“Building a Better Model for Care at Home,” an AHIP webinar presented by CareCentrix, featured Mary Naylor, Ph.D., RN, FAAN, Marian S. Ware Professor in Gerontology, Director of the NewCourtland Center for Transitions and Health; Terri Maxwell Ph.D., APRN, Chief Clinical Officer, Turn-Key Health, a CareCentrix Company; and Melissa Carr, General Manager, Home Services, CareCentrix

“Building a Better Model for Care at Home,” explores transitioning care to the home as mission-critical, with COVID-19 further spotlighting the importance of home-based care. Re-imagining the home as a destination of care across the entire continuum requires the adoption of three pillars of care management: embracing technology, assessing and addressing non-clinical needs, and finding ways to provide critical support stripped away as an unintended result of an overburdened system, social distancing and self-isolation.

The best home care model will rely heavily on technology such as telehealth, which means the healthcare system must find an optimal approach for integrating technology with the human experience. The swift and widespread adoption of telehealth has proven to be a virtual lifesaver during lock-down, especially for monitoring the seriously ill at home.

Making the most of the telehealth opportunity and delivering care in a timely and effective way requires careful planning and taking a full account of the population that will benefit the most from this service beyond the broader population.

As the nation continues to grapple with COVID-19, it highlights the need for a model of care that aligns with individuals’ values and preferences and is culturally sensitive to a diverse population and diverse needs. 

COVID-19 and Impact on Under-served Populations

The illness trajectories of those with COVID-19 have been, and will continue to be, quite unpredictable. People with serious health problems are at particularly high risk, while some with no identifiable risk factors are experiencing post-COVID syndrome, in which individuals with COVID-19 suddenly experience new health issues three or four weeks later, such as the advent of heart disease, renal disease and cognitive deficits.

One study shows that almost 80% of those who had COVID-19 experience persistent problems, shortness of breath and brain fog. The National Institutes of Health are studying and tracking the long-term consequences of the virus that may help provide insight for the future of caring for these individuals at home.

The pandemic has also revealed who in our society are most vulnerable, require special care and will be most impacted.

Vulnerable Populations

The group that has experienced the biggest impact are the elderly with chronic conditions. They are more likely to develop serious symptoms and, given fears about accessing emergency departments and hospitals, their conditions have worsened during this time in a way that will have severe long-term implications. Looking at the Medicare population, about 550,000 in mid-July had contracted the disease. For those 65 and older, 160,000 of them were hospitalized, 25% died while in the hospital, while the majority transitioned to home and, for a smaller percentage, hospice or a skilled nursing facility.

Minorities have been especially hard hit by COVID-19, with people of color disproportionately affected. In fact, Latinos and Blacks in the 45-55 age range are five times more likely to be hospitalized (REF) and two to three times more likely to die. Low-income individuals, Medicaid and dual-eligible members are also disproportionately affected because they tend to live in highly populated communities and dense housing in so-called “food deserts.”

We also witnessed hospitals serving under-served communities unable to get ventilators and PPE. As a nation, we must focus on these groups, including quality of life in the home. Many of the vulnerable, including the dual and Medicaid population will require an army of community health workers to address social determinants of health (SDoH) and other issues, who must be compensated accordingly.


SDoH—such as economic status, food insecurity, isolation/loneliness and reliable transportation—create significant challenges for under-served populations. The pandemic has exacerbated social isolation and economic woes and contributed to intense levels of fear, anxiety and depression. It will be important to tackle these issues to mitigate their long-term physical and mental effects. COVID-19 also makes it particularly essential to reach out to those living with serious illness on a regular basis.

Many community-based services, such as meal support and senior day care centers, were no longer available in the pandemic’s early months because of their reliance on volunteers. While some of these services are available again, gaps remain.

Home-based care, including home-based palliative care, played a fundamental role in addressing care gaps and SDoH during the height of the pandemic. For example, when Meals on Wheels stopped delivering to peoples’ homes, palliative care clinicians were able to contact and coordinate with a family member, friend or neighbor to deliver food to the home.

Until recently, addressing SDoH has not been a focus of healthcare. Moving care into the home brings greater attention on the non-medical needs driving healthcare costs in this country. Fortunately, we are seeing MA plans use supplemental benefits to pay for food services and transportation, as well as other measures, such as grab bars to prevent a fall that might otherwise lead to a hospital visit and a nursing home admission. Going forward, we will have to think about health care financing differently to better address these non-medical needs.

Building Trust During Lock-down

Another issue fueled by the pandemic has been a growing mistrust of the health care system due to concerns that they could contract COVID-19. Many people are still not utilizing emergency departments and hospitals as much as they should to treat serious symptoms and illness. This has the potential for an enormous long-term impact in terms of disease exacerbation, worsening chronic illness and spike in avoidable deaths.

Potential New Opportunities


The pandemic has brought about a telehealth revolution that has served as a real lifesaver, especially for monitoring patients in the home and rapidly responding to their needs. In the Medicare population, 14,000 telehealth visits skyrocketed to 1.7 million visits in a week.

Today, approximately 40% of primary care visits are delivered via telehealth, which happened virtually overnight. However, not everyone has access to these technologies, especially those without access to reliable internet. Older adults with hearing or vision loss or mobility challenges also may have barriers to accessing telehealth. In addition, there are challenges associated with language and literacy.

Going forward we need to co-design the health system and integrate communication technologies in a way that enables culturally sensitive trust building. We also need to address disparities to ensure that the most vulnerable can also benefit from telehealth, especially among the under-served populations in rural areas who do not have the infrastructure to support this important technology.

Regulatory Environment

Regulatory and payment fluidity also facilitated the use of telehealth and other technologies in homes. MA and commercial plans waived fees and cost sharing to allow telehealth and CMS relaxed a number of restrictions. These highly positive changes demonstrate that we do not have to wait years to change regulations to accommodate needs. What’s more, these changes bode well for the future of home care.

Perhaps the silver lining to the pandemic is that so many healthcare professionals quickly and deftly adopted innovation, remained agile in challenging environments and generously shared best practices across systems and settings, despite the hardship, uncertainty and human suffering. Many of these practices and opportunities will enable the health system to leap forward to deliver a better healthcare system that focused on the home for the benefit of all Americans.