CT Home Care Industry

August 04, 2025

Value Based Home Care Models

Value-Based Care Models in Connecticut Home Health

Connecticut's home health providers are shifting towards value-based care models that emphasize patient outcomes and cost efficiency over traditional fee-for-service approaches. These models, such as the Person-Centered Medical Home Plus (PCMH+) program under Medicaid, reward providers with shared savings when they meet quality standards and reduce overall costs. This transition encourages proactive care management, including chronic disease monitoring and preventive services delivered in patients' homes.

Value-based care integrates data-driven strategies to support population health, with home health agencies playing a key role in delivering services that align with these goals. For instance, recent statewide health plans highlight that reforms failing to address non-medical factors may limit effectiveness in improving population health.

Addressing Social Determinants of Health (SDOH)

Social determinants of health (SDOH) encompass factors like economic stability, housing, education, and access to nutritious food, which significantly influence health outcomes. In Connecticut, home health providers are increasingly screening for SDOH during home visits to identify barriers such as food insecurity or transportation issues. Team-based approaches, including community health workers (CHWs), facilitate referrals to community resources, enhancing care coordination.

State initiatives, like the Connecticut State Innovation Model (SIM), promote SDOH integration into primary and home care through value-based payment reforms, aiming for better chronic condition management and reduced emergency department visits.

The Role of Home Care Agencies

Home care agencies in Connecticut are uniquely positioned to address SDOH due to their direct access to patients' living environments. They conduct comprehensive assessments during home visits, identifying environmental risks like poor housing conditions that affect health. Programs such as the Leeway Community Living Model involve multidisciplinary teams, including nurses and social workers, to create individualized care plans that prevent hospital admissions.

Integration of CHWs into home health teams supports this by providing culturally sensitive education and linking patients to services like food pantries or utility assistance, aligning with value-based care by focusing on outcomes and cost savings.

Improving Health Equity in Underserved Communities

By targeting SDOH, Connecticut's home health providers aim to reduce disparities in care access and outcomes, particularly in underserved communities. Initiatives like community care teams (CCTs) and mobile integrated health programs focus on high-need populations, such as those with substance abuse or homelessness, offering home-based interventions to promote equity.

Statewide plans, including Healthy Connecticut 2025, emphasize collaborative efforts with local agencies to address environmental and social factors, ensuring culturally appropriate services that empower vulnerable groups and foster long-term health improvements.

Challenges and Future Directions

While progress is evident, challenges remain in fully integrating SDOH data into electronic health records and securing sustainable funding for value-based models. Future directions include expanding CHW roles and enhancing partnerships between home health providers and community organizations to drive measurable improvements in health equity.

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