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News Roundup: December 11, 2015

Doctors prescribe old-fashioned house calls when treating the old and frail

Published by The Washington Post
By Tara Bahrampour
December 11, 2015

Haydee Hernandez, 83, suffers from seizure disorder, degenerative joint disease and hypertension, and cannot walk well enough to visit the doctor. In many places in the country, the retired cafeteria worker would be in an assisted living facility. She is able to stay in her Columbia Heights apartment, surrounded by her plants and ceramic figurines, because her doctor comes to her.

Sitting in a wheelchair, Hernandez pointed to the spot where her oldest child took his last breath in her arms, two decades ago. “My son died in here,” she said, vowing, “I’m going to die in here.”

A study published last year in the Journal of the American Geriatrics Society, supported by other research, found that home-based primary care lowered costs as well as emergency room visits and hospitalization rates while increasing patients’ satisfaction with care. Now, a group of doctors — including Hernandez’s — is pushing to bring house calls to the nation’s 2 million oldest, frailest and costliest patients, saying it has the potential to save the government billions of dollars.

Independence at Home was developed by a group of doctors around the country who were already making house calls to such patients. Although the patients needed regular monitoring, they did not need to live in a nursing home or hospital as long as a provider could come regularly to take their blood pressure, talk about their medications and check other vital signs.

While such visits cost doctors more because of travel and care-coordination time, they can save Medicare large amounts of money otherwise spent on inpatient and residential care. Working with the American Academy of Home Care Medicine (AAHCM), the doctors developed a program through which Medicare would share the money saved via home care with the doctors who provided it.

A three-year pilot program in 17 practices around the country was included in the Affordable Care Act and implemented in 2012. The initial results were promising, and this summer Congress voted to extend it another two years for 14 of the practices.

Last Wednesday, K. Eric De Jonge, co-founder of the medical house-call program at MedStar Washington Hospital Center and president-elect of the AAHCM, spoke on the Hill pushing for Independence at Home (IAH) to be included in the Senate Finance Committee chronic care working group, with the goal of making it available nationwide.

“This provides a path for us to care for all of America’s most vulnerable and frail elders in the environment in which they prefer to live and lower total costs for Medicare,” he said in an interview.

His partner and program co-founder, George Taler, put it more dramatically: Implementing the program nationally, he said, “would totally reverse the numbers for the sustainability of Medicare for the future.”

Such a scenario would save Medicare an estimated $21 billion to
$34 billion over 10 years, according to an analysis by Jen Associates, commissioned by the AAHCM — money that would otherwise go to hospitals, short-term nursing homes and other costs.

In the first year of the pilot, participants saved more than $25 million — an average of $3,070 per beneficiary, according to the Centers for Medicare & Medicaid Services (CMS). The savings ranged between 6 percent and 31 percent across practices. Beneficiaries had fewer hospital readmissions and fewer hospital visits for conditions such as diabetes, high blood pressure, asthma and pneumonia. CMS passed $11.7 million of the savings to the providers.

Funding for house-call programs comes from a combination of the Medicare fee-for-service program, grants and private insurance. Results for the second year are expected soon.

In May, Finance Committee leaders said that they hoped to release a proposal to the public by the end of the year. Sen. Ron Wyden from Oregon, the top Democrat on the Finance Committee and a member of the working group, called IAH “an important opportunity for Medicare to lead a revolution in caring for people at home.”

Caring for chronically ill patients in their home is ideal, experts say. “If they’re at home, they’re in an environment that can expedite healing, for example, more natural light,” said Judah Ronch, dean of the Erickson School at the University of Maryland Baltimore County, which focuses on the elderly in society. Being at home also helps patients see themselves as “not a sick person,” he said.

Joyce Weatherly, 94, who suffers from hypertension, heart disease and osteoarthritis, sat in her Mount Pleasant living room last week, chatting with Taler, one of the doctors who came up with the idea for IAH.

Taler took her blood pressure and watched her walk unsteadily across the room, where her orange cat, Chester, crouched on an Oriental carpet. “When they tried to enroll me at that geriatric program at the hospital it was horrible. They took me from one computer to the other,” she said, adding, “It’s not just getting there, it’s waiting after you get there.”

Instead, the former government clerical worker waits on her couch for the home visits, which remind her of the 1920s, when her family doctor came in a buggy.

For her daily needs, Weatherly has a full-time assitant — a factor that could limit who is able to benefit from the program. Patients receiving home primary medical care must rely on a combination of family caregivers and paid assistants for other help, or Medicaid home help if a patient is eligible.

