First Home Health Provider to Face COVID-19 Sees Sharp Increase in LUPAs, Decrease in Therapy

EvergreenHealth Home Care has been dealing with the coronavirus longer than just about any other home health care agency in the country. Back in February, its affiliated hospital treated the first positive COVID-19 patient to die in the U.S.

Since then, Brent Korte — the not-for-profit’s chief home care officer — has been firefighting the virus left and right.

Based just outside of Seattle, EvergreenHealth Home Care is one of the largest home health and hospice providers in the Pacific Northwest, providing about 250,000 visits per year.

While Korte does not purport to have all the answers, hindsight is 20/20, which is why he’s sharing his story and the struggles his agency has faced with providers nationwide.

In our latest episode of Disrupt, Home Health Care News connected with Korte, who discussed what he would do differently if he could go back in time, along with how EvergreenHealth is grappling with coronavirus-specific problems, from increased Low Utilization Payment Adjustment (LUPA) claims to personal protective equipment (PPE) shortages.

To hear that conversation and more, you can subscribe to Disrupt via Apple Podcasts, Google Play Music, SoundCloud or your favorite podcast app.

In the meantime, you can find portions of HHCN’s discussion with Korte below, edited for length and clarity.

HHCN: Everyone is grappling with the coronavirus, but at EvergreenHealth you’ve been dealing with it since February. Can you walk me through your backstory on that and what a day in your life looks like now?

Korte: It was evening on Friday, Feb. 28, and I got a phone call from my boss.

She asked me if I was sitting down. She told me that the first death in the United States occurred at our hospital with a COVID-positive patient. I’ll never forget sitting up and walking out of the room, and just a flood of ideas and consequences and everything sort of ran through my head.

My next question to her was, “What happened?”

This patient hadn’t contracted COVID-19 at our hospital. But our hospital had chosen to step up and care for this patient.

I was overwhelmed with the idea that this was happening, not only in the United States, not only in Washington state and not only in Kirkland, Washington, but at the system where I work and lead our home care division.

My personality is to immediately put worry or concern to work, so I got up the next morning and headed in early and worked with hospital leadership to prop up our incident command. I spent many, many hours over that first weekend and week working through the proper way to to deal with a virus that frankly very, very few people really understood.

I actually think that it’s been a good thing that EvergreenHealth and Kirkland were the first to experience Coronavirus for a couple reasons.

Washington state was one of the first states to fully “flatten the curve” because we had aggressive social distancing early. It forced us to … prepare very quickly for what life is like in the health care world in a pandemic.

And it allowed us to lean on some of our best practices and a lot of the training we’ve had around dealing with crisis and disaster.

I don’t think there was any sleep in the first 24 hours. Fast forwarding through the weeks, we’ve gone from adrenaline to something that feels more normal. [We’ve spent this time] doing everything we could to try to face this crisis pragmatically, scientifically and bravely.

What’s been the hardest part of managing all that?

The hardest part has been making decisions that keep our clinicians safe, knowing that we have had limitations on everything from knowledge about the virus early on to limitations on PPE.

If our clinicians aren’t safe, then we can’t provide care. They, without a doubt, have been our absolute priority. We lean on science to keep our staff protected, and we lean on compassion to keep them supported.

Keeping our staff safe doesn’t only mean safety and protection from the virus, it means making sure that they’re … able to support their family, that they’re receiving paychecks and that they’re emotionally supported.

A big part of that safety is PPE. Can you walk me through the PPE protocols that you use?

Considering that, on day one, all we knew of the virus was from news reports and some local [and internal] communication, … it was really difficult for us to figure PPE out.

Our first move was to evaluate our PPE inventory. We looked great under normal times, but like many folks in the United States, we weren’t prepared for a viral outbreak or a pandemic.

We started by effectively doing what the hospital was doing, which was using N95 respirators for positive patients, and then we moved on from that, knowing that droplet precautions were sound and safe for positive patients if done correctly. That included goggles, gowns, gloves and surgical masks.

Then we laid off the gowns. Then we went to no masks at all, except for positive patients, and then went to masking for all patients. Now we are working to provide cloth masks for patients who can tolerate them.

Procurement is important, but conservation is critical. We have continually said, “Do we want to have two weeks of being overly protected? Or do we want to have two months of being adequately protected?”

It’s also super important to hold your medical supplier accountable. Push back if they’re only providing PPE based on allocation. To lean on the mentality of allocation — when we’ve never needed an allocation for massive PPE nationally, no one has — it doesn’t seem to make a ton of sense.

I was faced with the [decision]: Do we send staff out into the community to provide care to COVID-19 positive patients who are not fully protected? The answer is “no,” we would not do that, and we cannot do that.

We have to protect our staff so our staff can protect the community.

