North Shore-LIJ Selected Among 16 Programs Nationwide to Participate in a Federal Demonstration Program to Provide Home-Based Primary Care to Seniors

WESTBURY, NY – The North Shore-LIJ Health System was recently selected as one of 16 programs nationwide to participate in a three-year demonstration to provide home-based primary care to the elderly. The program, called Independence at Home, is part of the federal government’s efforts to test new ways of improving the delivery of health services to vulnerable seniors who are at risk for fragmented care that leads to excessive utilization of emergency rooms (ER) and hospitals.

The demonstration project, scheduled to begin this summer, is being conducted by the Center for Medicare & Medicaid Innovation, a part of the Centers for Medicare & Medicaid Services (CMS). Independence at Home uses home-based primary care teams directed by physicians and nurse practitioners to improve health outcomes and reduce utilization for Medicare recipients with multiple chronic conditions, primarily by avoiding unnecessary hospitalizations and ER visits.  The project will reward healthcare providers that deliver high-quality and high-value care.  Independence at Home, established by the Affordable Care Act, will serve up to 10,000 participants across the country.

Five years ago, North Shore-LIJ created the Westbury, NY-based Physician’s House Calls practice, which provides in-home primary care to patients in Queens and Long Island with limited mobility who might otherwise be unable to access necessary medical care.  Meeting certain criteria set by CMS, approximately 300 to 350 of the 700-plus House Calls’ patients have met the demonstration criteria to be included in the Independence at Home Program.

“The Independence at Home program fits squarely into North Shore-LIJ’s plans to efficiently care for our most vulnerable, high-cost members and patients in the preferred setting of their own homes,” said Jeremy Boal, MD, North Shore-LIJ’s chief medical officer.

Leading the demonstration program at North Shore-LIJ are Kristofer Smith, MD , medical director, and Merryl Siegel, regional executive director of Post-Acute Care Services.

“Our mission has always been to enable our older, chronically ill patients to stay at home as long as possible with the services they need to prevent unnecessary hospitalization,” said Ms. Siegel. “We are excited about the demonstration project because it allows us to intensify the management of our patients and strengthen home care and other post-acute services to avoid hospitalization. It’s simply better quality of care.”

“It is the goal of Independence at Home and the health system to deliver patient-centered, holistic, respectful medical care to all patients, particularly those in the last few years of life,” said Dr. Smith.  “Patients will tell you that they want to be home, be comfortable and be supported at home. The promise of having this demonstration within the North Shore-LIJ Health System is the many clinical resources to bring to home-bound patients other than the hospital.”

Medical practices participating in the federal pilot program are required to use electronic health record systems and remote patient monitoring.  Also, practices must be available 24 hours per day, seven days per week to deliver care.  Medicare beneficiaries applicable for the program must have at least two chronic illnesses (congestive heart failure, diabetes, stroke, etc.), need help with two or more activities of daily living (bathing, eating), have had a non-elective hospital admission in the last 12 months, and have used acute or sub-acute rehabilitation services within the past year.

Among other healthcare organizations selected to participate in Independence at Home were Boston Medical Center and Cleveland Clinic Home Care Services: Medical Care at Home Program.
For more information about North Shore-LIJ’s Physician House Call program, call: 516-876-4100 in Nassau/Suffolk; or 718-830-4327 in Queens.

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