Leveraging technology to provide better HLTH care

Healthcare and technology intersect daily, forming a portion of both the foundation of care provided to patients and the methods of delivery for providers. It’s therefore only logical that the two should engage in high-level conversation. Last month, the Alliance was proud to join the new HLTH conference as an Association Partner. In its inaugural year, HLTH brought together over 3500 attendees from across healthcare and tech for a three-day discussion with payers, providers, government, non-profits, and more on ways to innovate healthcare delivery in a changing landscape.

Home health care, particularly, offers a unique opportunity for tech to engage with healthcare delivery at a personal level. Providing care in the home is a deeply intimate act which requires providers respect patient’s homes and work within a different environment. Tech providers looking to further help the patient experience may find home health care providers a particularly well-positioned ally.

HLTH attendees got the chance to hear from CareCentrix CEO John Driscoll, who discussed how he believes risk-based models will help drive incentives to invest in home health and home and community-based services. Former Acting Administrator for the Centers for Medicare & Medicaid Services (CMS) Andy Slavitt also spoke of a need to invest in greater healthcare innovation for vulnerable populations such as the frail elderly.

While this was a good start, there is room for growth in the conversation. We know home health care is already leveraging technology, especially telehealth, to improve patient care; and we know that the needs of an aging population must be addressed, and that tech can help.

Over the last few years, AARP created the Tech Nest and Hatchery. The Nest, housed at the University of Illinois is a technology lab, which, according to Jose Hernandez, vice president of IT business operations at AARP, “Affords us an opportunity to marry up leading-edge technology and apply that to our social mission to disrupt aging, and allow folks to live independently and with dignity as they age.”

Meanwhile, the Hatchery housed in the Nation’s Capital, serves as a startup incubator for those looking to improve aging and connect with peers in the space.

Other examples of leveraging technology to improve care for aging populations are abound, and we know from “The Future of Home Health Care: A Strategic Framework for Optimizing Value” that the home health care delivery system of the future must be technology-enabled. This will require commitment on the part of agencies, collaboration from technology providers, and policy levers that incentive smart adoption.

Opportunity is ripe for even more innovation in technology that assists in the care of patients in their homes and communities, and the Alliance is excited to continue engaging our peers to find ways to improve patient care and experience.

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.

September #HomeHealthChat: Falls Prevention

On Tuesday, September 24th, the Alliance hosted its #homehealthchat on Twitter. The topic of the chat was falls prevention, featuring co-host the Visiting Nurse Service of New York, a not-for-profit organization that provides in-home nursing care, therapy and hospice and palliative services to New Yorkers of all ages and backgrounds.

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 email Jennifer Schiller at jschiller@ahhqi.org.

Below are some of the highlights from the chat:

Join the PCPCC and AHHQI Webinar On Home Health & Patient-Centered Medical Homes

The Patient-Centered Primary Care Collaborative and the Alliance will co-host a webinar next Monday, September 16th from 12 – 1:30 pm ET on “Bringing it Home with the PCMH: Partnering with Home Health to Improve Quality and Patient Outcomes.” The presentation will feature a panel discussion about the role of home health care in partnership with medical homes. The presentation will also include a brief overview of the value of home health, recommendations to integrate home health within the medical home model, and how partnerships with home health can help clinicians meet quality benchmarks.

To register for the Monday, Sept. 16th webinar, please click here.

Guest Speakers

Teresa L. Lee, JD, MPH
Executive Director, Alliance for Home Health Quality and Innovation (Moderator)

Steven H. Landers, MD, MPH
President, Chief Executive Officer, VNA Health Group
Chairman of the Board, Alliance for Home Health Quality and Innovation

Beth Hennessey, RN, BSN, MSN
Executive Director, Integrated Care at Sutter Care at Home

Paula Suter, RN, BSN, MA
Director, Chronic Care Management at Sutter Care at Home

About the Presentation
As patient-centered medical homes continue to offer the promise of improved patient outcomes, innovators are looking for better ways to leverage the medical neighborhood and coordinate care across settings. Care coordination, chronic disease management, supporting care transitions, incorporating physician home visits, and fostering patient engagement and patient satisfaction all present key opportunities for collaboration between medical homes and home health.

Inaugural #HomeHealthChat: Cost-Effective Home Health Care

On Tuesday, July 23rd, the Alliance hosted its inaugural #homehealthchat on Twitter. The Twitter chat focused on the cost-effectiveness of skilled home health care and featured the Partnership for Quality Home Healthcare (@PQHH) as the Alliance’s co-host.

The hour-long conversation covered topics ranging from the benefits of coordinated care to the consequences of reinstituting a copayment on home health care episodes. Chat attendees discussed and provided examples of home health care as a cost-saving and patient preferred alternative to other forms of post-acute care.

