The Future of Home Health Care Workshop Summary (2015) / Chapter Skim
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6 Models of Care and Approaches to Payment
6 Models of Care and Approaches to Payment
Pages 65-90
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From page 65... ...
6 Models of Care and Approaches to Payment No single model of care will be able to meet the needs of all individuals who receive (or want to receive) home health care.
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From page 66... ...
SOURCE: As presented by Peter Boling on September 30, 2014. Measuring the Value of Home Health Care The diversity of home health care experiences makes the components of care as well as their effects hard to measure in a reliable, consistent manner, "so that you can say structure, process, [and]
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From page 67... ...
. The most complicated, challenging, and expensive patients receiving home health care, Boling said, are those with a high comorbidity and illness burden who may need acute care at home, post-acute transitional care, or long-term health care.
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From page 68... ...
Medicaid recipients needing home health care encounter a program that, Boling said, offers discontinuous skilled care, a weak medical model, a slow response to urgent problems (resulting in unnecessary hospitalizations) , and inconsistent attention to needs for help with ADLs and a system that is not aligned with other programs and payers, notably, Medicare.
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From page 69... ...
Community-Based Care Transitions Program The Community-Based Care Transitions Program,1 created under Section 3026 of the Patient Protection and Affordable Care Act of 2010 (ACA) ,2 has devoted up to $500 million to tests of new transitional care models at more than 100 participating sites so far.
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From page 70... ...
It requires an experienced care team, and traditional fee-for-service payments do not cover its costs. Independence at Home Independence at Home,4 funded by Section 3024 of the ACA, is targeted to post-acute care patients with several serious chronic conditions and disabilities.
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From page 71... ...
• Targeting of the highest-risk patients is the key to achieving savings. • Transitional care models need to transition to longer-term care for many patients.
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From page 72... ...
Referrals can come from a hospital, a doctor's office, or a skilled nursing facility. Burnich noted that about 40 percent of the referrals come directly from physician practices, and "without the doctors' support, this program wouldn't be where it is today." The combination of AIM and integrated care management expertise in the home is yielding person-centered, evidence-based, coordinated care, he said.
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From page 73... ...
All of this, he said, rests on a curative plus palliative care foundation. The Sutter project received a health care innovation grant from the Centers for Medicare & Medicaid Services (CMS)
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From page 74... ...
Communication and Teamwork Although the visiting nurses complete the usual lengthy intake forms that assess patients for everything from the risk of falls to the medications that they take and the presence of depression, these records are often not well incorporated into the patients' records, Lopez said. Atrius's electronic health records system ensures that current assessments appear where they are convenient for physicians to access.
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From page 75... ...
Another specific team-building strategy is "geriatric roster reviews," which are regular team meetings in the doctor's office in which case reviews are done for patients identified to be at high risk. Program Design and Metrics VNACNH has developed a palliative care consult team that works with the primary care practice and the home health care staff to better manage patients near the end of life, and it also has a robust advance care planning program.
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From page 76... ...
Lopez said that the data collected for the Pioneer ACO and Medicare Advantage patients receiving VNACNH home health care services indicate that in comparison with the outcomes in previous years, • Hospital readmission rates are down; • VNACNH is providing an increasing proportion of home health care; • Eighty-five percent of patients admitted to VNACNH are screened for the risk of falls and for depression (with the outcome of the screening being documented in the electronic record) ; and • Ninety percent of patients have had a discussion about medicines, pain management, and home safety.
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From page 77... ...
It offers home health, hospice, and palliative care; Medicare Advantage; a managed long-term care plan; paraprofessional and private duty nursing; and aide services. On any given day, she said, approximately 66,000 people are under the agency's direct or coordinated care, and in 2013, its staff made some 2.3 million clinical visits for patients of all ages.
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From page 78... ...
Their training modules cover topics such as care transitions, evidence-based practices, social determinants of health, health literacy, sociodemographics, and biopsychosocial issues. The RN population care coordinators lead teams that include NPs, psychiatric NPs, pharmacists, hospital-based RN liaisons (who, in some cases, serve as transitional care coordinators)
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From page 79... ...
It has two projects under way to provide health and wellness services with behavioral health support for posttraumatic stress disorder and reconnections to primary care services for people affected by Hurricane Sandy. VNSNY also provides care coordination for the largest managed long-term care plan in the state.
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From page 80... ...
About 25 percent of the population served by the telephonic program has an in-home visit to assess the home and the patient's circumstances, and about 10 percent has ongoing, in-home care management. Hospital at Home MD/NP Home Visits Home Health (Skilled Services)
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From page 81... ...
They target this population through the Humana At Home Chronic Care Program, which is an ongoing care management program for this population with critical needs, complex illnesses, and multiple chronic conditions. To identify the members most at risk for future severe illness, Rackow said, the organization looks at both the presence of chronic illnesses and functional limitations affecting ADLs.
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From page 82... ...
This population is poorly served by fragmented care and the lack of coordination of care for multiple chronic conditions and receives inadequate care at the end of life, he said. Typical Optum clients are managed care plans and, increasingly, programs for dually eligible individuals that delegate the delivery of services for their high-risk populations to Optum.
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From page 83... ...
Further ore, Care Plus can reduce overall health care costs for members m with medically complex conditions by 42 to 52 percent compared with the costs for members whose care is not managed. In addition, as these extremely ill individuals approach the end of life, their rates of health care service utilization and costs are much lower than those for all Medicare patients, especially high-risk Medicare patients.
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From page 84... ...
It is client directed and not just client centered, and the clients' goals are exemplified by the following: "I want to be able to get up my stairs, so I can sleep in my bed instead of on my couch." Or, "I want to be able to stand long enough to be able to eat some foods, so I don't have to go back to the hospital." Program Approach By and large, program participants are low-income, dually eligible individuals recruited from community centers and mailings, but they are at high risk for functional limitations. CAPABLE provides clients with a team member who can make household repairs, a nurse, and an occupational therapist over 4 months.
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B has hypertension, congestive heart failure, diabetes, and arthritis. She was recently hospitalized for an exacerbation of her heart failure and just finished an episode of post-acute care in a skilled nursing facility.
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From page 86... ...
Results The program has been pilot tested and may be ready to be scaled up, Szanton said. According to Szanton, the pilot tests showed that the one-time cost of the 10 professional visits averages $3,300 per enrollee, including travel, clinical care coordination, and home repair and modification.
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From page 87... ...
Medicare Advantage is growing rapidly but under the ACA has built in some payment cuts that will discourage plans and providers from participating, Burnich said. Despite the advantages of capitation, not every senior will join Medicare Advantage, he said, and his organization is experimenting with other types of chronic care management programs.
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From page 88... ...
Lopez said that integration has been important to Atrius Health on multiple levels: alignment of mission and care delivery goals, provision of a financial bottom line, communication, and medical information sharing. Although Atrius could have worked with several visiting nurse associations in eastern and central Massachusetts instead of just one, he said, the alignment, goals, and financial and communications issues would have to have been worked out with each one of the associations and would have been burdensome.
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From page 89... ...
Madden-Baer said that VNSNY's home health care program started small and thought of itself as a laboratory for testing models of care, which have been added over time and which have allowed the evolution of VNSNY into a much larger organization. Technology is not the be-all and end-all, because "the warm touch is still a critical component," said Burnich, but there are ways to scale down through the use of technology, including through the use of sensory devices and video visits, for example.
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