Opening the Front Door to Better Care

Published by Huffington Post
By Steve Landers MD,MPH
January 25, 2016

This article is co-authored with Dr. Bruce Leff, Professor of Medicine and Director of the Center for Transformative Geriatric Research at Johns Hopkins@HopkinsMedicine.

America is experiencing a dramatic population shift — one that will turn the country on its head. As Baby Boomers age, more people will live with chronic conditions, like heart disease or dementia, and many will have difficulty with basic abilities like walking and managing their household.

These shifts will create enormous challenges for our country. We must do everything possible to ensure that older Americans remain independent and healthy at home, without experiencing the suffering, indignity, and costs associated with unnecessary hospitalizations and institutionalization.

Our success in answering this call will dictate quality of life vs. suffering for millions of people. The country’s economic health is also at stake as the growing costs of Medicare and Medicaid threaten to squeeze out funding for other priorities. A key to solving this vexing problem is improving access to quality care at home.

In the wake of the Affordable Care Act and the Medicare Access and CHIP Reauthorization Act of 2015, we are seeing a shift toward more care coordination and “value-based” care. These trends have led to more interest by doctors and hospitals in helping people succeed in home and community-based settings.

This new attention is a good start, but it’s not enough.

The focus of current reform efforts has centered on insurers, hospitals, physicians, and employers. Home-based care has been left out of high profile national policy conversations, despite the fact that most older Americans prefer to stay at home and “age in place.”

Our policymakers aren’t putting enough time and resources into strengthening home health care and developing new home-based care strategies. Further, some home care policy proposals actually risk hurting the positive programs that already exist.

Out of this leadership void, the Future of Home Health (FOHH) Project was born. Developed by the Alliance for Home Health Quality and Innovation , the FOHH Project has taken on the challenge of starting a national conversation on these issues and the project really picked up steam when the Institute of Medicine (IOM) and National Research Council (NRC) hosted ‘The Future of Home Health Care’ workshop. The summary book and videos from the workshop are available online.

A few overarching themes recurred throughout the workshop, these themes could provide a head start for leaders interested in improving care:

1. There’s no place like home. Stakeholders from many backgrounds called for a shift towards community based care–making the home the center of care whenever possible. Family caregivers at the workshop were especially passionate about the importance of home care.

2. Better care at lower costs. Home health care of the future must be a solution to high costs and quality of care concerns. One example is Medicare’sIndependence at Home Demonstration, which is showing that medical teams that make house calls to Medicare’s sickest and most costly patients at home can support these individuals and save lots of money.

3. Payment policy and regulations need improvement. To build and grow new approaches to home care there will need to be policy and payment changes that support innovation. Many current policies and programs are fragmented and outdated. There should be more coordination, integration, and alignment around addressing both medical and social issues. Several historical policies and programs have created an unnatural separation between medical and social concerns even though high quality care for an aging population requires both to work in concert.

4. Don’t forget about the workforce! We must improve training, especially in geriatrics and palliative care, for all types of health professionals. Developing people to work in team-based care will be key.

5. Technology, technology, technology. Smart use of mobile health, health information, remote monitoring, telemedicine, independent living, and point of care technologies are essential for the shift towards home and community based care.

6. Accurate report cards. Quality and outcomes will need to be measured in order to reflect the value of community and home-based care. We must take care to ensure appropriate quality measures that fit the needs and goals of older people with multiple medical problems, rather than current measures that often focus on single diseases.

The ultimate goal of the FOHH Project is to develop a framework for home health delivery in the future and to take advantage of the many promising innovations that have not been scaled widely due to gaps in policy and for lack of attention.

These efforts serve as a foundation for beginning a discussion, but more national dialogue is required, with input from a wide range of leaders. To truly have a person-centered, compassionate, and responsible healthcare system we must work on building a bright future and prominent role for home health care.

Recapping the Future of Home Health Southern Regional Symposium

In 2014, the Alliance launched the Future of Home Health Project, aimed at improving the understanding of the ways home health is currently used, and how it can be utilized in the future for older Americans and those with disabilities. Last week, as part of the Project, the Alliance held the first in a series of regional symposia.