The following questions were posed during the chat:

Q1: What makes home healthcare a cost-effective alternative to other settings?
Q2: Who benefits most from cost-effective home healthcare?
Q3: How would a co-pay affect patients who want to receive care at home?
Q4: What types of clinical and medical care can home health professionals offer patients with their homes?
Q5: What role can coordinated care play in improving the patient experience and quality of care?

The Alliance will host future home health-focused Twitter chats on the fourth Tuesday of every month at 2pm ET. Be sure to check here for updates on topics and questions! If you have topic ideas for future Twitter chats, or are interested in co-hosting a chat, please email C. Grace Whiting, the Alliance’s Director of Strategic Initiatives & Communications, at gwhiting@ahhqi.org.

Below are some of the highlights from the first chat:

Introducing the New “Healthy At Home” Twitter chat

The Alliance for Home Health Quality & Innovation is pleased to introduce our monthly Twitter chat. The “Healthy At Home” monthly Twitter chat intends to bring together various stakeholders in the home health policy community, including home health associations, providers and caregivers, patients and clinicians, and the policymaking community.

We’re excited to engage you in a new conversation about the value that home health care can offer to patients in the U.S. healthcare system.


WHEN: Fourth Tuesday of Each Month, 2pm ET

Next Chat:  Tuesday, July 23rd.  The Partnership for Quality Home Healthcare is our July co-host.  The chat will focus on “Cost-Effective Home Health Care.”

Discussion questions for the chat include:

  1. What makes home healthcare a cost-effective alternative to other settings?
  2. Who benefits most from cost-effective home healthcare?
  3. How would a co-pay affect patients who want to receive care at home?
  4. What types of clinical, medical care can home health professionals offer patients  within their home?
  5. What role can coordinated care play in improving the patient experience and quality of care?



Follow the hashtag #HomeHealthChat at www.twitter.com.



The Alliance will also host a half-hour “How To Twitter Chat” on Thursday, July 18th at 4 pm ET. Use the information below to join the webinar.

Webconference Information

1.  Visit http://fuze.me/20691910;

2.  Call (347) 817-7654 or (800) 844-3988; and

3.  Enter Meeting Number:  20691910

You may also view our handy “How To” Twitter Chat graphic here, which contains all the information to get you connected with the #HomeHealthChat each month.

Connecting Home Health Care to the Care Continuum: Thoughts from Pamela Duncan, Wake Forest Baptist Medical Center

Recently, the Alliance for Home Health Quality and Innovation profiled healthcare innovator Pamela W. Duncan, Ph.D. as part of the new Revolutionizing Healthcare-at-Home series, in an article titled, “Connecting Home Health Care to the Care Continuum.” One of the goals of this new series is to showcase how the innovative use of home health can improve the lives of patients and improve healthcare outcomes.

Dr. Duncan currently serves as a professor of neurology at the Sticht Center on Aging, Geriatrics & Gerontology at Wake Forest Baptist Medical Center and an Innovation Advisor for The Center for Medicare & Medicaid Innovation. Her most recent project for the CMS Innovation Advisors Program focuses on transitions for patients with congestive heart failure, looking at streamlining the transition between hospital and home health.

Article Highlights

  • Dr. Duncan’s work looks at health care in the context of a cohesive community of care, with home health playing a significant role in a patient’s disease management and the transition from hospital to home.
  • As the intermediary in the transition, home health offers both clinical care and connections to community resources—critically linking acute care treatment with at-home recovery.
  • While the data from the program is still new, Dr. Duncan says she has seen significant reductions in rehospitalizations using cross-continuum collaboration.
  • Creating transitional care programs like the one implemented by Dr. Duncan may help providers and health systems save time, energy, and money while improving patient outcomes.
  • In order to better utilize home health for care transitions to primary care and community-based resources, Dr. Duncan suggests that home health providers should place a greater emphasis on education and improving relationships with other members of the care continuum.

To read the full profile, please click here.

Celebrating Older Americans Month: Utilizing Home Health Care to “Unleash the Power of Age”

This month is Older Americans Month, a joint recognition month sponsored by the U.S. Department of Health and Human Services’ Administration for Community Living and Administration on Aging. The 2013 theme, “Unleash the Power of Age!”, celebrates the contributions of older Americans in this country. Some of the month’s activities include a “challenge” for adults age 60 and older to demonstrate how they continue to be actively engaged in their communities (for more information, please visit http://www.olderamericansmonth.acl.gov/challenge.html).

After receiving treatment for an injury or illness, many older Americans face the challenge of becoming active again. A look at the Home Health Chartbook identifies some characteristics of older adults using home health services:

  • Following an inpatient stay, 38.7 percent of Medicare beneficiaries are discharged to post-acute care.
  • Major joint replacement or reattachment of lower extremity without a major complication or comorbidity accounts for the largest percentage of Home Health Part A claims in 2010 at 10.77 percent, or 211,779 claims that year. Another 31,145 claims were made for hip and femur procedures with a complication or comorbidity.
  • Medicare home health users with the most common diagnoses experienced slightly lower 30-day rehospitalization rates than skilled nursing facility users, including a mere 4.33 percent rate among major joint replacement or reattachment patients.

