Now we’re talk­ing

Hos­pi­tal ex­ecs, pol­i­cy­mak­ers be­lat­edly rec­og­niz­ing value of home-health agen­cies

Modern Healthcare - - Opinions Commentary - Andy Carter

The leader of post-acute ser­vices of a ma­jor hos­pi­tal sys­tem in the Mid­west was al­most giddy with ex­cite­ment in a re­cent meet­ing of her home health­care peers from nearby states. “With Medi­care read­mis­sion penal­ties on the horizon, the rest of my sys­tem is sud­denly notic­ing me,” she said. “We’re be­ing en­gaged with a level of ur­gency and in­ter­est I’ve never seen be­fore. Now, in­stead of be­ing seen as a drag on the sys­tem’s bot­tom line, they’re rec­og­niz­ing our po­ten­tial as a ma­jor profit cen­ter.”

The will­ing­ness by hos­pi­tal lead­ers to cast a fresh eye on home health­care is driven by more than the threat of read­mis­sion penal­ties, how­ever. They are also rec­og­niz­ing the need to build re­la­tion­ships across the con­tin­uum of care in prepa­ra­tion for ac­cept­ing greater lev­els of ac­count­abil­ity for pa­tient and pop­u­la­tion health in their com­mu­ni­ties. Even if ac­count­able care or­ga­ni­za­tions never take flight un­der Medi­care, most hos­pi­tal sys­tem lead­ers agree that, at min­i­mum, their feet will be held to the fire to do more to im­prove pa­tient health, es­pe­cially among pa­tients with mul­ti­ple and costly chronic con­di­tions.

In the short term, strate­gies for im­prov­ing the tran­si­tion from hos­pi­tals to post-acute set­tings are at­tract­ing the most at­ten­tion and re­sources. One ex­am­ple, build­ing on tran­si­tional care mod­els, is the idea of “health coaches,” who pre­pare pa­tients and their fam­i­lies as pa­tients leave the hos­pi­tal, of­fer­ing ed­u­ca­tion in self-care, sup­port in co­or­di­nat­ing fol­low-up ap­point­ments, and even mak­ing home vis­its to check on progress. These mod­els have proven to be highly ef­fec­tive in re­duc­ing pre­ventable hos­pi­tal­iza­tions and im­proved pa­tient sat­is­fac­tion.

Yet, over the long term, we need to chal­lenge the sys­tem to do more than sim­ply en­sure a safe dis­charge from the hos­pi­tal to the home or a post-acute fa­cil­ity. It is cer­tain that poorly man­aged dis­charges from the hos­pi­tal are a huge source of waste and risk, but pa­tients with mul­ti­ple chronic con­di­tions (es­pe­cially older Medi­care pa­tients) face a host of other pro­found chal­lenges long after both the dis­charge and the all-important 30-day win­dow.

Jug­gling mul­ti­ple spe­cial­ists, man­ag­ing 10 or more med­i­ca­tions, main­tain­ing daily func­tion­ing, bat­tling the de­bil­i­tat­ing ef­fects of de­pres­sion and de­men­tia, or deal­ing with a spouse’s care needs all present huge chal­lenges to many of

Home health­care is bet­ting

its chronic-care ex­per­tise is per­fectly suited to ACOs.

these pa­tients and un­der­mine their health goals.

This is where the ex­pan­sive ca­pac­ity of home health­care comes in. In­no­va­tive thinkers such as Beth Hen­nessey and Paula Suter, both of Sut­ter VNA & Hospice, part of Sut­ter Health, Sacra­mento, Calif., have built a pow­er­ful case in the lit­er­a­ture doc­u­ment­ing the ways home-health agen­cies can lever­age their long, deep and suc­cess­ful ex­pe­ri­ence man­ag­ing pa­tients with com­plex chronic con­di­tions in the home. For more than 100 years, the best agen­cies have de­ployed mul­ti­dis­ci­plinary teams of nurses, ther­a­pists, so­cial work­ers, aides and oth­ers to the homes of pa­tients with some of the most vex­ing chronic clin­i­cal con­di­tions. These highly trained teams pro­vide a host of assess­ment, treat­ment, ed­u­ca­tion, co­or­di­na­tion, re­fer­ral, mon­i­tor­ing and be­hav­ior mod­i­fi­ca­tion coun­sel­ing ser­vices to achieve su­pe­rior qual­ity and fi­nan­cial out­comes, as doc­u­mented in at least one pub­lished study.

As Hen­nessey, Suter and oth­ers have noted, how­ever, home health’s real po­ten­tial has barely been tapped. To some de­gree, home health has been con­strained by Medi­care’s lim­ited vi­sion of what these agen­cies can do and be paid for—namely, in­ter­mit­tent care for a lim­ited pe­riod of time for home­bound pa­tients. De­spite their abil­ity to sup­port pa­tients with chronic con­di­tions in­def­i­nitely, and to help them im­prove their self-care skills and in­de­pen­dence, Medi­care cur­rently will not typ­i­cally re­im­burse home-health agen­cies for such an ex­tended role, and cer­tainly not in­def­i­nitely.

Medi­care’s cur­rent skep­ti­cism about the value of such “chronic-care co­or­di­na­tion” ser­vices has not stopped many home-health agen­cies from strength­en­ing their ca­pac­ity to pro­vide them to more pa­tients, partly in re­sponse to grow­ing de­mand from less skep­ti­cal quar­ters. Pro­gres­sive hos­pi­tal and physi­cian lead­ers busily con­struct­ing ACOs, for ex­am­ple, are be­gin­ning to ask home-health agen­cies for pro­pos­als to share re­spon­si­bil­ity for achiev­ing long-range care goals for these com­plex and costly pa­tients. For their part, the agen­cies are bet­ting that their chronic-care man­age­ment tal­ents are per­fectly suited to help ACOs achieve their clin­i­cal and fi­nan­cial goals.

Rapid adop­tion of these chronic and tran­si­tional care mod­els, and a wider ac­cep­tance of the value of a part­ner­ship be­tween hos­pi­tals and home-health agen­cies, de­pends on bet­ter data prov­ing their ef­fec­tive­ness. For­tu­nately, help is on the way thanks to the Pa­tient Pro­tec­tion and Af­ford­able Care Act. A com­bi­na­tion of pi­lot and demon­stra­tion pro­grams will cre­ate op­por­tu­ni­ties to col­lect ex­ten­sive data and con­duct solid eval­u­a­tions. As­sum­ing the eval­u­a­tions sup­port the find­ings of cost-ef­fec­tive­ness and good clin­i­cal out­comes al­ready re­ported, the chal­lenge for home health will quickly turn to ratch­et­ing up ca­pac­ity to meet de­mand from ACOs and any­one else striv­ing to im­prove the care of these pa­tients.

From be­ing seen all too of­ten as a fi­nan­cial drag to be­com­ing an en­gine for clin­i­cal ex­cel­lence, fi­nan­cial suc­cess and com­mu­nity health, home health­care will be­come a hotly sought-after part­ner. That’s a trans­for­ma­tion that will soon cap­ti­vate the imag­i­na­tion and at­ten­tion of pol­i­cy­mak­ers and aca­demics, fi­nally bring­ing them in line with the gen­eral pub­lic, which for more than 100 years has con­sis­tently been say­ing its fa­vorite set­ting for care is right in the home.

Andy Carter is pres­i­dent and CEO of the Vis­it­ing Nurse As­so­ci­a­tions of Amer­ica, Wash­ing­ton.

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