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News Roundup: March 25, 2016

Cutting-Edge Research Leads to More Targeted and Effective Home Health Care

Published by Huffington Post
By Marki Flannery
March 25, 2016

When a patient returns home after being hospitalized for congestive heart failure, how important is it to provide multiple nursing visits and schedule a doctor’s appointment that first week? Do non-English speaking patients do better when they’re assigned a visiting nurse who speaks their native language? And, are outcomes improved if patients have the same caregiver for each home care visit?

With home health care playing an ever-larger role in the field of medicine and wellness, there’s a growing need to ensure that home care services are being provided in a cost-effective fashion. That’s why the Visiting Nurse Service of New York, under the direction of Kathy Bowles, who heads up VNSNY’s Center for Home Care Policy and Research, is actively investigating questions like those mentioned above.

The center is devoted to the study of clinical and policy issues related to delivering high quality, cost-effective health services at home. What researchers at our center and other academic institutions are finding is that the key to effective and efficient home care involves understanding the specific needs of different patient populations and then tailoring home care services to meet those needs. In the process, a new paradigm of personalized home care is emerging.

Home Care for High-Risk Patients: What Works, What Doesn’t?

Patients at high risk of re-hospitalization have been a particular focus of research. In one ground-breaking study funded by a grant from the federal Agency for Healthcare Research and Quality, VNSNY investigators, led by Associate Director Christopher Murtaugh, are analyzing national home care records of 100,000 Medicare patients who had been hospitalized for congestive heart failure (CHF). A chronic condition that can turn life-threatening when symptoms flare up, CHF is a leading cause of hospital admissions in the U.S., and figuring out how to manage its symptoms in a home setting is a crucial goal for American health care.

In our study, investigators are determining whether the rate of hospital readmissions within 30 days of discharge is reduced when these patients have several “front-loaded” home visits from a nurse within one week of discharge and also see their physician that first week. To further reduce hospital readmissions among high-risk patients, our research center is also piloting an evidence-based screening tool that might help us to identify which patients should be seen within 24 hours after they arrive home from the hospital. “Current Medicare guidelines call for a home care nurse to visit every new patient within 48 hours of a physician-requested visit date,” explains Kathy. “But some patients are so unstable that they’re at risk of being readmitted within that window. This tool will let our intake clinicians flag these patients while they’re still in the hospital, so that agencies can send a visiting nurse to see them as soon as possible after they arrive home.”

We’re also conducting a large randomized clinical trial that is part of a Center for Stroke Disparities Solutions collaborative with New York University and Columbia University Medical Centers. The trial is testing a new community-based intervention designed to reduce the risk of a recurrent stroke among patients who have already suffered a stroke. “It’s an intense intervention, in which nurse practitioners and health coaches work closely with the patients to help them manage their blood pressure, diet, exercise and other important preventive factors,” says Kathy. “Patient enrollment and follow-up evaluations will continue through this year. Study results should help address disparities in the outcomes of a very vulnerable patient population.”

Charting a Path toward Personalized Home Care

Some of the most interesting work at our research center is focused on providing a more personalized connection between home care providers and their patients. One of our most important studies in this regard is an NIH-funded study involving non-English speaking patients. The study, led by Allison Squires of NYU College of Nursing with VNSNY Senior Research Scientist Penny Feldman as a co-investigator, will investigate whether assigning a nurse who speaks that patient’s own language impacts outcomes like re-hospitalizations, functional status and number of home care visits. We’re hoping that this study will provide some insights on how to achieve equally effective health care outcomes across different home care populations.

Another VNSNY research project is taking aim at health care disparities that affect members of the lesbian, gay, bisexual and transgender (LGBT) community. While the American public is increasingly accepting of various orientations, evidence suggests that self-identified LGBT patients still tend to have less access to appropriate medical care than other groups. To get better information about these health disparities, New York State now wants health care providers, including home care nurses, to document their patients’ sexual orientation and gender identity. Until, now, however, no one has asked nurses how they feel about being required to discuss such a personal subject with their patients. In collaboration with researchers at Columbia University, VNSNY’s Dawn Dowding has been conducting focus groups among VNSNY nurses to explore this issue, including what training and support nurses might need to carry out the mandate.