Patients older than 85 are the nation’s fastest-growing cohort, and as the massive baby-boomer generation ages, that growth will accelerate: In the next 15 years, the number of people ages 80 to 84 will leap from 5.7 million to 10.5 million. Experts have warned of a looming crisis.

At the same time, the medical industry has resorted to outdated solutions, Taler said, adding that too often after an acute crisis, patients are sent to live in a facility even when round-the-clock care is not necessary.

“It is so much easier to discharge a patient to a nursing home than to set up a home-care program,” he said. “Two-thirds of people in nursing homes probably no longer need to be there because they don’t need 24-and-7 nursing care. . . . IAH provides the opportunity to move these people back into the community or to prevent new ones from coming in.”

A national implementation could substantially reduce hospital beds, he said, with nursing homes taking over some of the medium-tech care, such as delivering intravenous medications and fluid, that hospitals now provide.

Not all primary-care practices would qualify — house calls require specialized skills, and doctors would need to employ or partner with nurse practitioners and social workers and be able to coordinate care with family members. Someone would need to be on call 24 hours a day, seven days a week.

Those requirements, along with the growing number of older Americans, mean IAH is not likely to put nursing homes out of business, said Mike Cheek, senior vice president for finance policy and legal affairs at the American Health Care Association, which represents 13,000 nursing homes and assisted living facilities.

“Our businesses are most concerned about meeting the demands in the coming years,” he said, adding that if IAH were implemented nationally, some facilities might be interested in developing partnerships with participating providers, teaming up with them to help deliver some of the in-home skilled care.

But in some cases, facilities would no longer be required.

“Many old people in hospitals don’t need to be there,” Ronch said. “It’s not about serving the needs of the institution, but serving the needs of the people. It’s the idea that we can deconstruct the health-care system and reconstruct it to serve the patient in a way that’s fiscally and medically better.”

Beyond Readmissions: Inside One Health Network’s Home Care Initiative

Published by Home Health Care News
By Kourtney Liepelt
December 11, 2015

Reducing medical expenditures and lowering hospital readmission rates are only part of the equation when it comes to one health network’s all-encompassing home care initiative.

More than anything, Pittsburgh, Pennsylvania-based Allegheny Health Network (AHN) is focused on maintaining control over the quality of care and services delivered once patients leave the hospital, made possible through its Healthcare@Home program, Brian Holzer, a physician who oversees the program as senior vice president of diversified services, tells Home Health Care News.

“Our goal isn’t necessarily to drop readmission rates,” Holzer says. “The ultimate goal is the ability to manage a population of patients, keep them in the home, and do so in a high-quality manner.”

After several partnerships were forged with various home health, technology and medication companies at the end of 2014, AHN introduced each of its service offerings under one umbrella by April in an effort to achieve such a mission. It was an undertaking that required a joint venture with home health and hospice provider Celtic Healthcare Inc. to effectively form the second-largest such provider in the region*, and a connection with Johns Hopkins Home Care Group to acquire a majority stake in Klingensmith HealthCare and its expertise in home care and medical equipment.

“We realized that if we tried to do it ourselves, it would have taken a lot of capital upfront,” Holzer tells SHN.

Forty transitional care coordinators have been hired and tasked with assessing patients and developing their care plans upon discharge if home care services are required. The utilization of these employees, along with fully integrating all facets of the program, has resulted in a 5% reduction in readmissions within 30 days of discharge, quantified by a $5 million reduction in “unnecessary medical expenditures,” Holzer says.

“We wanted to take out the complexities and inefficiencies of running these in silos,” he says.

The result—a model “truly centralizing all of the services required to deliver home-based care.”

“In a value-based world, if we’re able to save organizations millions of dollars in rehospitalization penalties, this is where the new model is going to be,” Holzer says.

Home visiting program can help reduce hospital, nursing home visits, study says

Published by Star Tribune
By Christopher Snowbeck
December 11, 2015

House calls from health care workers can help reduce costly admissions to the hospital or nursing home, according to a new report.

The study published Monday in the journal Health Affairs looked at the effectiveness of a UnitedHealth Group program for Medicare beneficiaries and found that people who used it had up to 14 percent fewer hospital admissions compared with other Medicare patients.

Participants in the program also were more likely to visit the doctor's office, according to research that was funded by the Minnetonka-based health insurer.

"We found that a home visiting program can lead to meaningful cuts in the amount of inpatient care used by Medicare patients," said Soeren Mattke, the study's lead author with California-based RAND Corp., in a statement. "This is significant since many other strategies to reduce inpatient care among Medicare recipients generally have been unsuccessful."