Hosted in advance of the Southwest/Gulf Coast Regional Home Care & Hospice Conference and Exhibition in New Orleans, the Alliance’s Future of Home Health Southern Regional Symposium, “Preparing for the Future: Building on the IOM Future of Home Health Care Workshop,” brought together regional and national providers, thought leaders, and stakeholders for a dialogue on home health and its future in the health care landscape.

Participants heard from speakers from the Institute of Medicine (IOM), Kindred Healthcare, Case Western Reserve University, the Brookings Institution, the National Alliance for Caregiving, and Virginia Commonwealth University on how the future of home health care should look and what needs to be done to get there. The symposium panels discussed issues related to workforce, patient and caregiver interaction, measures, innovative payment models, collaboration with physicians, reducing hospitalizations, and more.

The day started out with a recap of the Fall 2014 Institute of Medicine and National Research Council Future of Home Health Care Workshop, featuring Dr. Tracy Lustig of the IOM and Dr. Elizabeth Madigan of Case Western Reserve, who served as a co-chair of the workshop. A quick look at the themes from the Workshop can be found here.

During the next panel on “Perspectives on the Role of Home Health in New Health Care Delivery Models,” Mary Van De Kamp of Kindred Healthcare spoke about shifting the focus from reducing only rehospitalizations to reducing hospitalizations overall. She explained that home health over time will position itself as being more than only a provider of post-acute care. The theme of driving home health care away from just post-acute and toward more patient-centered, community-based care is one that can be found throughout the Project, and in new and innovative models of care delivery. Both Dr. Peter Boling of Virginia Commonwealth University and Dr. Barbara Gage of the Brookings Institution and the Post-Acute Care Center for Reform (PACCR) discussed a few of the aforementioned innovative models in their presentations as well.

In the final panel, Kate Jones of Amedisys and Gail Hunt of the National Alliance for Caregiving joined Dr. Gage to discuss ways to prepare for the future of home health care. Mrs. Jones talked about the needs of the workforce and ways to achieve better workforce planning, while Ms. Hunt brought the discussion back to the patient and caregiver, and the critical need to communicate effectively with both in order to avoid readmissions and achieve the Triple Aim.

Finally, Dr. Robert Rosati of the Visiting Nurse Association Health Group led a recap of the day’s discussion and encouraged participants to share their reactions to the issues raised in each session. We collaboratively unpacked the key themes to focus on for the future of home health care.

The Alliance is thankful to all of our panelists, moderators, and participants for bringing such important topics to the table and allowing us to delve further into a critical discussion as the population ages and health care in the U.S. continues to evolve.

We’re looking forward to continuing to take the discourse outside of just Washington, DC, and we hope you’ll be able to join us at an upcoming event. Please keep checking back for more information on upcoming regional symposia in the Northeast, Midwest, and West, and follow along on Twitter using the #FutureofHH.

Recap of Congressman Rush Capitol Hill Briefing on the Past, Present, and Future of Health Care in America

On Tuesday, Alliance Executive Director Teresa Lee was invited by Congressman Bobby Rush (D-IL) to speak at a briefing on Capitol Hill entitled, “Health Care from 30,000 feet – Past, Present and Future from an Industry Perspective.” The panel, which also featured Dr. Deirdre Walton of the National Black Nurses Association, Ms. Alethia Jackson of Walgreens Co., and Mr. Srinu Sonti of Senator Richard Durbin’s (D-IL) office, was moderated by Dr. Michelle Gourdine, a health policy expert and the CEO of Michelle Gourdine & Associates who holds appointments at Johns Hopkins Bloomberg School of Public Health and University of Maryland School of Medicine.

