Care-at-home helps support those with complex conditions

Sometimes, the best care one can receive is at home. Frequently going to a care facility can be disruptive, especially if there are barriers to transportation. And for those living with multiple chronic conditions like congestive heart failure (CHF), diabetes, hypertension, and chronic obstructive pulmonary disease (COPD), ongoing, active management is essential to prevent flare-ups and urgent trips to the hospital. 

In order to help this population spend more time in the comfort of their home, UnitedHealthcare Community Plan of Tennessee and Spiras Health are working to support members with complex, chronic conditions using the Spiras Health Care-at-Home model. Led by nurse practitioners, this clinical model addresses both health and social risks with UnitedHealthcare members and helps coordinate care with the member’s personal physician(s).

Previous models of care for people with complex conditions have been much more linear,¹ with care systems designed to treat one condition at a time. Lack of communication among providers can also make care more difficult. Research has shown that emerging care models for people living with multiple chronic conditions should include:

• Team-based care
• Care coordination
• Community partnerships
• Shared decision-making
• Home-based support
• Understanding the patient’s treatment burden, including social risk factors
• Continuous communication¹

Lisa, a field clinician with Spiras, said she saw one patient with COPD and other chronic conditions, who had been in and out of the ER many times over the course of a year. With a home visit, Lisa, along with Sarah, a nurse practitioner, were able to assist the member by reviewing her medications and helping with her weekly injections. They also communicated with her primary care provider to coordinate care and initiate a care plan.   

“Spiras Health and UnitedHealthcare share a commitment to addressing the needs of patients with complex chronic conditions. Our unique and specialized home-based approach focuses on improving the member’s health and quality of life while reducing costs,” said Scott A. Bowers, CEO, Spiras Health. 

Spiras clinical team members see how this model makes an impact on their patients, with empowerment, education, and hope. Sometimes, patients with chronic conditions feel disenfranchised or overwhelmed by their treatment. Having a trusted team visiting their home, where they’re most comfortable, can help alleviate these stressors and thus provide better care. 

“All they want is for someone to come into the home and listen,” Lisa said. “I feel like we’re making a huge difference with our patients.”