” said Brent Feorene, executive director for AAHCM. “The site will also serve as a provider resource for timely information about HBPC, new payment policies and educational content on quality of care. Ultimately, this project will help expand services to populations with serious advanced illness.” The directory is being built using a human-centered design process to ensure it encompasses all the information its various users need and is slated to launch during the fourth quarter of this year.
  • The National Home-Based Primary Care Learning Network led by Dr. Christine Ritchie at Massachusetts General Hospital and Dr. Bruce Leff at Johns Hopkins University School of Medicine will work to expand and enhance a national quality improvement Learning Network among HBPC practices. “The Learning Network will be comprised of practices that identify new and ongoing quality and practice issues in HBPC, develop practice-guided strategies to address these issues, and use real-time, practice-based, data-driven initiatives to evaluate the effectiveness of these efforts,” said Naomi Gallopyn, program manager for Massachusetts General Hospital. The group recently completed a similar project with nine HBPC practices and is now seeking applications to grow their Learning Network with an additional 10 practices (deadline is April 24, 2020). For more information, please visit
  • The Home Centered Care Institute (HCCI) will build on its strong foundation and leverage the expertise of its staff, faculty and partners to develop and implement an enhanced multi-modal educational strategy. “HCCI is uniquely qualified to meet the current and growing demand for education and training of the home-based primary care workforce,” said Melissa Singleton, Chief Learning Officer for HCCI. “By further enhancing our offerings around clinical and practice management topics, we are equipping providers around the country with the knowledge and skills to be successful. Ultimately, this grant will help achieve HCCI’s goal of expanding the workforce, enhancing patient and caregiver satisfaction, lowering overall costs, and providing higher quality care for home-limited patients.”

“Increasing access to high-quality, home-based primary care is one profoundly important way that we can make health care more age-friendly and focused on what matters to older adults and their families,” said Scott Bane, JD, MPA, Program Officer at The John A. Hartford Foundation.  “The collaborative work of these three organizations will help more providers deliver the right kind of care in the right place for older adults with the most complex needs.”

About The John A. Hartford Foundation

The John A. Hartford Foundation, based in New York City, is a private, nonpartisan philanthropy dedicated to improving the care of older adults. Established in 1929, the Foundation has three priority areas: creating age-friendly health systems, supporting family caregiving, and improving serious illness and end-of-life care. For more information, visit and follow @johnahartford.

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HCCI House Call Practicum™ Helps Set Providers up for Success

About this Article:

Learn more about the HCCI House Call Practicum™ from one of its recent participants. The program offers a unique two-day ridealong, an individualized educational experience offering learners the opportunity to shadow both direct clinical care and back-office practice support.


Home-Based Primary Care (HBPC) describes the field of providing quality medical care in the home to patients who have difficulty obtaining, or are completely unable to access, office-based primary care. This is typically because they are frail, chronically ill, functionally limited and/or homebound. This type of care can provide many benefits, including the reduction of emergency room visits and hospital readmissions, along with improving overall health outcomes and reducing health care costs. One of the main goals of the Home Centered Care Institute (HCCI) is to educate providers and practices in providing HBPC, oftentimes referred to as “house calls.”

The HCCI House Call Practicum™, one of HCCI’s educational offerings, allows participants to acquire new knowledge and skills in house call operations and clinical care for medically complex patients in the home. For those considering adding house call services to their practice, the Practicum illustrates key fundamental processes, systems and approaches. For those already practicing HBPC, the Practicum provides an opportunity to improve upon what they’re currently doing by learning directly from leaders in the field.

Earlier this year, Lynn Simpkins, Nurse Practitioner, Bon Secours Health System, participated in the Practicum with Cleveland Clinic, an HCCI Center of Excellence for Home-Based Primary Care and Practice Excellence Partner™. Simpkins has built her 30+ year career as a family and geriatric nurse practitioner and is currently focusing on home-based care. She recently shared takeaways from her Practicum experience with HCCInsights.

HCCInsights: What are some challenges that you face daily with your HBPC practice?

Simpkins: Like most providers, we have the challenge of a sick patient population but with the added complexity of providing those patients with care in a home setting. Social, financial and unique medical challenges all play into what we need to address.

HCCInsights: Why did you decide to participate in the HCCI House Call Practicum?