Home health is a vital post-acute tool for patients, especially older Americans, looking to safely recover from injury or illness while continuing to work toward a healthy and productive future. One rapidly growing treatment in particular – total knee replacement (TKR) procedures- are critical for older Americans who wish to remain active and involved in their community. A recent article from the Cleveland Clinic Journal of Medicine’s electronic supplement, “Optimizing Home Health Care: Enhanced Value and Improved Outcomes” focuses on the ways home health can benefit TKR patients.

In an effort to address patient concerns over the length of expected recovery from TKR, a Rapid Recovery Care Path was developed which emphasizes discharging patients back into their homes as soon as it appears safe to do so. Since the program’s implementation in 2006, the program has shown several positive results, including lower readmission rates for patients discharged to home as compared to rates before the protocol was implemented, and a cost savings to the system of about one-third compared to patients discharged to an inpatient post-acute facility. (The full article on TKR can be found here.) Better outcomes at decreased costs will help older Americans stay active members of the community, continuing to improve the lives of others.

Additionally, older patients have found they prefer to recover at home as described in an April 2013 study in the International Journal of Nursing. In the study, early assisted discharge patients (those who were discharged on day four and received visits from a home care nurse until day seven) managing from Chronic Obstructive Pulmonary Disease preferred to receive care in the home. (To read an abstract of the article, click here.) Similarly, a 2011 study published in Telemed and E-Health shows high-levels of patient and healthcare professional satisfaction using in-home telerehabilitaion. (To read an abstract of the article, click here.)  These studies confirm that in general, older adults prefer to recover from illness in settings that allow for more independence—specifically the home.

We at the Alliance, as part of the home health care community, congratulate and thank older Americans for their positive contributions to society, and encourage the continued support of our older population. In order to best care for, and thus benefit further from, the older American population we must be steadfast in our commitment to providing high quality health care.  Home health lets older Americans in need continue to contribute to society from a safe and comfortable setting while they are treated.  Appropriate use of home health enables a very capable and important population to unleash the power of age.



When Being Disruptive at Home is a Good Thing

Guest Blog: Dr. Jack Lewin, Lewin and Associates, LLC

This month, we’re featuring Jack Lewin, Chairman of the National Coalition on Health Care, as our guest blogger. Dr. Lewin is a primary care physician trained in internal medicine with experience in medical practice, public health, hospital leadership, health policy, and association leadership. He previously served as the Chief Executive Officer for the American College of Cardiology and currently serves on the board for the eHealth Initiative at the National Coalition on Health Care. 

It’s common knowledge among health policy insiders that reducing unnecessary hospitalizations and rehospitalizations is where the big savings in health care expenditures will be achieved. However, as long as hospitals are paid on a volume of admissions basis, there is little financial incentive for hospitals and/or hospital-based physicians to reduce preventable admissions and hospital-based services. That’s why all the policy wonks want doctors like me—and the hospitals with which we work—to shift to new payment models that reward better outcomes at lower costs (“value”): models where the lower costs will largely be generated by reducing unnecessary hospital care.

Medicare has begun penalizing hospitals that have higher rates of re-admissions. In many parts of the country, 30% or more of Medicare patients discharged from the hospital bounce back within 30 days; comparing similar populations of patients in some settings, that number can be as low as 10%. There’s a lot of variation, mostly related to the care and support people receive after they leave the hospital. In my view, the most disruptive innovations coming in the health care of the future will not be the amazing and beneficial developments forthcoming in genetics, genomics, pharmacology or new technology. Rather, I see the big game-changer coming from the application of these kinds of things to the redesign of personalized care models for people at home, in the workplace, and in the community. New models of patient-activated care at home—for prevention, wellness, and disease management—are the future of reducing hospital costs, and health care costs in general. Home care innovation is the most disruptive innovation out there!

It won’t be just hospital care that new models of care at home will radically affect: doctors’ office and outpatient clinic visits will be reduced as well. My friend, San Diego-based cardiologist and author, Eric Topol has widely shared his view that the majority of doctor’s office and clinic visits for established patient-physician relationships are unnecessary and can be replaced with new virtual visits and clinical communications using e-mail and person-to-person video-connections at home and at work. (A video of his interview on Rock Center with Brian Williams may be seen here.) Over the past few years, Kaiser Permanente has reduced outpatient clinic visits by 25% by encouraging more secure e-mail communication with beneficiaries and their caregivers. This kind of care model is more convenient and efficient for everybody, when appropriately applied. Virtual visits, home bio-monitoring, and health apps using mobile devices, will allow doctors, nurses, patients, families and caregivers to be clinically connected more conveniently and effectively—at home and/or in the workplace. I predict that even most medical specialist consultations will occur virtually in the not so distant future.

