Enhancing continuity of care and reducing unnecessary utilization in high-risk and homebound patients: the emerging role of the residentialist in the health care delivery system

As much as 6% of the aging population is severely disabled. A significant portion of Medicare spending is attributable to this population, who frequently use acute services and are prone to acute hospitalizations, hospital readmissions, and futile care. For this high-risk, frail, elderly population, data suggest that many of these episodes of care are compounded by suboptimal postdischarge continuity, and by ongoing gaps in access and continuity. An old model of care is emerging as a reinvention of the traditional house call, using the services of clinicians providing care in the home. This paper discusses the evolution of this practice model into a set of competencies and skills defined as residentialist care. Residentialists offer significant potential to create a disruptive innovation in care delivery, close gaps in care, and improve efficiency and continuity of health care to the high-risk, homebound, frail elderly.