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.