In her remarks, Ms. Lee provided an overview of home health’s value proposition, noting that skilled home health generally serves a poorer, sicker, and more racially and ethnically diverse set of patients than other post-acute care settings. Given that most seniors prefer to age in place, skilled home health is the most cost-effective option when clinically appropriate. However, siloed payment systems threaten the effectiveness of the system by promoting fragmented care, which rewards volume over value. Coupled with issues pertaining to the current home health benefit and the lack of infrastructure necessary for an aging population, changes need to be made to support health care delivery going forward. However, the system is seeing positive results with innovative models, projects, and demonstrations that are making good use of home health and home-based care, including the Independence at Home (IAH) demonstration and the Veterans Affairs Home Based Primary Care (HBPC) program; Medicare’s Program of All-Inclusive Care for the Elderly (PACE), as well accountable care organizations (ACOs), bundled payment arrangements, and community-based care transitions programs. The success of these models is promising and serves as a harbinger of the future.

Discussion on the panel also centered on how to make health care more accessible for the total population in the future. A few key takeaways from the event include:

  1. Reform the patchwork health care system: One way to do this is through improved health information technology and health information exchange. Mr. Sonti spoke of a need for greater communication across all settings of care in order to improve coordination and delivery of care.
  2. Move toward community-based care, with the home as a locus of care: Jackson noted that Walgreens is in the midst of working on greater use of its retail clinics and in-home infusion services to provide community-based care.
  3. Push toward optimization of the workforce: Walton emphasized a need to allow nurse practitioners to practice up to their certification levels, as well as for better coordination and communication with physicians in keeping care out of the acute setting.
  4. Considerations relating to scaling new models: Lee and Mr. Sonti noted that dissemination of health care delivery system reforms on a large scale would need to bear in mind considerations relating to risk. Policy-makers will need to balance the interest in reform with considerations involving beneficiary access to care.

The topics covered during the briefing are critical to the advancement of health care delivery in the future and we invite everyone to continue the dialogue through the Alliance’s Future of Home Health Project. You can reach us via email at futureofhh@ahhqi.org, follow us on Twitter at #FutureofHH, or join us for our ‘Future of Home Health Symposium: Tackling Critical Issues for the Future of Home and Community Based Care’ next month here in Washington, DC. More information on the Symposium can be found here.

Guest Blog: Thanking Family Caregivers Starts with Family-Centered Care

In honor of Thanksgiving and National Family Caregivers Month, Gail Hunt, President and CEO of the National Alliance for Caregiving shares her thoughts of the importance of family caregivers in the delivery of home health care.

Note: This post originally appeared on LillyPad here.

You’ve gathered your closest friends and family and the table is set for Thanksgiving. This is a moment of gratitude. Consider, in that moment, that someone around the table may one day be your family caregiver. Maybe you will care for them. (Maybe you already do.)

Each year, we give thanks for caregivers during November as part of National Family Caregivers Month. This month in particular we’ve been thinking about what happens when “Care Comes Home.” We talk about the benefits of home- and community-based care in reducing costs and meeting patient demands. But have we discussed the impact on family caregivers when health systems move to home-based care?

Many families rely on home-based care, including the short-term Medicare Home Health Benefit and long-term programs like the Veterans Administration’s Home-Based Primary Care. Others depend heavily on home health aides and telehealth to provide in-home care support. These are critical tools that help aging and medically complex patients live with dignity and independence in their homes.

But as demand continues to grow, policymakers should be aware of the need to better support caregivers who are the backbone of these models. Research has shown that a majority of caregivers help with at least one Activity of Daily Living (such as the daily bathing or dressing of a loved one). Many help with more. Caregivers have also reported that they conduct medical tasks within the home, which can be a source of tremendous anxiety. If the goals of healthcare reform include better managing care transitions, avoiding hospitalizations, and improving chronic care management, then it’s time to start talking about how family caregivers can be part of the answer.

There are several high-impact solutions for policy makers to consider:

  • Include family caregivers as part of the healthcare team. This means implementing “patient-and-family centered care”, collecting caregiver-reported outcomes, and noting the family caregiver in the medical record (both electronic and paper).
  • Assess the caregiver and provide training for caregivers during care transitions. Caregivers are often expected to provide support for health needs, personal and household care, and emotional support following the discharge of a loved one from the hospital. Clinicians should be cognizant of the role that caregivers are being asked to play and be sure to assess the willingness and ability of the caregiver to take on this role before discharge.
  • Develop better technologies to support patient health at home. Two key areas to think about: medication management and care coordination. Family caregivers can be partners in this, but teaching them how to use the tools and communicate with clinicians will be key to making telehealth programs more successful.