“The requirement sounds straightforward but it’s actually far from simple, since patients can be very hesitant to discuss their sexual orientation,” explained Dawn. The study is finding that nurses have varying comfort levels around making such inquiries, and generally prefer to let the patient volunteer information about his or her orientation. One early conclusion is that a significant push is needed to educate nurses on why this information is important for their patients’ long-term health outcomes. “Nurses need to see the underlying value in collecting this information,” Dawn noted, “so they don’t feel it’s simply being done for its own sake.”

We’re also hoping to study how patient outcomes are affected by continuity of care — for example, whether a patient does or doesn’t have the same nurse on each home visit. If funded, this NIH study, led by VNSNY Senior Evaluation Scientist David Russell, will evaluate patient data from multiple U.S. home care agencies, looking at how factors such as cognitive impairment influence a patient’s need for continuity of care.

For personalized home care to be truly effective, of course, the nation’s home care clinicians need to have each patient’s information at their fingertips. Our Senior Scientist, Dawn Dowding is working on that, having recently received NIH funding to study how our nurses benefit from real-time dashboards with customized patient data displays.

While there is still much to learn, the active research now underway in the home health care field means that we will only get better at delivering targeted, cost-effective home care in the future. And that’s promising news for our nation’s health as we strive to provide the best evidence-based care possible.

Palliative Care Drives Value in New Payment Landscape

Published by Home Health Care News
By Amy Baxter
March 25, 2016

New payment models are upon us, and palliative care providers are jumping on the opportunities to expand their reach with other health care groups. With the fee-for-service era on its way out, alternative payment models for palliative care are growing.

“Payment change is happening now,” Phil Rodgers, MD FAAHPM, said while speaking at the AAHPM & HPNA Annual Assembly in Chicago March 11. “Fee-for-service is under fire.”

Rodgers compared payment models that are currently being phased out to the business of football.

“It’s a lot like the business of football,” Rodgers explained during the forum. “[The objective is to] put as many people in seats and have them pay regardless of the game. Now, we have to start incentivizing different things. Move from volume to value.”

With more opportunities on the horizon, palliative care providers are taking different approaches to drive value and cost savings across the health system.

The ACO Answer

Under new CMS incentives, more health care entities are working together to take on more risk with other partners.

“Whether you like it or not, you will be working in a risk-sharing role,” Rodgers said. “The government is not asking you to eat your vegetables.”

However, there is a great upside to these evolving payer models. For a lot of health providers that offer palliative care, working with an accountable care organization (ACO) is the answer to expanding and paying for these services.

ProHEALTH Care Associates, one of the largest integrated physician group practices in the New York metropolitan area, is part of a Medicare Shared Savings program than encompasses 30,000 patients. Being a part of the program enables the group to bill for house calls, advance care planning and chronic care management.

In its first year, the ACO brought in $11 million, according to Dana Lustbader, MD, chair of the department of palliative medicine with ProHealth. In the second year, the ACO brought in $8 million by targeting the top 2% to 5% of the highest acuity patients.

By targeting this top patient group and working in an ACO, ProHEALTH can serve more patients who need palliative care.

Integrated Approach

Community-based palliative care is increasing in demand, but incentives for these services have largely kept care within clinical setting.

Aspire Health is the largest provider of home-based palliative care, operating in nine states with near-term plans to be working in 12. The provider supports palliative care patients through its integrated system of partnerships to meet needs in the community throughout the continuum of care.

With a care support team of palliative care physicians, nurse practitioners, patient care coordinators, social workers and chaplains, Aspire Health’s team partners with other physician groups to bring these services into home settings.

