For years, home health agencies across the country have had numerous reasons to focus on reducing their 60-day re-hospitalization rate. Yet performance in this area has slightly worsened, the Centers for Medicare & Medicaid Services (CMS) noted in its recently proposed Medicare payment update for 2019.
Because of this trend, CMS is proposing to increase the weight that the 60-day re-hospitalization measure holds in the ongoing nine-state value-based purchasing pilot.
“We believe that increasing the weight given to the claims-based measures, and the Acute Care Hospitalization: Unplanned Hospitalization during first 60 days of Home Health measure in particular, may give HHAs greater incentive to focus on quality improvement in the claims based measures,” the proposed rule states.
That is, agencies in the nine VBP states would now see payments tied more directly to how well they keep patients from returning to the hospital within 60 days of discharge. Given that VBP might eventually roll out across the country, providers nationwide are taking note of this change.
There are several other reasons for agencies to focus on reducing their 60-day readmissions, too, including the fact that a variety of important referral sources, such as health systems and Medicare Advantage plans, are interested in reducing costs for their patient populations—and hospitalizations drive costs up.
Under the 2010 Affordable Care Act, acute-care hospitals face Medicare penalties if their hospital readmissions exceed certain thresholds for certain patients, meaning they also are looking to refer to post-acute partners that are skilled in keeping patients from returning.
A complicated process
Considering these incentives for reducing the 60-day readmission rate have already been in place for years, it might seem surprising that agencies have not improved more in this area.
But providers say that’s a tough ask for several reasons.
The trend “is not surprising … because it’s a really complicated process,” OhioHealth Home Care Director of Clinical Excellence Ann Dickinson, RN, MS, told Home Health Care News. “The way they slice and dice that data, you can look at it in variety of ways.”
OhioHealth Home Care provides services throughout central Ohio. It is affiliated with OhioHealth, a nonprofit health care system encompassing 11 hospitals and spanning 47 counties.
Other home health providers similarly point to nuances in the data.
Although there is “certainly an argument to be made for an uptick in the 60-day rate, the 30-day rate looks like it’s been dropping,” Mike Johnson, practice leader for home health at Bayada Home Health Care, told HHCN. “If you look at the six months from August through January, the rates crept up. [But] it looks like in January and February they’re dropping back down. To me, they’re holding a bit steady.”
Moorestown, New Jersey-based Bayada is one of the largest home health providers in the nation, serving 22 states out of more than 335 offices.
While the national readmission rates stands at about 15.8%, “ours is closer to 14%, but it’s also been fairly flat … We’re not seeing a demonstrable decrease in the last couple months,” Johnson said.
OhioHealth data show similar results.
“We’re at 14.7%. It depends, again, on whether you’re slicing the data for 30, 60 or 90 days,” Dickinson said.
Despite the CMS statement, providers believe that home health care has experienced “pretty significant improvement since the Readmission Reduction Program has been put in place,” Johnson said, referring to the Affordable Care Act provisions tying hospital payments to readmission rates.
The pressing questions for providers, according to Johnson, are: “Why are we at a plateau, or why might we be slipping back a little bit?”
One hypothesis is that, as the health care system overall has shifted away from facility-based care toward home-based care, providers like Bayada are now seeing higher-acuity patients, he said.
If patient conditions degrade or don’t improve while home care readmission rates hold steady, “that might actually be a good thing,” Johnson said.
“If the acuity stayed where it was, then maybe we’d see more of a decrease in readmissions,” he added.
Another factor could be the public’s trained response to health care episodes, including minor incidents. Despite efforts on the part of home health providers to change ingrained habits, they are hard to break.
“Everyone … knows how to dial 911. The message that sends is, if you’re worried, go right to hospital,” Johnson said. “You can’t blame people for that behavior.”
Home health care providers continue to advance their efforts to reduce hospitalizations.
“If you’re going to do it right, it takes a lot of collaboration,” OhioHealth’s Dickinson said. She also highlighted the importance of considering the whole patient and not just their current diagnosis or medication list.
“It takes looking at the patient across the whole care continuum,” she said. “If you see them in a vacuum and your strategies are solely tied up inside that 60-day episode, I don’t think you’re going to be successful.”
OhioHealth achieves success with behavioral interviewing—asking patients what’s important to them, what they’re concerned about and what fears they harbor.
Bayada works to ease patient fears and uncertainty that prompt behaviors leading to readmissions, such as seeking hospital care for minor incidents. “We’re looking to drive down readmissions by … managing people’s anxiety” with better post-hospital education and accessibility to alternative resources, Johnson said.
In addition, OhioHealth and other providers are leaning on technology such as telehealth and predictive analytics to help drive care that is more timely and targeted, so that higher-risk patients receive more attention.
“We’re going to use a lot of data” including individual patient needs, risks and opportunities to remediate risks, Dickinson said.
Home care providers rely on building industry relationships and collaboration to determine the best next steps for patients. Bayada’s home health care sector forges venture relationships with other health systems to devise readmission rate goals and strategies.
“If we keep working on these problems in our individual silos, we’re going to hit a plateau that we’re not going to get past,” Johnson said.
Written by Katie Pyzyk