Next year is the 2015 White House Conference on Aging and the 50th anniversaries of the Medicare and Medicaid programs. It’s a perfect time to start talking about whole-system health that addresses not just the needs of the patient, but those family and friends who support them. Let’s show our thanks but recognizing both the contributions that caregivers make to our society and how these contributions can enable better healthcare at lower costs.


Gail Gibson Hunt is President and CEO of the National Alliance for Caregiving. Established in 1996, the National Alliance for Caregiving is a nonprofit coalition of national organizations focused on advancing family caregiving through research, innovation and advocacy. To learn more, please visit www.caregiving.org.

October #HomeHealthChat: Next Steps in the Future of Home Health

On Tuesday, October 28th, the Alliance hosted its monthly #homehealthchat on Twitter.

The chat focused on recapping the IOM/NRC Future of Home Health Workshop, with a focus on next steps for obtaining an ideal future.

The co-hosted was Dr. Olga Jarrín (@OJ_RN). Dr. Jarrín is a health services researcher focused on improving the design, delivery and outcomes of home health care. She is currently working with Dr. Linda Aiken (@LindaAiken_Penn) in the Center for Health Outcomes and Policy Research (@Penn_CHOPR) at the University of Pennsylvania School of Nursing (@PennNursing) on the RN4CAST-United States survey, which is the largest study of nursing care (including home health) and patient outcomes ever.

The Alliance hosts a home health-focused Twitter chat on the fourth Tuesday of every month at 2 pm ET. Be sure to check here for updates on topics, co-hosts, and questions!

If you have topic ideas for future Twitter chats, or are interested in co-hosting a chat, please contact the Alliance’s Special Assistant to the Executive Director Jennifer Schiller here.

Below are some of the highlights from the chat:

IOM Workshop on the Future of Home Health Care: Panel on New Models and Approaches to Payment

From Alliance Executive Director Teresa Lee:

In the days and weeks to come, the Alliance will be digesting the issues and themes raised at the Institute of Medicine and National Research Council Workshop on the Future of Home Health Care on September 30 and October 1. I had the privilege of moderating a dynamic panel on new models and approaches to payment that are making good use of home health and home based care. While the discussion is still fresh in our minds, I would like to share my summary of the key takeaways from that panel.

After an overview by Peter Boling of Virginia Commonwealth University Medical Center, we listened to presentations from health system leaders who presented their specific approaches to new models that are making good use of home health and home-based care. We were fortunate to hear from six luminaries who spoke of the innovative models led by their organizations:

  • Jeff Burnich, Senior Vice President of Sutter Health
  • Richard Lopez, Chief Medical Officer of Atrius Health
  • Rose Madden-Baer, Senior Vice President, Population Health Management, Visiting Nurse Service of New York (VNSNY)
  • Eric Rackow, President and CEO of Humana at Home
  • Ronald Shumacher, Chief Medical Officer of Optum Complex Population Management (a division of United Health Group)
  • Sarah Szanton, Professor at Johns Hopkins School of Nursing

Looking across the models they described, the following key elements and themes surfaced.

Most of the new models are focusing on the sickest patients, described at varying break points. For example, they may be focusing on the sickest 5% that drive 50% of spend; or the sickest 25% that drive 80% of spend. These patients were described as typically being poly-pharmacy, using many different physicians, and being frequent users of facility-based care (especially hospitalization and emergency departments).

To identify these patients, most use risk stratification. Often this involves patients with multiple chronic conditions. However, the panel and workshop participants also strongly emphasized the importance of functional status (assessing IADL and ADL limitations) in identifying patients—health information data analytics and assessment are key in this regard.

Although there were a variety of care delivery and payment models described – everything  from advanced illness management to bundled payment arrangements, to accountable care organizations to home-based primary care, to hospital at home – all with home health or home-based care components, there were at least five common and key elements.