Simpkins: In addition to the challenges I mentioned, during my work with our HBPC program, our practice has grown more than threefold. This growth has been amazing but posed challenges for us in keeping up with the demands that come with that success. Seeing how Cleveland Clinic manages its patient population of over 2,500 individuals helped me to find ways to apply a similar approach that will work for our team and allow us to successfully scale our program.

HCCInsights: What was Day One of the Practicum like?

Simpkins: I spent most of the first day with a nurse practitioner in the field going on house calls. My first impression of Cleveland Clinic’s program was that everything — systems, care, planning— seemed to be calm and seamless.

The technology used, including the software, also set the team up for success to best serve patients. It allowed the nurse practitioner I shadowed to be much more efficient because she was not constantly asking and answering questions through chats or over the phone, having to chart in another system, or needing to deal with connectivity issues.

It was also good to see how they managed one challenge associated with house calls that we previously faced – namely scheduling. We were giving our patients specific appointment times.  However, it’s difficult to correctly estimate the amount of time needed to treat cases while factoring in traffic and other unforeseen circumstances. This led to us often being late. The Cleveland Clinic team schedules appointments in four-hour windows, which gives the provider some breathing room.

And, most important, the patient care during the house calls was, in a word, “fantastic.”

HCCInsights: After the first day, it sounds like you had a good sense of Cleveland Clinic’s care model. What did Day Two offer?

Simpkins: I spent time in the practice’s office with an administrator learning about their systems, guidelines, safety protocol, and more. This body of work is the core of what makes them so successful and able to offer great care. The administrator I worked with was so giving of her time and very transparent, which helped me see the inner workings of their processes and procedures.

I also had the chance to get a good overview of their back-end practices, such as how a referral is sent, how they handle emergencies, and how they manage their monthly staff meetings and training schedules. I also saw how their nurses triage patients over the phone to determine if they need to go to the hospital or can be cared for by an HBPC provider. Plus, I learned a lot from their billing team about their practices.

HCCInsights: What were you surprised to learn during the Practicum?

Simpkins: One of the most surprising, yet incredibly useful, things I learned about, as I mentioned previously, was their block scheduling in four-hour increments. In the past, we had many patients refuse appointments because the proposed times didn’t work for their schedule. Cleveland Clinic sets visit expectations with their patients from the beginning. It was clear that block scheduling benefits both patients and providers.

HCCInsights: Were there any learnings from the Practicum you were able to implement right away in your practice?

Simpkins: Yes, we started reviewing some of our procedures right away, like our safety guidelines, and began to apply what I learned. We have also continued to implement the teachings from the Practicum throughout the year. For example, right now, we are working to move nurses away from scheduling so that they can focus solely on clinical work.

HCCInsights: What would you tell future Practicum participants?

Simpkins: The program is very worthwhile no matter what stage of practice you are in – because the activity is very individualized. For example, if you are currently offering HBPC, it gives you an opportunity to improve. If providing home care is new to you, you can begin with strong principles and practices from day one.


To learn more about the HCCI House Call Practicum™ program and/or register, click here. There’s also an optional one-day Telemedicine Elective shadowing opportunity, also presented by Cleveland Clinic, that can be added on to the two-day Practicum, or attended on its own.

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International Workshop Shows How Small the World Really Is

GSA 2019 International Workshop on Home Care Medicine

On Friday, November 15, over 45 professionals in the field of gerontology attended the first-ever International Workshop on Home Care Medicine in Austin, Texas, as part of the Gerontological Society of America’s (GSA) Annual Scientific Meeting. The GSA describes itself as “the oldest and largest interdisciplinary scientific organization devoted to the advancement of gerontological research, learning, and practice.”

Recognizing the need to expand the “home care medicine conversation” globally, GSA invited the Home Centered Care Institute (HCCI) and American Academy of Home Care Medicine (AAHCM) to develop and co-lead the workshop. The session brought presenters together with participants from countries around the world, including Canada, China, France, Italy, Japan, the Netherlands, Spain, and the United States.

Aaron Yao, PhD, lead researcher for HCCI and Cheeloo Scholar Professor at Shandong University in China, played a key role in organizing the workshop. The program was designed to present recent trends and developments in home care medicine, facilitate the building of strategic partnerships to address global challenges, and provide an opportunity for peer networking.

