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A quick guide to managing home-based care services in health systems

Adrian Schauer, AlayaCare Co-founder & CEO

I’ve watched the home-based care industry evolve over the last 9 years. The demand for patient care delivered in the comfort of one’s home is rapidly increasing, and it’s the gold standard both in terms of patient preference and health system cost.   

To consistently meet this gold standard, a strategic approach is important. Since founding AlayaCare, I’ve worked with many organizations supplying home-based care services worldwide and gained valuable insights into different delivery models and processes health systems use to deliver patient-centered care.  

I’ve compiled a list of recommendations to help health systems manage the delivery of home-based services and explore how to help you achieve your goals of delivering exceptional care.  

1. Standardized assessments ensure effective and equitable care plans

As healthcare progresses and advances, it’s clear that home-based care services are an effective way to improve patient outcomes. I have seen firsthand that organizations using standardized assessment tools are able to better optimize care plans for patients receiving home-based care services and then benchmark the outcomes of those care plans to ensure quality service delivery.  

Utilizing standardized tools is widely recognized as the foundation for conducting an evidence-based assessment. By employing standardized tools, caregivers can gather reliable and comparable data, allowing for more accurate analysis and interpretation1

Standardized assessments create efficiency, quality, safety, and patient satisfaction within health systems. For home-based care, it provides consistent evaluation criteria, ensuring reliable and comparable results across different patients and settings. This can be applied to multiple applications such as resource allocation, quality indicators, outcome measures, and most importantly care plans. 

Our AlayaCare InterRai Assessment tool is a standardized assessment tool within the AlayaCloud platform that empowers case managers and payers to create personalized care plans for each patient based on their medical, psychological, and social requirements. Our smart form building tools allow these assessment tools to be configured and evolved based on the needs and priorities of the local setting. 

With these standardized assessments in place, home-based care providers can access consistent, real-time data. That allows them to fine-tune their care plans and improve outcomes for patients. This means better care and lower care costs in the long run. Analyzing patient data with these tools also allows researchers and health systems to find previously unnoticed issues, leading to a cycle of continuous improvement.  

By taking advantage of the power of standardized assessments, home-based care providers are paving the way for more informed and effective decisions that help patients in their care and the healthcare system.  

2. Patient-centered care is the future of home-based care 

Money follows the patient

Home-based care delivery is becoming increasingly important as the healthcare industry shifts its focus to patient-centered care. Encouraging active collaboration and shared decision-making between patients and their circle of care2.  

Patient-centered care models can help3

  • Improve the patient experience of care, quality, and satisfaction 
  • Improve health outcomes  
  • Lower costs 

Based on these observations and outcomes of patient-centered care models, health systems should consider what I call the “money follows the patient” model, which gives patients more control over their care by allowing them to choose their preferred care provider for their home-based care services. Under this model, the health system connects certified agencies through a marketplace letting the patient decide who will supply their care. 

It ensures that patients receive high-quality care tailored to their needs, with the freedom to choose and change providers if necessary.  The health system pays for the care services the chosen agency provides, meaning the money ‘follows’ the patient rather than being tied to a specific provider or institution. 

By using this ‘money follows the patient’ model, health systems can enhance the quality of patient care, resulting in…  

  • higher patient satisfaction,  
  • lower hospital readmissions,  
  • and reduced overall healthcare costs.  

We can improve patient outcomes and reduce healthcare costs by placing patients in control and promoting the effective use of home-based care services. This approach maximizes the benefits of a market-based approach to value, while also ensuring equitable access to care. 

Patient freedom and autonomy  

I firmly believe patients should have more freedom and autonomy within their care plans. Patients choosing their providers can move them towards independent living and self-care for older folks and people with a chronic disease or disability. Nowadays, caregivers in home care have been shifting from a caring attitude toward promoting patient autonomy4.  

At AlayaCare, we’re committed to empowering patients to take the wheel when it comes to their care, putting them firmly in control of their own health and well-being. 

Patients deserve the right to not only choose their care providers and have the freedom to switch providers but also should be a part of shared decision-making for their provided care – which the AHRQ calls the Share Approach. Providing them with this freedom is essential to ensuring that they receive high-quality care that is tailored to their unique needs and preferences which empowers individuals to take charge of their health and wellbeing, promoting better health outcomes and increasing their satisfaction.  

3. Outcome measurement is the key factor in the success of home-based care 

As I have discussed so far, home-based care is built on the foundation of delivering personalized care to patients in the comfort of their own homes. To ensure that patients receive high-quality care, health systems need to focus on outcomes as a key factor in the success of home-based care: 

  1. By tracking and reporting outcomes, health systems can evaluate care effectiveness, identify areas for improvement, and make data-driven decisions to enhance care.  
  2. To foster accountability and transparency, outcomes should be communicated to the case manager in the public health system, enabling collaboration among stakeholders to continuously improve care and achieve better outcomes for patients receiving home-based care. In some jurisdictions, the case manager is effectively the Primary Care Physician (PCP), but even in this case the point stands.