  1. Integration with both primary care (physicians and APRNs) and palliative care and end of life care;
  2. Focus on care coordination/management and care transitions;
  3. Post-acute care as a major focus, but still more important is working to achieve proactive preventive maintenance care;
  4. Nursing and therapy continue to play critical roles, but making good use of paraprofessionals (home care aides) will be key (and VNSNY in particular is cultivating the role and training of paraprofessionals in care);
  5. Telehealth and remote monitoring, including phone calls, as a means to engage patients and gain scale efficiently.

Person-centered goal setting and integration of family caregivers as key members of the team also was a critical theme raised during this panel of the IOM workshop. The CAPABLE model presented by Professor Sarah Szanton of Johns Hopkins University focuses on the person’s priority goals. Rather than a health goal such as achieving a certain HbA1c level, this might be the patient’s desire to walk down a set of stairs to use the kitchen sink. While Szanton’s presentation was the only one that explicitly called person-centeredness out as a critical goal, this is a theme that one finds often as a best practice in home health care. Clearly though, it was unique as a focus area for execution in the CAPABLE model, which is integrating use of a handyman’s modifications with nursing and occupational therapy.

Though many of these new models using home health care are emerging, several of the speakers described their impact on outcomes, both in terms of quality and cost:

  • Sutter Health’s Advanced Illness Management (AIM) program: At 90 days post-AIM enrollment, there was a 59% reduction in hospitalizations and 19% reduction in ED visits and 67% reduction in ICU days. This saved $8,290 in total cost per AIM enrollee over 90 days.
  • Optum Complex Population Management, which is part of United Health Group: Using Medicare Advantage plan data, the Optum CarePlus Home Visiting Provider program (which is a combination of home visits with care management and telehealth) showed a reduction in medical costs at the end of life. Those patients who were home care managed had costs in the last month of life of $4,665 per patient; comparable Medicare high risk patients not in the program cost $17,559 per patient.
  • Various Humana at Home chronic care management and care transitions programs reduced hospitalizations by 42% and re-hospitalizations by 39%.

The panelists also discussed key policy and payment reforms that might need to be addressed to achieve implementation of these new models of care more broadly. The following were among the key policy approaches identified.

  • Reimbursing appropriately to address functionality or functional status is critical, and the ability of home health to support functional needs should be reimbursed adequately.
  • Post-acute care bundling arrangements (specifically in the CMS bundled payments for care improvement (BPCI) initiative, model 3) are allowing for more flexibility and creativity in the delivery of care. One key policy change that has been made in the context of BPCI model 3 is that the homebound requirement has been waived in certain contexts. BPCI model 3 is also enabling greater use of nurse practitioners and coordination with primary care.
  • Capitation is a payment approach that was highlighted as one that could help to support these new models of care.
  • Payment for value (value based purchasing) was another key approach discussed.

During the workshop panel, participants discussed the key theme of vertical integration. The panelists specifically discussed the impact of integration among providers and payers. Some of the panelists stated such integration had been important as a means to achieve goals related to:

  • Alignment of incentives;
  • Reaching a “financial bottom line”; and
  • Improved communication of key information among payers and providers.

The panel left many asking how one might achieve similar results on a smaller scale. Panelists emphasized that their programs too started small and they recommended not expanding faster than one could deliver or produce results. There should be a focus on best practices, protocols, and tracking of both quality and cost metrics.

As the IOM workshop concluded with insights and themes raised in a “Reactor” panel at the end of the second day, Kathryn Bowles of the University of Pennsylvania School of Nursing and the VNSNY later raised a key point that related back to this panel on new models and approaches. She reflected that the focus on the 5%, 15% or 25% sickest patients is good, but that we should not forget about the rest of the population.

I could not agree more. Though population trends are forcing policy-makers to prioritize the sickest among us who are driving cost increases, true population health will require us to think broadly about the entire U.S. population. We need to remember to frame our thinking about the future of home health care, and the future of our country, with the entire population in mind.