February #HomeHealthChat: Home Health Value-Based Purchasing

The February #HomeHealthChat was co-hosted by Visiting Nurse Associations of America (@VNAA). Visiting Nurse Associations of America leads efforts to transform home-based care toward value-based care delivery and payment models. VNAA directly supports home-based care providers through unparalleled peer-to-peer networking, innovative operational and program development support, organizational strategic planning resources, clinical education and training, and identification of leading vendors, products and services.

The #HomeHealthChat focused on Home Health Value-Based Purchasing.

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 Director of Communications and Events Jen Schiller here.

Below are some of the highlights from the chat:

Home Health is Where the Heart is

This February, in celebration of American Heart Month, don’t overlook the importance of the home as a critical place of care for those with heart conditions.

A quick look at the most recent year available shows that heart failure, hypertension, and other heart conditions are common among the home health care population.

  • Heart failure and shock (with and without major complication or comorbidity) are the third and fourth most common MS-DRGs for home health Medicare Part A episodes
  • Heart failure is the fifth most common diagnosis (using ICD-9 codes) among all Medicare Home Health claims.
  • Ninety-eight percent of the time on average nationally, home health teams met the quality measure for treating heart failure symptoms.

Nationally, hypertension is the most common chronic condition among Medicare beneficiaries with 27.5 million beneficiaries aged 65+ diagnosed. Other heart conditions, which include coronary artery disease, peripheral vascular disease, and peripheral artery disease, is third, and congestive heart failure is 12th, in front of mental illness/disorder, Alzheimer’s Disease, and broken hips.

The Home Health Quality Improvement (HHQI) National Campaign sheds further light on the common symptoms on a heart attack, as well as some of the risk factors for heart attack and heart disease in a recent blog post.

Given both the preference to age in place and the lower cost to the system home health care affords, more and more Boomers will be receiving home health care in the future. And it turns out, the home can be a critical care provider for many suffering from various heart conditions.

A few years ago, the Alliance did a series of profiles on utilizing new programs and technology to reduce readmissions, all with a focus on heart failure patients. These case studies showed a decrease in rehospitalization rates for heart failure patients using an array of telehealth programs. Interventions in the programs included patient education on how the heart works, care transitions from hospital to home, and telemonitoring measurements.

For instance, in 2007 the Visiting Nursing Association of Western New York began a hospital to home program in conjunction with what was then Cardiocom (now Medtronic Care Management), which utilized telehealth data to track patient progress and identify a need for possible early intervention. The program was instituted for cardiac patients including those with heart failure, hypertension, post coronary artery bypass graft surgery, atrial fibrillation, coronary atherosclerosis, and chronic obstructive pulmonary disorder (COPD). Typically, patients would digitally check-in with weight and blood pressure measurements, as well as a few health-related questions. A telehealth team would receive the information almost instantaneously, and would review whether a patient was following their prescribed medical regime. If the team spotted an issue, they worked with the patient’s physician to make adjustments. During the course of the program, the Visiting Nursing Association of Western New York saw an 11 percent decrease in acute care hospitalizations and high patient satisfaction ratings.

Programs such at the one implemented by VNA of WNY demonstrate one way in which home health can be a vital resource for those with an array of heart conditions. Working hand-in-hand, technology and home health are poised to continue serving many more happy hearts in the future.

Low 30-Day Readmissions from Home Health Signal Positive Results for CJR Model

Current research on major joint replacement points to successful uses of home health care as the post-acute care setting for patients. Merits of home-based care include reduced cost, improved clinical outcomes, and increased patient satisfaction. Now, with the recently introduced Centers for Medicare and Medicaid Services Comprehensive Care for Joint Replacement (CJR) Model, which will begin on April 1 of this year, home health sits at the forefront of providing cost-effective and high-quality patient care for patients following hip and knee replacements.

The low rates of 30-day readmission for patients with MS-DRG-470 (major joint replacement) (the 30-day readmission rate nationally is 3.54% from home health, compared with 6.83% from skilled nursing facilities), make the benefit of home health, especially after hip and knee replacement, crystal clear and should help CMS and those participating in the CJR Model to better understand the best means of treating patients.

Knee replacements are one of the most common surgeries performed on Medicare beneficiaries, underscoring the need to develop models that improve patient care delivery, including enhanced efficiencies and reduced costs. Nationally, nearly 10 percent of total home health Medicare Part A home health claims are for patients receiving care after a major joint replacement or reattachment of lower extremity without major complications of comorbidities. Among home health claims, major joint replacement is over three times more common as an MS-DRG than the next most common MS-DRG. In 2013, almost 200,000 home health Part A claims were filed nationally for patients after hip and knee replacements, signaling a need for high quality, safe, and cost-effective models of care after such orthopedic procedures. According to the Clinically Appropriate and Cost-Effective Placement report from 2012, when home health agencies are the first setting of care, Medicare sees an average of over $5,000 in cost savings for each MS-DRG 470 patient’s episode (defined as inpatient hospitalization and the 60 days post-discharge).

In addition to the clinical and cost savings benefits above, recovery and therapy in the home setting allow clinicians to address the unique needs of individual patients, make families feel more comfortable in assisting with care, and assists patients to more quickly resume activities of daily living, such as bathing and dressing. The Cleveland Clinic Model for Home Care After Knee Replacement, profiled in the Cleveland Clinic Journal of Medicine supplement article, “In-home care following total knee replacement,” provides an excellent example for the future success of the CJR Model.

The article outlines The Cleveland Clinic Total Knee Care Path, an integrated care approach, emphasizing home health care in discharge planning and care transitions. Patient and family education is critical and should begin early and remain consistent. The following goals are emphasized in the Cleveland Clinic program:

  • Shared decision-making
  • A home care environment that includes support of family and friends
  • Patient and family education to enhance shared decision-making
  • Return to the home environment as soon as it is deemed safe
  • Elimination of unnecessary or duplicative treatments, tests, or interventions
  • Acceptance of multiple plans or paths in response to changing clinical conditions

In the 10 years since the Cleveland Clinic has integrated home health care into recovery from a total knee replacement, results have been very positive, including a reduction in the average acute care hospital length of stay, increased discharge to home rates, reduced readmission rates, and lower costs to the overall system. In fact, patients discharged to home use fewer resources and cost the system one third as much as patients who receive inpatient post-acute care. Discharge to home rates rose from 32 percent to 74 percent, and hospital stay length decreased by an average of almost one full day, saving money by limiting longer facility stays.

The CJR Model represents a step forward in promoting quality care for patients, as the home is, when clinically appropriate, an ideal setting for patients after an acute care stay when coupled with skilled home health care services. By looking at the readmissions and cost data, along with the successful CCJM Model, we can get a clearer picture of the ways of home health can be utilized to maximize outcomes, reduce cost, and improve patient experience.