When it comes to outcome measurement, another essential part I’ve seen is longitudinal Social Determinants of Health (SDOH) and change-of-condition surveillance. SDOH contributes significantly to health inequalities, and extensive evidence from the past three decades confirms the significant impact of nonmedical factors on overall physical and mental well-being. – such as, in the US, on average, there is a 15-year difference in life expectancy between the most advantaged and disadvantaged citizens5. Tackling these issues will reduce health disparities and promote health equity across the population, and by tracking SDOH over time, health systems can find underlying factors that may be contributing to poor health outcomes and develop targeted interventions to address these factors. 

4. Improving reimbursement rates and cost savings with preventative care 

As a health system, there are many reasons to consider investing in home-based care services. One key factor to consider is the impact on reimbursement rates.  When a healthcare system bears the overall cost of care for a patient, it’s cheaper to do preventative care in the home vs paying the higher cost when the patient is readmitted to the hospital.  

Let’s make this simpler. Picture the big bills that come from a hospital stay – everything from the cost of the bed to all the tests, treatments, and medications. Now, think about the costs of doing some care at home like regular check-ups, managing medicines, and changing daily habits. The difference in cost is pretty clear. So, when health systems invest in home-based care, they’re less likely to deal with the hefty costs of hospital stays and can better manage their money. Plus, it’s not just about saving money. This approach also helps improve the quality of care for patients, which makes everyone happier. 

With my years of experience with health systems supplying home-based care, the reimbursement rate set by a health system should be closely tied to the quality of care provided, particularly in home-based care services. Why? Because many studies have shown that home-based care vs institutionalized care improved patient happiness, decreased the risk of hospital admission, and had fewer adverse health outcomes6.  

For example, a study at Mount Sinai Health System found that hospital readmission rates were lower for Hospital-at-Home patients compared to hospital inpatients (8.6% vs. 15.6%)7.  

By prioritizing high-quality home-based care, health systems can significantly improve their reimbursement rates and save costs.  

5. Leverage technology to facilitate the exchange of health information between systems 

At AlayaCare, we know that using technology is essential to the success of home-based care services. For example, North Country Home Services improved productivity and compliance and increased their state reimbursement rate after implementing the right technology8

I highly recommend using technology that meets the Fast Healthcare Interoperability Resources (FHIR) standard to help the exchange of information between different healthcare systems. By implementing interoperable technology, health systems can ensure that information is exchanged in a standardized and secure manner. This can help improve care coordination, reduce errors, and improve the overall quality of care for patients. 

Integrating home-based care services with primary care, specialist, and acute care systems through a Health Information Exchange (HIE) can further improve coordination and reduce gaps in care services. By exchanging health information between different providers and service settings, patients can receive the most appropriate and effective care possible. 

Leveraging technology in this way increases the efficiency of home-based care services. Automating processes and workflows can reduce administrative burdens and allow providers to focus on delivering higher-quality care to patients. 

In summary, using technology, specifically the FHIR standard, and HIEs, can be crucial to the success of home-based care services and can improve care coordination, reduce errors, and improve the overall quality of care provided to patients receiving home-based care services. 

During my time at AlayaCare, I gained valuable insights into various delivery models and processes used by health systems worldwide. I’ve seen firsthand how to provide patient-centered care through working with organizations offering home-based care services. With these recommendations, I hope health systems planning to set up and evolve home-based care systems will use these best practices to ensure their patients receive the best quality care.  

About the author

Adrian Schauer

Adrian Schauer
Co-Founder and CEO

Adrian is a serial technology entrepreneur having built two successful mobile software companies; both achieving leadership positions in their respective markets before being acquired. Adrian is an active Angel Investor and sits on the boards of several companies including fast-growing technology firms like the point-of-care medical device company Chipcare, the SaaS company TrackTik, and the GRC software provider Resolver. Adrian is also the co-founder of the Madiro Fund, a charitable organization created to support innovative solutions to the health problems in low-income countries.


  1. Neugebauer J, Tóthová V, Doležalová J. Use of Standardized and Non-Standardized Tools for Measuring the Risk of Falls and Independence in Clinical Practice. Int J Environ Res Public Health. 2021 Mar 20;18(6):3226. doi: 10.3390/ijerph18063226. PMID: 33804715; PMCID: PMC8004039.
  4. Jacobs G. Patient autonomy in home care: Nurses’ relational practices of responsibility. Nurs Ethics. 2019 Sep;26(6):1638-1653. doi: 10.1177/0969733018772070. Epub 2018 May 7. PMID: 29734887
  7. Federman AD, Soones T, DeCherrie LV, Leff B, Siu AL. Association of a Bundled Hospital-at-Home and 30-Day Postacute Transitional Care Program With Clinical Outcomes and Patient Experiences. JAMA Intern Med. 2018;178(8):1033-1040. 
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