Even for very sick people, home care will play a much more prominent role. I serve as Chief Medial Officer for an exciting new start-up company called Clinically Home, which is rolling out a novel ‘acute-care-at-home’ model. As part of the model, emergency room or clinic patients being admitted to the hospital, and who meet carefully researched clinical criteria, are offered the option of getting their full-service ‘hospital’ care at their instantly hi-tech-equipped home. We estimate that about 20-25% of people admitted to the hospital in most settings could more comfortably and safely be treated and closely monitored for many clinical conditions at home. In addition to reducing hospital stays, new home care models will increasingly be able to prevent avoidable emergency room visits and admissions to long-term care facilities.

Health care needs to continue to be a personal and intimate experience; but today the primary care doctor is often disconnected from—and often even unaware of—their patient’s admission to the hospital. The inpatient may see a different hospitalist they don’t know on each shift, and scary infectious agents living in hospitals pose a threat to patients. If one doesn’t absolutely need to be in the hospital, why be there? We overuse hospitals, in part, because we don’t have hi-tech, hi-touch, high quality, team-based care-at-home models up and running where most of us live—yet. Hospitals, emergency rooms, doctors’ offices, and long-term care facilities remain vitally important parts of health care’s future, but we need to find ways to improve outcomes, patient satisfaction, and disease prevention and management more consistently and efficiently. Home and community-based care is a critical and under-envisioned key to actually achieving those goals.

The Alliance would like to thank Dr. Lewin for his time and insight.  If you would like to recommend a guest blogger for the Alliance, please contact the Alliance’s Director of Strategic Initiatives & Communications C. Grace Whiting, at gwhiting@ahhqi.org

Alliance and Cleveland Clinic Journal of Medicine Host Capitol Hill Briefing

Guest Author: Steven Landers, MD, MPH
President and CEO, VNA Health Group
Board of Directors Chairman, Alliance for Home Health Quality and Innovation 

This past Tuesday, I had the privilege to moderate a Capitol Hill briefing as part of a collaboration between the Alliance for Home Health Quality and Innovation and the Cleveland Clinic Journal of Medicine. The briefing focused on home health and its overall value to the health care delivery system, through a discussion on a supplement and corresponding Clinical Medical Education (CME) program in partnership with the Cleveland Clinic.

The supplement, titled, “Optimizing Home Health Care: Enhanced Value and Improved Outcomes”, compiles articles from distinguished physicians, nurses and academics, who are experts in delivering health care at home. This research represents the Alliance’s support of peer-reviewed work demonstrating how home health can be used more effectively to address patient needs, improve outcomes, and lower costs in the Medicare system.

Fellow panelists included:

  • Peter Boling, MD, Chair, Division of Geriatric Medicine, Virginia Commonwealth University
  • Michael Fleming, MD, FAAFP, Chief Medical Officer, Amedisys, Inc.
  • Mark Froimson, MD, MBA, President, Euclid Hospital, Cleveland Clinic Health System
  • Eiran Gorodeski, MD, MPH, Heart and Vascular Institute, Cleveland Clinic Executive Director
  • Margherita Labson, RN, MSHSA, CPHQ, CCM, Executive Director, Home Care Program, The Joint Commission

Below are a few highlights and key points from the information packed hour:

  •  The Amedisys care transitions initiative decreased the average 12-month readmission rate from 17 percent to 12 percent.
  • The VCU Medical Center implemented a hospital-based transitional care program (TCP) 12 years ago that has served more than 500 patients.  This program resulted in a decreased use of hospital resources— including fewer inpatient days, shorter lengths of stay, and fewer intensive care unit days— after enrollment in the TCP.
  • A home-based care path following Total Knee Replacement reduces the patient’s hospital stay and lowers readmission rates.
  • The Heart Care at Home program helps patients avoid the “black hole” of returning home after hospital discharge with complicated medication regimes and restrictions through visits with home care nurses and the use of telehealth.
  • Palliative care and home health can work in tandem to reduce pain and manage symptoms while still pursing curative or life-prolonging treatments. Two programs- Kaiser Permanente’s In-Home Palliative Care Program and Sutter Health’s Advanced Illness Management (AIM) program have been successful in their efforts. The Kaiser program delivers all service into the home and contributed to increased patient satisfaction and an average cost savings of $8,000 per person and a 52% reduction in readmission rates heart failure patients.

If you missed the briefing, please visit ahhqi.org to view the webcast and materials. We will also be bringing you a detailed blog post on each of the author’s articles in the coming weeks, so please be sure to check back here for updates!