The workshop was made up of four panel sessions featuring participants from different countries and allowed for extensive Q&A. The four panel themes were Service Delivery and Interprofessional Care, Technology (Mobile Diagnostics, EMR) in Home Care, Payments and Revenue Models, and Workforce Education and Training.

When asked what stood out most for him about the program, Yao answered, “The workshop’s message to me was simple but powerful – that aging has no borders and that great minds think alike.”

Melissa Singleton, Chief Learning Officer, HCCI, also found unique value in the event, “Having the chance to hear people from around the world talk about this growing and much-needed field of medicine reminded me of how very much alike we all are. Of course, each country has its own methodology, such as how they train providers, their payment models, and so on. But, even with that, finding our commonalities and sharing best practices make the world a little smaller, the challenges more manageable and the opportunities for collaboration even greater.”

The GSA workshop was not HCCI’s first appearance on an international stage. A little over a year ago, Yao facilitated an invitation for Dr. Thomas Cornwell, Chief Executive Officer of HCCI, to teach at the Shandong University School of Healthcare Management. Since then, much of HCCI’s curriculum has been translated into Chinese, and a total of 1,250 Chinese providers have been trained by HCCI faculty. The recent collaboration for GSA was an opportunity to bring Dr. Cornwell and HCCI back together with colleagues at Shandong University, as well as to meet new leaders in the field from around the world.

Benefits of HBPC Caregiver Stories HCCIntel Uncategorized

Community Paramedics Make House Calls and Change Lives

Ottawa  |  Elizabeth Payne  |  Aug 21, 2019

Maria Makkos greets Stephanie Rose at the front door of Makkos’s Arnprior apartment building.

“You are here to see me?” she asks, grinning broadly as she leads the community paramedic to her tidy unit.

Over her shoulder, Rose, the paramedic, carries a heavy black bag containing a blood pressure cuff, equipment for drawing blood, papers and other medical equipment.

Makkos, 82, is the third client the community paramedic has seen this morning.

Rose checks Makkos’s blood pressure, which is high. When they sort through her medication, Rose discovers the elderly woman hasn’t been taking it regularly.

“You are busted, I caught you red-handed,” says Rose with a laugh and a wag of the finger.

Makkos, who still drives and walks to stay fit, says she is determined to remain healthy so she doesn’t have to go into the hospital.

“Don’t’ worry, that is the last place we want you to be,” says Rose. “We are going to help you stay here, but we just want to make sure you are safe.” Taking her medicine on time, she tells Makkos, is crucial to staying healthy and in her own home.

Before she leaves, Makkos wistfully jokes that she wants Rose’s visit to last all day.

In a role reminiscent of a family doctor doing house calls, Rose visits clients to check on their health and just to chat. The conversations, sprinkled with laughter, are as important as the testing to determine what people need to remain independent and as healthy as possible, she says.  Read more

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Slowly Getting Serious: The New CMS Primary Care Models And Implications For Serious Illness Care

|  Health Affairs | Mark Japinga, Mathew Alexander, David Casarett, William K. Bleser, Mark B. McClellan, Robert S. Saunders

In April, the Centers for Medicare and Medicaid Services (CMS) introduced five new payment models as part of its Primary Care First (PCF) and Direct Contracting (DC) programs. The models represent CMS’s latest push to move primary care providers away from fee-for-service payments and into care models that focus on total cost of care, using varying levels of capitated payments that can help facilitate investment in critical services not sufficiently reimbursed under fee-for-service, such as care coordination, 24-hour call centers, and home visiting.

Care for high-risk, high-need patients earns significant attention, especially in the Serious Illness Populations (SIP) track within PCF. This model specifically builds on proposals from the American Association for Hospice and Palliative Medicine (AAHPM) and the Coalition to Transform Advanced Care (C-TAC) and offers the clearest glimpse yet into how CMS is incorporating new delivery models targeting this population.

The implementation challenges for practices will be similar to those found by our recent work on serious illness care in accountable care organizations (ACOs). This includes a national survey and case studies on diverse ACOs with mature serious illness care programs and sustained success in ACO models, which chronicled how some ACOs are going beyond simply identifying a serious illness population and working to transform their care. This research is especially relevant given that PCF and SIP, as currently described, focus more on improving whole-person care for high-risk patients with multiple chronic conditions, centralized in primary care settings. This is a key distinction from the AAHPM and C-TAC models, which focus on advanced illness, pre-hospice, or end-of-life care with a strong role for palliative care teams. In other words, these models may serve as a bridge to more comprehensive, person-focused serious illness care approaches in the coming years.