The HouseCalls program has become a regular talking point for UnitedHealth Group officials when describing how the company's Optum division is trying to improve care while making it more efficient.

UnitedHealth Group is the nation's largest health insurer. During an investors conference earlier this month, company officials said HouseCalls will deliver more than 1.1 million visits to patient homes next year.

"Our nurse practitioners, armed with secure smart tablets instead of black leather bags, help patients follow prescribed treatment plans, make annual visits to their physicians and get appropriate vaccinations," said Larry Renfro, the Optum chief executive, during the conference in New York.

The home visits are provided annually. They typically last 45 to 60 minutes and include an evaluation of current and past health problems, a review of medications, a physical exam and certain assessments. The house call generates a written care plan that's shared with the patient's regular doctor, and can generate referrals too other providers for services.

The study published Monday looked at Medicare beneficiaries eligible for the HouseCalls program between 2008 and 2012 in five states and compared their experiences with those of other Medicare enrollees.

Depending on their type of Medicare coverage, enrollees in HouseCalls saw a reduction in hospital admissions that ranged from 1 percent to 14 percent, according to the study. The report also found a slightly lower risk of nursing home admission.

In addition, beneficiaries had anywhere from a 2 percent to 6 percent increase in trips to the doctor's office. The study compared outcomes for people in the traditional Medicare program, those in Medicare health plans and beneficiaries in special Medicare health plans with certain chronic health care conditions.

The study did not estimate dollars saved through the insurer's program, said Kristy Duffey, a senior vice president with Optum.

"The study shows we've decreased hospitalizations up to 14 percent," Duffey said. "As we identify needs, we're putting those members in a perfect program. … We're going to prevent chronic conditions from even happening, and so we should be able to save dollars."

The HouseCalls program operates in 39 states including Wisconsin, but not Minnesota. It was initially developed by a Baltimore-based health plan called XLHealth, which UnitedHealth Group acquired in 2012.

The company did not disclose an acquisition price when the deal was announced in late 2011, but Bloomberg reported the price tag at roughly $2 billion.

Dear Baby Boomers, Plan Ahead to Age at Home

Published by Huffington Post
Steve Landers MD,MPH
December 11, 2015

When envisioning your "golden years," maybe you see yourself relaxing, volunteering, enjoying carefree days by the pool or ocean, or spending extra time with family and friends. No one sees themselves in a nursing home. And, most people don't envision being isolated at home struggling with the basics of life, especially not members of the rock n rollin', transformative generation we call "the baby boomers."

Although the untroubled poolside scenario may not be in the cards for everyone, the worst situations can be avoided. You can plan ahead so you're empowered to age successfully in your home and community and remain as independent as possible.

The first step is having the courage to recognize head-on that it's more likely than not that you will have many months, maybe years, of limited ability to handle basic things you take for granted when healthy. It is common to develop physical limitations due to conditions such as arthritis, heart disease, stroke, osteoporosis, or problems with memory and thinking from Alzheimer's disease and dementia. Good health behavior, good medical care, good genes, and good luck may keep you healthier longer, but eventually Father Time catches up.

Here are four suggestions for planning ahead:

1. Prepare Your Home

Do you have a downstairs bedroom and shower? Is the bathroom accessible for a wheelchair and outfitted with safety features? Are there many steps or level changes to enter or move about the home? Do you keep your home free of clutter and well lit? Have you optimized security, safety, and home automation technologies? Depending on your answers it may be time to modify your home---this is easier to do in advance than during a crisis.

2. Communicate Your Goals

The culture of the American medicine is to keep doing more. More tests, more specialists, more medicines. At times this enhances longevity and heroic outcomes, but there are real risks for older people. Hospitals can be dangerous places for older patients, and treatment side effects can increase as people age. A growing collection of medicines and doctors without overarching care coordination becomes a problem in and of itself.

Sometimes 'less is more.' But, it will be hard for doctors and family to buck the trend unless you give instructions on what's important to you. If being home is a high priority--write it down and tell someone. If you don't want your last days spent on a ventilator in intensive care, then you need written advance directives. Your choices don't have to be black and white (eg "do everything" or "do nothing"). To get at the nuances consider going beyond the standard documents and use innovative tools like the Stanford Letter Project or Vimty.

It may be helpful to even document the types of prayer, music, or foods you enjoy, and what your interests and favorite causes are. Sharing these things can help ensure that your individualism, dignity, and comfort are preserved.

