In-Home Care Providers Must Break Through Barriers to Handle More Long-Term Care Volume

There are several trends shaping senior care in the United States, with two of the biggest being continued Medicare Advantage (MA) growth and the steady shift of health care into the home.

Yet if in-home care operators want to capitalize on those trends, they’ll have to break through traditional payment and operational barriers. That’s particularly true for home-based care entities looking to roll out new care models for patients who would have otherwise gone to skilled nursing facilities (SNFs).

The “SNF-at-home concept” has gained a lot of traction in the wake of the COVID-19 pandemic, but there are still plenty of questions left to answer, according to Anne Tumlinson, founder and CEO of the Washington, D.C.-based ATI Advisory.


“I think there’s a limit to what can be done in a home setting, and I worry about caregivers who are not really prepared to bring somebody home,” Tumlinson said at the 2021 Navigator Leadership Summit. “Whatever this model is, it’d better be robust.”

On the payment front, breaking through barriers means figuring out ways to make managed care work for providers. Despite steady MA growth, most home health organizations still lean on fee-for-service Medicare, while home care agencies largely remain stuck in the private-pay world.

About 43% of the nearly 63 million people eligible for Medicare enrolled in an MA plan for 2021. Looking ahead, MA enrollment is projected to clear 51% by 2025, potentially hitting 64% by the end of 2028.


“If your organization does not have a Medicare Advantage strategy that goes beyond just arguing over contracts, you need one,” said Tumlinson, who was speaking to SNF operators and in-home care executives alike.

Care Advantage is just one example of an in-home care provider that has gotten creative with its payer partners. The PE-backed company has secured a pay-for-performance arrangement with an Anthem health plan in Virginia to help manage its long-term care members in the home.

“It’s one gradual step,” Care Advantage CEO Tim Hanold previously told Home Health Care News. “Then eventually, it’s about true value-based care, in which we want to share in risk and have skin in the game in regard to outcomes and members’ well-being.”

Meanwhile, when it comes to the actual delivery of care, home-based care providers will need to overhaul their operations if they want to keep the volume increases they’ve won since the public health emergency began.

In April 2020, home health agencies and SNF operators sat at 68% and 69% of their 2019 volume baselines, respectively, according to data from CarePort, a WellSky company.

Home health providers reached 107% of 2019’s levels by July, but SNFs still sat at 80%. As of January, SNF volumes climbed up to 90% of pre-pandemic baselines, with home health volumes hitting 108%.

“What’s happening is, the total number of patients available for skilled nursing facilities to take has actually gone down,” Tumlinson said. “And then on top of that, the share of that pie, that piece of the pie, is smaller.”

Many health care experts believe that trend to continue or even accelerate, especially if the Biden administration is able to pass its American Jobs Plan as proposed. The $2 trillion infrastructure bill sets aside $400 billion to beef up home- and community-based care programs.

Tumlinson and others in the post-acute space, however, warn that in-home care isn’t a one-size-fits-all solution, pointing to the ancillary services that residents of senior housing and care facilities receive. Those services include meals and laundry, plus around-the-clock assistance with using the bathroom and other activities of daily living.

“I think to make home care a really robust part of the delivery system, there’s a lot of work to do,” Tumlinson said.

And despite the narrative of facilities versus in-home care, a majority of seniors already received care in the home prior to the pandemic.

“Two-thirds of the older adults who have a long-term care level of need, meaning they could be in assisted living or … a nursing home, they’re actually living in single-family dwellings today,” Tumlinson said. “This is actually a pre-COVID statistics. So it’s not like senior living [communities] or skilled nursing facilities were dominating the marketplace.”

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