The year 2012 has been challenging for Home Health Providers and their employees. Most report declines in financial performance and patient census, and nearly all agencies struggle with the recent regulatory changes to the PPS model. Face to face rules and therapy reassessments are now facts of life, and they burden agencies on a daily basis. Many clinicians are aware that something is happening to the homecare industry, but are unsure of just how they will be personally affected. Med Pac proposals outline monumental changes involving therapy payment and patient co-pays. Reports of further challenges ahead; Accountable Care Organizations (ACOs), with Care Transition programs to decrease re-hospitalizations through Post-Acute Bundling, add to the uncertainty. When wondering where we go from here, both Home Health agencies and clinicians should consider advice from an industry leader regarding the future of homecare services.

 

After delivering a recent presentation at the 2012 Home Care Association of Florida’s Annual Conference; “The Future Is Here: New Care Practices for Home Health Providers”, the author attended Bill Dombi’s “National Update on Homecare” address. As Vice President for Law at the National Association of Home Care and Hospice (NAHC) for the last 25 years, he is certainly a well-established advocate for in-home services. Describing the future of homecare, Dombi commented;

 

“Home Health is still going forward, homecare will be bigger, stronger, and more a mainstream part of healthcare in the future. The new model will be based on integrated care with one purpose: keeping people at home rather than anywhere else; if they happen to leave the home to go to the hospital, it’s getting them back home sooner. Ten years from now, homecare will still be around but it will be different; it will not be what we see today, it will be a much, much bigger realm of homecare services; it may not even be called Home Health anymore.”

 

But Dombi described new opportunities emerging for Home Health in the near future; “Come October, hospitals that have too many readmissions will be paying for those and hospitals across the country are already turning to home care and saying “How can you help out?” Home Health has the skill set and the infrastructure, you just have to adapt. It’s not just price per visit, its outcomes. If I’m an ACO, I don’t want you because you’re cheaper, I want you because you cost less in a dynamic way: less re-hospitalizations, better management of patients, better integration…”       

      

And finally, he recommended that today is the time to address tomorrow, specifying that Home Health Providers; “Budget some of your energy and resources towards keeping the ship afloat, dealing with current care, the proposed cuts, etc, while devoting energies as well to these new opportunities that are out there. If you don’t, somebody else is, and they will be the one who succeeds.”

 

The Accountable Care Organization (ACO), mandated by the Affordable Care Act, is designed to find savings while improving care at the same time. Through partnering physicians and hospitals together to deliver care with a focus on wellness, they hope to rewire the traditional care model. By placing financial responsibility on healthcare providers, the ACO seeks to lower costs by producing savings via improved efficiencies. These gains will be seen at various points throughout the Medicare continuum, and the changes that produce them will affect all Providers in the near future.

 

By today’s standards, Medicare Providers (and their clinicians) must see more patients, or provide more care, to increase their income. Under the ACO, income can be gained by decreasing care costs; basically getting people better faster. In effect, the ACO introduces a payment model that is not entirely volume-based, instead focusing on healthcare savings as a goal. This premium on wellness focuses programming on the quality of care, rather than on the traditional volume based episodes.

 

In order for ACOs to be successful, Medicare must "incentivize hospitals, physicians, post-acute care facilities, and other providers involved to form linkages and facilitate coordination of care delivery."⁽¹⁾ These healthcare groups, working together with the focused goal of using less care for patient programs, can reduce the total costs of acute episodes. With regards to Care Transitions, the ACO program to decrease hospital readmissions, the Post-Acute Bundling model will involve LTACH, SNF and Home Health Providers.

 

Bundling involves moving the financial responsibility of the hospital-discharged patient to the hospital itself. It essentially partners the hospital with the Post-Acute Providers currently receiving their discharged patients by making hospitals responsible for the care costs of these patients. In our favor, recent statistics show decreases in hospital readmissions when homecare is utilized at discharge. More good news about the Bundling concept: the affordability of homecare makes them the preferred Post-Acute Provider when compared to LTACH or SNF inpatient care. And as a result, hospitals will view Home Health as the desired discharge destination.

 

All Part A hospital patients will eventually be Bundled, as Medicare essentially eliminates payment coverage for patients readmitted to the hospital within 30 days of discharge under the Bundling model. Many hospitals, especially those without a Home Health agency, will seek homecare agencies who can deliver an entirely new type of services focused on decreasing costs. Hospitals will create Preferred Vendor Rosters, comprised of Home Health Providers with skill sets that support the Bundling goal of creating savings. Homecare physician affiliations will weaken as the performance of the Provider becomes financial reality for both the doctor and the involved hospital. Patient choice will remain intact, but the lowered cost of care produced by successfully managed Care Transition programs will redefine “reasonable and necessary” care levels.

 

In late December of 2011, the Detroit Medical Center (DMC) was selected as one of 32 organizations to participate in the innovative Medicare-operated Pioneer ACO Model program. As a leader in progressive care delivery, the DMC is excited about the opportunity to develop the ACO Model, and has developed a Care Transition Network to Bundle their patients. By moving ahead with this new care concept, DMC hopes to produce savings while decreasing readmission rates; these are the building blocks of a successful ACO.

 

HHSM was engaged as a Post-Acute consultant with the DMC in 2011. Our role was to assess potential vendor partners, create programming goals for Bundled episodes, and develop clinical protocols for patient movement and care parameters. An element of our selection was our working history across the care continuum, which includes IRF, SNF, and Home Health experiences, as well as the development of our Utilization Review program for Home Health:S.U.R.C.H. Teaming with DMC executives, we developed a Bundling roster of Providers from all care types, and established clinical and programming expectations for ACO patients referred to them. The changes required for participation were rigorous, including the use of Utilization Review, EMR access, financial and cost reporting, and clinically-oriented care management. The vendors found it difficult to grasp at first due to the philosophical changes required by the ACO concept; more care management required for a shorter length of stay? As one of the Post-Acute SNF representatives remarked about these requirements for the Bundling roster; “You’re talking about a culture change!!”

 

At HHSM, we are national leaders in Care Transitions involving Post-Acute Vendors, and HHSM clients of all sizes have begun ACO preparations to date. Some have entered talks or negotiations with hospitals or health systems, eager and poised to adopt the care protocols of the future. We have worked with VNAs, large and small for-profit agencies, hospital-based or free-standing Providers, and health systems in nearly a dozen states, all focused on their role in the future of community care. These new Medicare models define success in terms of creating savings when compared to the current PPS model, and the changes in the day to day operations of Home Health Providers are significant. Outcomes are discussed (so how are yours?), care coordination (including timely documentation) is essential; therapy volumes (and content) focus