Just documenting directives is not enough. You will need doctors that understand your wishes and who will advocate for you at difficult moments. In 2016 Medicare will begin paying doctors for advance care discussions, a lack of payment shouldn't be an excuse, and it's a red flag if your doctor won't have this type of discussion.

3. Identify People You Can Trust

There will be a time, possibly many months, when you can't direct things like medical care, living arrangements, finances, and basic household tasks. Who will step in? Are you sure your caregivers will be able and willing? Do they know and support your preferences? Will they abuse the power you're granting them? Are the relevant records and documents well-kept and organized in a way that will help them? Consider whether you need one or several delegates for different issues or perspectives. Consult an attorney and financial professionals for their advice.

4. Know Home Care and Long-Term-Care Options and Who Pays

Believe it or not, the term "home care" can be confusing! There's a variety of options with different purposes that are paid for in different ways. For example, home health nursing and physical therapy to treat specific medical problems is paid for by Medicare. However, basic personal care is almost never covered by Medicare.

The Visiting Nurse Associations are non-profit organizations that offer a wide range of home and community services. You can also consult your state associations for home care to get a variety of local contacts. Other important resources are your Area Agency on Aging and long-term-care organizations. Many hospital systems and religious organizations also offer home health. And, several sophisticated national companies have offices and locations offering home care throughout the country.

If you can't easily leave the home for medical care, home visiting physicians will be essential. The American Academy of Home Care Medicine is an organization focused on making sure house calls are available. And, don't forget that hospice care is primarily a type of home care; hospice can be an essential resource for being able to live in the comfort of one's home late in life if you have serious illness.

Get involved as a volunteer or advocate for home care, it's personally rewarding, and will familiarize you with the available services in your community. Home care doesn't always get the attention of other 'causes' and there have even been some recent political efforts to cut home care benefits and limit services. Your involvement can help ensure good options are available when you and your loved ones need them.

UnitedHealth's HouseCalls reduces hospital readmissions

Published by Fierce Health Payer
By Joanne Finnegan
December 11, 2015

HouseCalls, which sends a physician or nurse practitioner on a home visit to Medicare Advantage members, helped reduce hospital and nursing home admissions, according to a new study.

The study looked at the results of the UnitedHealth Medicare Home Visit Program, which has been active in five states since January 2008.

Researchers from the Rand Corporation compared HouseCalls participants to Medicare beneficiaries enrolled in traditional fee-for-service Medicare or in Medicare Advantage plans not eligible for the program.

Results were published in Health Affairs and showed that:

Participants had up to 14 percent fewer hospital admissions in the 12 months after the home visit
Participants had lower risk of nursing home admissions
The number of physician office visits, mostly to specialists, increased
Effects on emergency room visits were mixed
The visits, combined with referral services, can support aging in place, promote physician office visits and preempt costly institutional care, the researchers found. The HouseCalls program was offered to plan members in Arkansas, Georgia, Missouri, South Carolina and Texas.

As FierceHealthPayer previously reported, UnitedHealth has expanded its presence in the patient care business through its Optum unit, which operates the HouseCalls program.

"This study shows that our in-home-based care model is helping seniors access the care they need and preempts costly hospitalizations and nursing home admissions," Kristy Duffey, Optum's senior vice president of clinical operations for HouseCalls and Complex Care Management, said in an announcement.

Optum has also been financially successful, as revenues for the health services business unit jumped 61 percent in third-quarter earnings released by UnitedHealth this fall.

Fix Public Health the Cleveland Clinic Way

Published by Huffington Post
Steve Landers MD,MPH
December 11, 2015

Doctors and hospitals, who have historically emphasized facility-based care, are realizing community health and human services are essential for great outcomes and cost-effective care. The perfectly performed surgery or hospital stay can be for naught if the person returns home without basic supports and primary care. Often people are expensively treated in hospitals and emergency rooms because of inadequate community resources. Government and private sector reformers are responding to these challenges by changing payment incentives for doctors and hospitals to drive efficiency and quality improvement. This medical industry transformation is being called "population health," "accountable care," and "value-based care." No matter their name, the new financing arrangements will struggle to improve quality and costs without high performing primary care, public health, and related social services.

Advocates for public health often highlight the problem of under-funding and call for more spending. But, many problems stem from a fragmented industry where the narrow perspectives of small programs, government departments, administrators and boards take precedent over broader care improvement. I am one of those administrators and urge that before spending more we need innovation in how we organize and deliver these services.