Read the full article

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House Calls Are Reaching the Tipping Point — Now We Need the Workforce

home-based primary care training and education

Written by: Thomas Cornwell, Home Centered Care Institute; Northwestern Medicine Regional Medical Group
Journal of Patient-Centered Research and Reviews


Home-based primary care (HBPC) improves the lives of high-cost, frail, homebound patients and their caregivers while reducing costs by keeping patients at home and reducing the use of hospitals and nursing homes. Several forces are behind the resurgence of HBPC, including the rapidly aging population, advancements in portable medical technology, evidence showing the value of HBPC, and improved payments for HBPC. There are 2 million to 4 million patients who could benefit from HBPC, but only 12% are receiving it. The number of these patients is expected to double over the next two decades. This requires a larger and better prepared HBPC workforce, making St. Clair and colleagues’ article published within this same issue very timely. They showed residents exposed to HBPC had increased interests in providing HBPC in the future. They also found HBPC training fulfilled all 6 Accreditation Council of Graduate Medical Education core competencies and at least 16 of the 22 Family Medicine Milestone Project subcompetencies. Such medical education curricula are necessary to sufficiently develop a future workforce capable of appropriately providing HBPC to an increasing number of patients.

Recommended Citation

Cornwell T. House calls are reaching the tipping point — now we need the workforce. J Patient Cent Res Rev. 2019;6:188-91.

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AAHCM and HCCI present a webinar on new CMS Primary Cares Payment Models

Woman watching a webinar

The American Academy of Home Care Medicine (AAHCM) in collaboration with the Home Centered Care Institute (HCCI) will host a webinar Tues. July 30 at 4 pm (ET) on the new CMS Primary Cares Initiative payment models relevant to home care medicine. The three different payment models will be discussed in detail; Primary Care First (PCF), Seriously Ill Population (SIP), and Direct Contracting (DC).


CMS Primary Cares Initiative

In April, the Center for Medicare and Medicaid Innovation (CMMI) announced a CMS Primary Cares Initiative which includes new payment demonstrations meant to promote value-based care, with a shift of up to 25 percent of primary care Medicare fee-for-service patients to these new models. Primary Care First (PCF), Seriously Ill Population (SIP), and Direct Contracting (DC) will offer enhanced payment for home care medicine and other providers to provide primary care for people with advanced illness.

Primary Care First (PCF) & Seriously Ill Population (SIP)

The Primary Care First (PCF) and Seriously Ill Population (SIP) models will be offered in 22 states and 4 regions for a January 2020 start date:   STATEWIDE in Alaska, Arkansas, California, Colorado, Delaware, Florida, Hawaii, Louisiana, Maine, Massachusetts, Michigan, Montana, Nebraska, New Hampshire, New Jersey, North Dakota, Ohio, Oklahoma, Oregon, Rhode Island, Tennessee, and Virginia. In Local Regions of Greater Buffalo, NY, Kansas City (Kansas and Missouri), Greater Philadelphia (Pennsylvania), North Hudson-Capital Area, NY, and Northern Kentucky.

PCF/SIP Timeline:   A letter of intent (LOI) is not required for PCF or SIP.   A request for application (RFA) will be released in the coming weeks and is required for participation.  Both models are scheduled to begin January 2020.

Direct Contracting

The Direct Contracting (DC) path will engage practices or groups of providers who can reach 5,000 beneficiaries by Year 3 (with potential exceptions for smaller practices), as well as Health systems, Accountable Care Organizations, Medicare Advantage plans, and Medicaid Managed Care Organizations.  DC builds upon the Next Generation ACO model and has no geographic limitations on who may apply.   The DC path will include three models: Professional PBP, Global PBP, Geographic PBP (Proposed).

Timeline:  A Letter of Intent (LOI) is required to apply for participation in the DC Models and is due on Friday, August 2. The LOI is non-binding. CMS will then release the request for application (RFA), which will be required for participation. All models are scheduled to begin January 2020 except the DC Geographic Option, which will begin at a later date.

