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How technology enables home-based, patient-centered care for chronic disease

Patient-centered care in the home health space has long been a challenge to provide, particularly for those with chronic conditions. But now, thanks to new breakthroughs in EHR technology and innovations by organizations like MatrixCare, that situation is rapidly changing.

In recent years, new tools have emerged to enable the harmonious, seamless, and secure transition of patient information between different platforms, providers, and partners. The result is that providers and payers get the info they need when they need it—and patients are empowered to better engage in their own health, which may help to drive better outcomes.

It’s all part of a new digital network created to allow for more efficient sharing of critical private health information (PHI) among patients, home health providers, primary care providers, HME providers, and the PHR/payer endpoint directory. And it’s also designed to ensure that care is centered on the patient, which can help to:

  • Inform better care decisions
  • Reduce readmissions
  • Decrease the total cost of patient care
  • Increase provider satisfaction
  • Improve the patient experience

To illustrate how it all works, let’s take a look at the journey of one patient named George Bench.

George’s journey to home-based, patient-centered care

Meet George Bench, a retired postal worker who was previously diagnosed with type 2 diabetes, along with hypertension and hyperlipidemia. At age 71, George experienced a worsening of his condition in 2020. As a result, his engagement in his own health has suffered, and his mobility has been compromised.

Neglecting to take his medication, failing to understand the severity of his condition, and inactivity because of the pandemic are all factors in George’s situation. They’re also all extremely common among patients with chronic conditions in general. And in the past, it’s been something of a challenge to address these issues in the home care space—which is exactly where George is headed.

Because of his now limited mobility, his PCP has referred him to a home health provider to better manage his condition. And upon accepting that referral, the home health provider’s first job is to attempt to gather George’s relevant past PHI to better arrange his care.

They do so with the help of the CommonWell Health Alliance data exchange, where George’s new home-based physician can easily query and retrieve previous records. A nationwide network that connects EHRs through record locator and data brokerage services, CommonWell allows an admitting provider to see all of a patient’s previous health history.

Thanks to CommonWell, important data can get to the right place at the right time through a sophisticated network of participating EHR providers, such as MatrixCare. The service also sends out notifications letting everyone in George’s care history know that he now has a new PCP. Data can also be contributed to the network directly by EHR upon request.

Bringing together the elements of patient-centered care

So far, so good—but George’s story isn’t quite finished yet. At the beginning of the year, his new Medicare Advantage plan kicks in. And because it doesn’t include his previous PCP in its network, he needs to choose a new provider. He starts to worry about his health records and whether his new home health provider and insurance company will be able to access them.

That’s where the Council for Affordable Quality Healthcare (CAQH) comes in. A non-profit organization with an endpoint directory of health data, the system is designed to let providers across different networks pull the critical information they need (with the patient’s permission, of course) and provide it to the appropriate insurer.

Where CommonWell is important as a data exchange, the CAQH serves as a repository for payer APIs so they can support access to information for patients—and allows patients to get info about benefits. As the industry continues to adjust payer requirements, we can expect to see the use of this service increase almost exponentially in the years to come.

George can now use patient-centered apps like OneRecord to request information from his old plan to provide to his new plan and to his PCP. The app works in coordination with the CAQH to show his new plan, his new PCP, and his new home-based nurse that a face-to-face visit had occurred in the past and that the old plan had approved home health.

Later, when George’s new home-based PCP recommends durable medical equipment, the HME provider can also easily access this network. A direct, secure message from the PCP generates an order to be delivered to the patient’s home, where the provider can continue to provide care with the assistance of the equipment that’s been rented out by the DME company.

The future of patient-centered care is here

Thanks to these interoperable services, systems, and networks, George’s providers were able to coordinate his care across different providers, insurance plans, venues of care, and health IT systems—including records from a system whose EHR provider isn’t yet a CommonWell Service Adopter.

Even better, the process empowered George to better manage his own care and be a more empowered patient, all of which resulted in positive health outcomes for George. The process is fast for patients and empowers them to improve participation and engagement—always critical for patients with chronic conditions.

At MatrixCare, we’re proud to be not just a member organization of this powerful network enabling patient-centered care at home, but also one of the first organizations to implement the notification service with CommonWell. We’re one of the only organizations currently scaling it, and turning it on for every new registration, as well as anyone else who requests it.

It’s all part of the job of facilitating patient-centered care in the home space. And we’ve worked for years to make sure we can meet these needs where the technology is now—not where we want it to be, or where it will be tomorrow—to best benefit the patients and the providers who use it.

Want to learn more? Let’s connect!


Chris Pugliese
Chris Pugliese

Chris Pugliese is a Senior Product Manager of Integration and Interoperability for MatrixCare. Chris has spent the last decade working with post-acute technology and EMRs, and the last 5 years focused on interoperability. His strength is enabling technology, as well as educating on the growing importance of interoperability and its benefits to the post-acute care settings. In a short time, Chris has become a leader, spearheading integration and interoperability initiatives within and outside of MatrixCare. Recent industry committee roles and responsibilities include: Leadership Team Member for the Post Acute Interoperability Work Group (PACIO), Technical Lead for the Functional Status Subgroup for the PACIO initiative – developing FHIR Profiles for Functional Status, CommonWell Health Alliance Use Case Committee member, CommonWell Health Alliance Specification Workgroup member


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