Consider a hypothetical newborn and mom going home from the hospital to a high poverty neighborhood; they are at risk for several disastrous and expensive health problems that are potentially preventable. In many communities they may have access to a Federally Qualified Health Center (FQHC) or a volunteer clinic supported by the Federal Tort Claims Act (FTCA), nutrition support and health education from the Women Infants and Children (WIC) program, developmental resources from Early Intervention (EI), Nurse Family Partnership (NFP), Healthy Families programming, and an array of other programs addressing abuse prevention, energy assistance, obesity prevention, care coordination, environmental health, housing, and other risks. However, this panoply of federal, state, local and private programming is confusing and fragmented for the vulnerable families they serve. And, these programs don't generally work seamlessly with one another or with the doctors and hospitals in their communities.

Though there are different program acronyms, the same types of confusing lists of programs exist for aging and long-term care, and programs addressing people living with disabilities and mental illness.

While these disparate initiatives were launched with good intentions to fill gaps in the safety net, the piecemeal approach is a problem. Instead of there being no wrong front door for help, there's confusion, missed opportunities, and wasteful duplication. Instead of a well-directed orchestra of support, there's a gaggle of soloists tooting their own horns in their own ways. There are too few examples of true teamwork and service integration, and many of the organizations delivering these programs have their own organizational independence and uniqueness as core strategic priorities.

In community health we sometimes delude ourselves into thinking that purely because we are local and knowing of the community that this is enough to make up for the many flaws of fragmentation. Local knowledge and input from the community and populations served are essential, but these attributes shouldn't be barriers to integration and maturation. The cottage industry model for public health is failing.

We can do better

It doesn't have to be this way. Vulnerable citizens at risk for unnecessary suffering and unnecessarily costly care and the taxpayers and philanthropists that fund this work would be better served by larger regional private entities bringing together a patchwork of relevant services. These "accountable community health enterprises" would have high impact boards with experienced leaders, strategic plans focused on improving population level health outcomes, public transparency, expert management teams, modern information technology and analytics systems that link to local hospitals and doctors, and a supported and engaged workforce that know they are all part of one team with shared measures of success. These entities could work hand in glove with the local health systems, and in some communities where it made sense they could be operationally one in the same.

Cleveland Clinic has been rated the best place for heart care for 2 decades straight--there's both excellence and efficiency. While the Clinic has not historically emphasized public health and human services, every day I am more convinced that key elements of the Cleveland Clinic "Way" are relevant beyond heart care to improving community health. The diverse and highly trained public health workforce can be better organized in larger collaborative group "practices" with unified clinician led teams. Physicians, surgeons and other professionals in Cleveland Clinic's Heart and Vascular Institute have a myriad of unique skills and pedigrees and individual expertise--but, they know what's important to great care is playing their note at the right time and place.

They also know what their colleagues are doing because everyone is on a shared electronic system that provides transparency across different services. The shared records system ensures the left hand knows what the right hand is doing, and also means patients don't repeatedly complete archaic paper forms as they move from point to point. Community health enterprises should have similar unified information systems that cross programs--in many instances they could probably latch on to the products developed for physicians and hospitals with reasonable modifications.

Cleveland Clinic also focuses on quality improvement and public transparency of outcomes, even when things aren't as perfect as they may hope. In addition to traditional health quality measures, there's also substantial investment in measuring and improving the overall patient care experience. There's a need for better outcomes measurement and public reporting for public health and social services--especially population measures that cut across multiple programs. Doing well requires modern analytics and information systems, and performance improvement talent--the types of resources more likely to be cultivated in larger regional enterprises than in mom and pop operations.

Cleveland Clinic wasn't built overnight, and there are other key structural and organizational culture assets. However, many concepts can be applied to community health services. In my own organization, the Visiting Nurse Association Health Group, in New Jersey we have been working toward integrating programs and services using a similar approach. We have aligned the work of WIC, NFP, FQHC, EI, Ryan White HIV/AIDS, and other programs into one "Children and Family Health Institute." There are similar initiatives under way connecting home-based primary care and palliative care for older adults in an "Advanced Care Institute." We have made initial strides and there's a lot of promise, but we have a real long way to go.

Our efforts to improve, and similar efforts in other communities, would be more likely to succeed with policy changes to facilitate multiple government supported health services operating on one electronic record system. Waivers and demonstrations should be developed to promote funding changes to provide block funding for multiple programmatic areas across multiple levels of government rather than piecemeal funding. And, quality measures for these "accountable community health enterprises" should be developed.

Better health outcomes, less suffering, and lower costs are possible if a high performing medical system is connected to a high performing community health and social service system.