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The Doctor Will See You Now, In Your Home

doctor house call medicine visit

The old-fashioned house call is back in a big way. Here’s how it works.

June, 2019  |  Harvard Health Newsletter  |

It’s hard to get to the doctor when you don’t drive anymore or you’re struggling with several chronic medical conditions. The result may be missed appointments and a lack of needed care.

But a growing trend makes it far easier for older adults to get medical attention, bringing routine exams and diagnostic tests to the patient’s doorstep. It’s called home-based medical care — when doctors, nurse practitioners, physician assistants, or other providers visit and treat older adults right in their homes.

Different from home health care

Home-based medical care isn’t the same as home health care, which sends skilled nurses and therapists to your home specifically to help you recover from illness, injury, or surgery, with the goal of helping you get better and regain your independence.

Instead, home-based medical care is more like a beefed-up house call. “These are their regular visits. The only difference is that we bring the equipment to them,” says Dr. Diane McMullin, a geriatrician with the House Calls program at Harvard-affiliated Mount Auburn Hospital.

In some cases, the house call provider can visit when you develop a sudden illness, like an infection. Some providers can bring mobile x-ray or ultrasound machines and equipment to draw blood and collect urine.

Is it covered?

“Medicare began recognizing home visits about 20 years ago,” says Brent Feorene, executive director of the American Academy of Home Care Medicine. And the number of Medicare-funded house calls has been increasing. For example, Medicare paid for 1.6 million home care visits in 2001. By 2015, the number was 2.6 million.

But Medicare won’t pay for a house call as a simple matter of convenience. “The expert must certify that the visit was medically necessary,” Feorene says.

What’s considered medically necessary? Coverage generally applies when an older adult has a condition that restricts the ability to leave home, making a visit to the doctor’s office considerably taxing. For example, the person might need the help of an assistive walking device or wheelchair, the assistance of another person, or medical transportation; or the person may have a cognitive, psychiatric, or emotional issue that makes it hard to get to an appointment.

Whether your private insurance will pay for a house call is a different story. That depends on your insurer.

Read the full article

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‘Eyes In The Home’: ACOs Use Home Visits To Improve Care Management, Identify Needs, And Reduce Hospital Use

Home visit from nurse practitioner

June, 2019  |

Authors: Taressa K. Fraze, Laura B. Beidler, Adam D. M. Briggs, Carrie H. Colla


Home visits are used for a variety of services and patient populations. We used national survey data from physician practices and accountable care organizations (ACOs), paired with qualitative interviews, to learn about home visiting programs. ACO practices were more likely to report using care transitions home visits than non-ACO practices were. Eighty percent of ACOs reported using home visits for some of their patients, with larger ACOs more commonly using home visits. Interviewed ACOs reported using home visits as part of care management and care transitions programs as well as to evaluate patients’ home environments and identify needs. ACOs most often used nonphysician staff to conduct home visits. Home visit implementation for some types of patients can be challenging because of barriers related to reimbursement, staffing, and resources.

More than a half-century ago, it was not unusual for physicians to make house calls. Modern medicine, however, transitioned care from the patient’s home to the provider’s office in an effort to improve efficiency.1,2 Still, there are advantages to house calls: to offer the patient convenience and safety, help providers build more personal relationships with patients, comprehensively assess patients’ needs, and identify issues related to the home environment.3 Moreover, many patients benefit from more intensive, home-based care,4,5 and evidence suggests that care provided in patients’ homes can both reduce costs and improve quality.47 Medicare has created new reimbursement models to support home visits for patients who are functionally unable to attend office-based visits.8

Home visits can improve the quality of care by easing transitions between care settings, enhancing care management, and helping older patients successfully age at home.3,9 Home visits can be used for a variety of services and patient populations, such as care management for patients with chronic disease, home-based primary or acute care, postdischarge care transitions, and support for frail patients. Home visits have the potential to reduce spending by preventing readmissions or by helping people with complex needs manage their conditions in lower-acuity (and lower-cost) settings.7,10 Home visits are particularly useful for addressing unforeseen challenges after discharge, such as those related to obtaining support from caregivers, understanding a care plan, understanding the full spectrum of medications a patient has at home, and making necessary adjustments to the home environment.4,10

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