In-home care stands to become ever more central to the U.S. health care system in the years ahead, but for providers to reach their full potential, there still are important steps that need to be taken. Specifically, regulatory barriers need to come down, more flexibility needs to be baked into payment models and efforts to root out fraud need to be more targeted.
These recommendations come in conjunction with the publication of “The Future of Home Health Care: A Strategic Framework for Optimizing Value” in the peer-reviewed journal Home Health Care Management and Practice. To prepare the report, the Alliance for Home Health Quality and Innovation (AHHQI) conducted and/or commissioned qualitative research, a literature review, and case studies, and used themes from a 2014 Institute of Medicine and National Research Council workshop as a jumping-off point.
The overall takeaway from this report is positive for home health.
“In our interviews with policy leaders, including former policymakers at the highest levels of CMS, in addition to leaders in caregiving and health care system leaders, all really are in agreement that in the new models that are going to be the focus of health care delivery system reform, like bundling and ACOs, home health care is going to be a big winner,” Teresa Lee, executive director of AHHQI, told Home Health Care News. “So, in that context, what we’ve tried to build out in a discussion of this project is that we need to be leveraging that opportunity as a home health community.”
Preliminary findings from this project already have been shared in various formats and venues, and the report published this month contains a final version of the framework that has been shared in these previews. Notably, it lays out the four “pillars” that will differentiate a home health agency of the future: providing care that is person-centered; providing care that is seamlessly connected and coordinated; prioritizing quality; and being technology enabled.
The future home health agency also will play three critical roles, the final report states. Namely: providing post-acute and acute care at home; partnering with primary care; and partnering with home- and community-based long-term care providers. By playing these roles, home health agencies will be able to both support hospitalizations and other medical escalations, and enable patients to have lives that are integrated in their communities.
Yet, to achieve this vision of the future, there are some important issues to address, according to the report authors.
3 Areas for Change
Regulatory barriers: Regulatory barriers present one such challenge, specifically to enable home health agencies to share risk in new payment models and fully participate in coordinated care with other providers, the report states.
“Stakeholder interviews … highlighted several regulatory barriers within the structure of the home health benefit that preclude effective care coordination, provisions that prevent the necessary level of integration and coordination with other providers,” the report authors wrote.
One issue that has hampered integration and care coordination—and created an obstacle for agencies seeking to become more tech-enabled—is that home health agencies have not been eligible for the same financial incentives for implementing electronic health records (EHRs) as other types of providers. While the Centers for Medicare & Medicaid Services (CMS) has stated the home health agencies may be eligible for some of these payments moving forward, it is “unclear” whether this will be sufficient for supporting the health technology investments needed of the future, according to the report.
More flexibility: Alternative payment models are shifting the health care system away from rewarding providers for the volume of services provided, in favor of tying payments more to quality outcomes and coordinated services. Home health is an important player in these models, as it is often the lowest-cost setting and also is the place where patients themselves would prefer to receive care. However, related to the issue of regulatory barriers, the way that some of the alternative payment models are designed does not allow home health to fully maximize its value.
The requirement that Medicare beneficiaries be “homebound” in order to utilize home health services was one such constraint identified in the report. For alternative payment models, such as bundled payments or accountable care organizations (ACOs), there is the potential that waivers can be tested to provide more flexibility in who can tap home health benefits.
These sorts of waivers should indeed be tested to help encourage practices that both are clinically appropriate and cost effective, the report recommends.
Targeted fraud crackdowns: Government watchdogs and other oversight bodies have singled out home health fraud as a major issue, and have launched aggressive efforts to identify and root out bad actors.
While such efforts are needed to ensure program integrity and reduce waste, when crackdowns become overly broad, they risk imposing unsustainable burdens on high quality providers, the report notes.
While it is not specifically mentioned in the report, one such problematic fraud prevention program is the Pre-Claim Review (PCR) demonstration currently underway in Illinois, according to AHHQI’s Lee.
“Pre-claim review’s focus is the review of home health documentation,” Lee said. “The irony is that truly bad actors may be fabricating documentation that can look perfect. But for a good, compliant home health provider that knows the importance of coordinating care and working well with the physician, who should be providing appropriate documentation, the pre-claim review process is a major obstacle to operation.”
In addressing these three areas, the home health industry will need to engage multiple stakeholders, including patients, caregivers, policymakers, and payers, the report states. Another essential strategy is going to be collecting the data to make a compelling argument to the necessary individuals and organizations, according to Tracey Moorhead, CEO and president of the Visiting Nurse Associations of America (VNAA) and an author of the report.
“I think that the most critical component of overcoming the current regulatory and administrative burden is effectively developing and communicating the evidence case for the value of home-based care,” Moorhead told HHCN. “It’s going to take real data, it’s going to require us to show that we have a cost savings opportunity in health care to help improve value, to get us that seat at the table we need in the deisgn of those health care delivery models.”
One effort she singled out is AHHQI’s research into the value that home health contributes in episodes of care related to joint replacements.
“VNAA has also developed a database where we’re collecting data from many of our members, and we’ve developed a dashboard that demonstrates outcomes and impact,” she said. “We can track how our agencies are doing against a national average for specific conditions and populations, and this, too, is another component to that evidence-case for home-based care.”
The fact that CMS recently delayed the further rollout of pre-claim review is one reason to believe that policymakers indeed are receptive to the sort of evidence-based case that the home health industry can put together, Lee said.
The three areas foregrounded in the report are far from the only challenges facing home health agencies—for example, workforce issues also are top-of-mind for many providers, as the AHHQI paper also described. But while creating change across all these domains and creating the “home health agency of the future” may not be easy, the rewards of doing so could be profound—as the report concludes, “the pursuit of this transformation process has the potential to improve the way health care is delivered in America.”
Written by Tim Mullaney