Another interesting aspect we’ve heard from a lot of home health providers is that they’ve seen changes to supply and demand in terms of their services. What are you experiencing?

COVID-19 has really obscured the so-called economics of home care.

Our patients needed us before Feb. 28. They need us now. And they’re going to need us after there’s a vaccine for COVID or we’re able to move forward in a more normal way.

In fact, [COVID-19] has probably compounded the need, but there are a lot of factors at play.

We’re seeing our clinicians being denied access to congregate living facilities. We have respect for assisted living facilities and … adult family homes. However, it’s important [to] … recognize that the work home care providers are doing is the work that keeps patients out of hospitals.

For us to be seen as a possible vector is logical, but what isn’t logical, necessarily, is that care would be withheld or prohibited from patients who have that need. We’re working hard with our facility partners in the community to make sure that our clinicians have access.

We’ve seen a significant decrease in our total number of visits. I think that hospice has seen a just under 50% decrease in visits, and home health is right at a 26% decrease in visits.

On the home health side, that’s a big deal. We have never considered that any of our visits were superfluous, and in this time, the visits are absolutely needed. To have a decrease in visits has impacted our ability to make sure that our patients are not deconditioning and at an increased risk of going back to the hospital.

On the hospice front, despite our decrease in visits, we have seen a sharp increase in telephonic interactions — so we’re working on virtual care.

We also are working really hard to ensure that we’re supporting our therapy team. Therapy is in a tough situation right now. We have seen a sharp increase in nursing, but our therapy visits have probably seen the most drastic decrease.

This discussion around therapy and visit volume brings me into a question I have about PDGM: What implications does COVID-19 have in light of that payment reform? For example, how are you grappling with things like LUPAs and other issues?

Our team had this moment when … the home health leaders all looked up and said, “Weren’t we already kind of working on what was going to be our hardest year ever?”

We half laughed and half sulked in our chairs — and then kept working through it.

COVID took over, and PDGM seemed to take a backseat. PDGM hasn’t been forgotten. It’s been part of our decision-making, but when you’re having to make a choice between what PPE keeps our clinicians safe … and have we coded for all of our core comorbidities through PDGM? We’re going to choose the former.

Part of this is LUPAs. We’ve started to look at LUPAs very pragmatically. We aren’t going to force a clinician to do a certain number of visits that aren’t necessary under the veil of COVID-19.

We’ve really aimed at that [LUPA number] being our minimum amount of visits, whereas before, frankly, we were doing a heck of a lot more than the LUPA number. Then we supplement that number with telephonic interactions.

The other bit is therapy utilization. We have to make sure that our therapists are continuing to go out, because if our patients continue to decondition, they’re going to put stresses on the health care system.

Would you say either of those areas have been pain points for you or have you been able to successfully navigate those problems?

We have a strong assumption that our LUPA levels have sharply increased — or have increased sharply from what our LUPAs would have been without COVID-19, more specifically.

And we do know that therapy utilization has decreased. Now, through PDGM, therapy is not as formally incentivized as it was through the Prospective Payment System (PPS).

If we’re able to provide visits in some form, financially, from a revenue perspective and from a breaking-through-the-LUPA-ceiling perspective, then perhaps we’ll be okay. But we are very, very cognizant of ensuring that we provide a minimum amount of visits.

This harkens back to a key consideration I hope every leader in home health is asking, which is: “What is the balance between protecting our patients in their home and protecting the public’s health?”

Looking back, what, if anything, would you have done anything differently in handling all this?

I would go back in time and change my bachelor’s degree in microbiology to a degree in epidemiology, so I’ll give you that one.

I would have ordered a stockpile of PPE to keep on hand for times like this. I would have heeded warnings more carefully about epidemics in viral spread. I would have done as much as possible to get to know the patients that we’ve lost before they were infected.

I’d be more outspoken for the need for our country to support public health, post-acute care and home care, hospice and home health in the way that we support defense. I would have read more articles based on science and never questioned that science or thought that this simply wouldn’t happen because it’s not convenient.

What’s the biggest advice you’d like to share with other agencies?

Get your leadership team together right now and agree upon your approach, talk through difficulties, have conversations about the elephant in the room, and make sure that you iron out where everyone stands.

It’s [also] critical we support our staff and we see them for what they’re doing and for the risks that they’re taking. We need to provide them constant information and give them the support they deserve.

Finally, what impact do you think COVID-19 will have on the home-based care industry long-term?

Without a doubt, there’s going to be a higher recognition of home care, home health and hospice — of the need for more support, knowledge of and funding for home-based care.

I hope that this is going to lead toward more progressive regulatory considerations, more considerations toward virtual care [and] telehealth.

And hopefully, home care will continue to have a louder voice in conversations at the top levels of government to ensure that we have a seat at the table that is positioned to our relevance.

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