Other providers are also integrating with physician groups. With CMS penalizing hospitals for readmissions, palliative care providers have a big opportunity to help manage patient outcomes, says Jim Mittelberger, MD, director and chief medical officer of Optum Center for Palliative and Supportive Care.

Optum Center—formerly known as Evercare Hospice & Palliative Care—is a national hospice and palliative care provider that supports integrated palliative care programs with numerous physician-led provider organizations. The fully integrated approach can help reduce hospitalizations significantly by bringing palliative care leaders and providers on board with a larger group or organization.

This course provides some serious advantages for palliative care providers, including access to resources of a larger system, access to data and information and engagement in a larger system change, Mittelberger has found.

Twenty-five percent of Medicare costs come from patients in the last year of life, and about half of that is from just the top 5% of the highest acuity patients. Palliative care, which targets these patients, can help reduce these costs and improve patient outcomes when working with physician-led groups, according to Mittelberger.

“We palliative care providers understand the more care delivered at the right place at the right time will lead to less cost,” Mittelberger said during a session at the annual assembly. “We can save the overall system a lot of money.”

Hospitals Mull Home Care Strategies as Market Heats Up

Published by Media Health Leaders
By Christopher Cheney
March 25, 2016

With payment reform, technology advances, and other market forces shifting medical service delivery away from the hospital setting, home care presents both business opportunity and risk.

As hospitals reach outside their walls to be more closely involved in the entire care continuum of patients, home care presents some tantalizing opportunities.

With Medicare reimbursement changes providing a financial foundation for change, home care is increasingly becoming a critical component of integrated health systems, says Sheila Schubert, administrator of home health for Hollywood, FL-based Memorial Healthcare System.

“For a very long time, people have known this is the way medical care should be delivered. This has been predicted for more than 20 years, and now it’s really happening. We’re doing IV drips at home. We’re monitoring patients at home. Services that used to be done in the ICU are now being done in the home,” she says.

Schubert joined the staff at Memorial Healthcare five years ago and has worked in home care for two decades. “People are so much more comfortable if they can receive good care and be in their home.”

Memorial Healthcare, which has offered home-care services to patients since 1992 and operates five acute-care hospitals in southern Florida, is well-positioned for growth. “All of the components of a home health agency to serve the community were in place, including a staff trained in home health,” she says.

Recent changes in Medicare reimbursement rules such as the Hospital Readmissions Reduction Program and new payment models such as pricing services based on episodes of care are major drivers of change in home health.

In response, Memorial Healthcare has shifted away from its per-visit payment model for home care toward bundled payment models that are designed to promote quality and good clinical outcomes. Schubert anticipates “bundled payments based on diagnosis for acute care and post-acute care across the care continuum. We will be paid based on the quality of care and outcomes.”

The biggest bang for the home-care buck is in the area of cost avoidance, such as reductions in avoidable hospital readmissions. “Home care has taken the lead to make sure there are smooth transitions,” she says.

While cost avoidance may not be as exciting in the C-Suite as revenue growth, limiting unnecessary medical expenses is one of the keys to delivering value-based care. “It’s not that home care has to be a money-maker. It’s that home care improves health in the community and supports the health system,” she says.

Entering the Home-Health Market Through Acquisitions

Home care has followed a different, but no less significant evolutionary path at Pittsburgh-based Allegheny Health Network, which entered the home health market in 2014 through the acquisition of four companies. Each of the acquired companies had experience in a prime home-health specialty: home nursing, infusion therapy, medical equipment, and hospice.

“We own and operate all the home-health segments,” says Brian Holzer, senior vice president for diversified services at AHN, which runs seven acute-care hospitals in western Pennsylvania. “Once we acquired all the companies, we built a new care coordinator model.”

Care coordinators are a crucial component of Healthcare @ Home, the business unit that manages AHN’s home-health services, he says. Instead of having a handful of care coordinators at each home-health subsidiary, there are about 40 care coordinators on the Healthcare @ Home staff who help the subsidiaries coordinate all home-health services for each patient. “We have four home-health companies, but a single point of contact for the patient,” Holzer says.