The Patient Protection and Affordable Care Act will have an enormous impact on the healthcare delivery system. Home healthcare agencies, along with the rest of the provider community, will have great opportunities to rise to the occasion. This will require hard work as we all adjust to the new normal of accountable care. Transformation on this scale will not be for everyone and many home healthcare agencies will not survive. Embracing change will be necessary to succeed in the new world of value-based care.
The biggest changes are the measure of success and payment for agencies. Today, agencies work in a volume-based world: the more the Medicare admissions, the more the agency is paid. Agencies understand the complexities of case mix weight, visits per episode, and how that impacts revenue. In a value-based world, agencies will not necessarily be paid for the episode, visit, or hour of care. Already agencies are involved in risk arrangements; in other words, they provide care and if the patient or accountable care organization (ACO) achieves its metrics for quality and expense, the home healthcare receives a portion of the profit.
What will we need to change or discard as the payment model changes?
Home healthcare has long followed rules and regulations-whether state, federal, or insurance company, we are an industry of rule followers. Certainly agencies will still need to comply with the myriad of rules and regulations of today for some payers, but will need to embrace the new paradigm or perhaps it's more accurate to say create a new paradigm of care delivery.
In the world of value-based contracting, which rules should remain in place and, more importantly, which will no longer be relevant? Moving to population health, the 60-day episode of care will not be relevant as patients will belong to an ACO or Medicare Shared Saving Program for life (until they decide on a new doctor). That means we will not just be happy if we reduce 30, 60, or 90-day readmissions as we may be monitoring these patients long term. How will agencies handle patients who do not seem to comply or are not making progress?
This change to long-term responsibility will require all clinicians to have a new set of skills. We will need to learn about patient engagement, motivational interviewing, and a host of techniques aimed at making patients feel a sense of responsibility for their health status.
Today's patient education materials, for the most part, are one size fits all, not aimed at a specific set of the population. Does it make sense to give everyone one set of instructions or should we begin to tailor the tools to the patient's level of health literacy? Successful models of care already have determined that patients learn at different paces and having specific sets of teaching tools geared to specific patients will raise the level of compliance.
Most clinicians do not naturally begin a patient encounter by asking about the patient's goals of care, instead we revert back to what we learned in school. We assess the patient from top to bottom, develop a plan of care, obtain approval by the physician, and tell the patient what they need to do to get better. At no time do clinicians ask them how they wanted to proceed, if they had a specific goal they were working toward or if they understood why they hadn't gotten better in the past. Clinicians need to find something that will trigger a greater degree of commitment on the patient's part so they are a partner in their recovery. New skills will be required to improve the outcomes for all our patients.
Whether someone is homebound, has skilled needs, two visit minimums all become meaningless if agencies receive a global payment for an episode of care. If a patient is at risk for rehospitalization it does not matter if they can drive a car. It has proven that most patients come home from the hospital with new medications and do not understand what to do with the old medications along with the new medications. Why not go in for one visit and do medication reconciliation with the shoe box of old medications and the list of new ones? Additional assessments can be made to check if the patient needs other types of support.
Lastly, agencies need to create a mixture of Medicare and non-Medicare services to address the needs of various populations. Today agencies do not often mix skilled care with nonskilled or offer a patient on Medicare private pay services. In fact, agencies feel conflicted about overseeing the care of private pay aides or live in support. Moving forward, ACOs will be paying agencies to achieve outcomes for a patient population. Agencies may be packaging the postacute care of a total joint replacement patient. Rather than sending the patient to a skilled nursing facility due to a frail caregiver, as one example, a live-in personal care worker may be far more cost-effective to provide higher patient satisfaction and improved outcomes.
Our industry has much to offer in the accountable care, value-based world, but to maintain a place in the new care delivery model we will need to adapt. It is an exciting time and I know we will rise to the challenge.
Awards Presented at Annual VNAA Meeting in Las Vegas
Clinician of the Year
Heather Smith, Advanced Home Care High Point, NC
Even though Heather Smith has only been in homecare for a few short years, she has fallen in love with her job and those who benefit from her expertise as a Physical Therapist. The reason that she enjoys her work is because, according to her, "Homecare = Reality care."
Agency Board Member of the Year
Carol M. Kanarek, VNA of the Treasure Coast
Carol Kanarek remembers clearly the tears that flowed the first time she gave her dying father an insulin injection. She was so concerned about doing it correctly that she practiced on an orange first. During those difficult times as a daughter-caregiver, she was touched by the tender dedication and skills of a team of VNA nurses who cared for her father. A year later, Carol said yes to a friend who had been urging her for months to join the VNA's hospice committee and later the VNA board of directors.
Quality Team Award Nomination
Brenda Bartock and VNS Rochester
Brenda Bartock has been with VNS Rochester for more than 20 years and has earned a reputation as a transformational leader. Her team received grant funding from the Greater Rochester Health Foundation to expand evidence-based protocols for effective use of telehealth in a broader rural region and to test the effectiveness of the use of biometric monitoring as a stand-alone (without home care) tool to improve health outcomes for patients with chronic illnesses.
Administrative Leader of the Year
Marki Flannery
Marki joined Visiting Nurse Service of New York (VNSNY) 32 years ago and became President of Partners in Care in 1996. Under her leadership, Partners in Care has become the largest licensed home care agency in New York, and Marki led expansions in staffing, service geographies and new product lines.
Innovative Leader of the Year
Rose Madden-Baer
A visionary leader in healthcare, Dr. Rose Madden-Baer, Vice President, Clinical Operations Strategy and Development at the Visiting Nurse Service of New York (VNSNY), develops and disseminates evidence based models of care that have informed community based service delivery at our organization and at the national level.