FUTURE Talks: A Panel Discussion with Forcura

This article is brought to you by Forcura. The article is based on a live Q&A session with Forcura Founder & CEO Craig Mandeville, and Medalogix President & CEO Elliott Wood at the HHCN FUTURE event in Chicago held on September 30, 2021. The interview has been edited for clarity.    

Home Health Care News: We’re going to spend the next 30 minutes talking about care communication and some of the trends around outcomes and data. The world has been turned upside down in the last 18 months, and the pandemic has shifted the perceived value of home health and what it looks like today. Talk to us about how that perceived value has shifted to the home.

Craig Mandeville: COVID aside, think the home has always been the best place for care. I don’t think that’s changed post-COVID. What is gratifying to see is bipartisan support on the Hill or in Choose Home, which is a new reimbursement model with a lot of benefits around moving patients to the home faster. It’s arguably a better reimbursement with higher gross margins potential for home health agencies.


Elliott Wood: We were just debating that question earlier today: Did it really change the perceived value? We were both talking about how health care has become very personal during the pandemic. We have, on our team, two people who have lost immediate family members to complications with COVID. I watched my grandmother catch COVID through the window at a SNF.

Heath care has become a very personal thing to everybody. I think more than anything, it’s raised awareness that there’s a better way to do this, and not everybody has to go from a hospital to an inpatient rehab facility or SNF and step down the traditional continuum. Even for folks who have spent their entire career in health care, it has raised awareness of the opportunity to drastically change the way that care is delivered.

It’s a terrible thing to have to watch your loved ones through a window and not get to be with them, touch them and be a part of that experience. Yes, it has raised awareness and the perception of value, but I think a lot of that’s because it’s become personal to everybody.


You both mentioned the personal aspect, and Craig touched on partisan politics. We’re going to go there for a half second. Health care has almost become a divisive political issue these days. Obviously, that translates into delivery of care to the home, and when everybody wants to figure out how to deliver care to the home, you get this partisan overview of the pressure around what to do, or what not to do.

How can the home health care industry help share ideas and knowledge to other parts of the industry that need to deliver care and services to the home?

Wood: Craig and I both support The Partnership for Quality of Home Healthcare. They’re a big supporter of the Choose Home Act. One of the cool things we’ve seen as supporters of this organization is the bipartisan support around The Choose Home Care Act. For all of the politicking that happens, it has been cool to experience some alignment around this topic.

The other element is that you want home health and hospice to be talking to the Hill about what’s possible, how you can drive more care and how to reduce overall cost of care as well. But even as we have conversations with other groups here today, we want to share information without giving away the secret sauce that makes home health special and allows these providers to drive value.

We want to make sure we are helping our customers take advantage of that opportunity, so they are the ones delivering a lot of that value in the home.

Mandeville: I think this industry is so disconnected, but it has come together over the last 18 months. Look at NAHC and The Partnership. I felt like at some point, there were 75 state agencies supporting NAHC. That was incredibly frustrating for me coming into this industry because everybody had their own agenda and no one was aligning. It took a global emergency to put our heads together and start communicating.

There’s more that we can all do. Get out and share these stories — like Elliott shared about his grandmother — with your local constituents, because everyone has their own story, and health care in the home is definitely the best place. You’re seeing so many different service lines take place in the home now.

Definitely. This morning, there was talk about the process of primary care, acute care and post-acute care [working together]. Talk to us about the glue you think holds that together going forward. We’ll start with Craig on that one.

Mandeville: I don’t know. I think the glue is a little loose [laughs]. To me, they’re all competing with each other. We definitely need that connectivity. Running a technology company focused on connectivity, interoperability, communication and collaboration, I think we all need to work better together as technology companies, and more importantly, the EHRs in each one of those pillars, because you’re dealing with a lot of companies that have very old technology. Some of it’s a little more modern than others but very constricted in the way they want to share data.

Having an open API framework, allowing connectivity across EHRs and each of those three constituents will allow a better place for patients for that continuum of care through different service lines. I don’t agree there’s glue there. I think there’s a lack thereof.

There’s always the people-process-tech conversation. The reality is that the glue that holds different constituents together is economics and money. There’s been a lot of good conversation today with groups that are taking risks and managing risk. I think there’s a huge opportunity to align the three groups you just mentioned through risk-sharing. Bruce [Greenstein] with LHC Group was talking about the different ways they’re getting into risk-based contracting, they own ACOs. At the end of the day, the glue will be the alignment of incentives, and we’re not quite there yet. I think there’s a lot happening in the industry that could bear fruit along those lines.

Adding a fourth leg to that stool, we also talked about pre-acute in some of the earlier sessions. The panel before us was about social determinants of health. Tell me a little bit about how you see some of the pre-acute aspects translate into what you’re seeing with your clients today?

Mandeville: I think from a pre-acute standpoint, a lot of it is about fluid data flow and absorbing that information in real-time. Today, disconnected systems result in hours, if not a complete day, to take on a referral that’s coming from the community or a hospital. Understand what it is. Can we schedule for it? What actually happened to this patient in the last two, three weeks? Are there comorbidities here? There is a lot of absorbing information through the mind and a lack of data.

From our standpoint, automating that entire process and getting real-time information to those who need it is the definition of pre-acute, because if you have better information at the bedside, on-demand, you can make informed decisions. Today, I don’t see that happening. Forcura’s in the business of connectivity, moving information faster and connecting systems. Doing that, we’re investing millions of dollars to ensure we can automate that information so the best decisions are made and patients don’t wind up back in the ER.

Wood: I had written down in my notes that 50% of the population in home health is coming from the hospital. Somebody else said today that MedPAC’s latest number was 66%. I had not heard that yet. Two out of every three patients are coming from the community, they’re coming from physicians. What this means is home health is a pre-acute solution. What happens when you have a patient at home and the agency doesn’t take very good care of them? They’re going to end up in the hospital.

That was a stark realization for me today. Craig talked about how they’re playing and supporting their customers there. We’re a machine-learning company. We’re driving insights and clinical decision support to achieve the right level of care for the patient. A lot of it is ensuring the customer and the patient are getting what they need. If they have an issue, they’re homebound. They’re getting sent to a home health agency by a physician because the physician recognizes, “Hey, this patient is declining and they need support to improve and be independent in the community.”

I think there’s a huge opportunity for home health to align with physician practices, especially physician practices that are starting to take financial risk.

Looking ahead, success and outcomes used to be, “I don’t want to see you back here in my office; I don’t want to see you back at the hospital.” How are outcome measurements changing from your point of view?

Wood: As a data science company, our customers are primarily home health and hospice agencies. We have done a lot of work supporting them with payers and health systems. The conversation with these strategic partner groups is changing. There’s dialogue with these strategic partners about how they might create a narrow network and develop a high-performance network of PAC providers. I think that’s common. Everybody we’re talking to, especially the groups that are managing risk, they are starting to pick who their providers are and who they want to work with. They don’t want to work with 10,000 agencies.

Especially because of the risk dynamic, it’s going to shift from, “Hey, I don’t want to see you back here,” because the truth is the hospitals do unless they’re in some kind of risk-bearing situation. As the health systems and physicians start taking on more risk, it’s going to change to, “Who are the home health groups that I can partner with? Who can I trust? When I send them a patient, are they going to take them no matter who the payer is? Is the transition from the hospital to home going to be an effective one? Is the agency to be in the home within 24 hours after I discharge this patient? Or is this patient going to go three or four days without knowing whether or not they’ve been admitted to an agency’s census? Are they getting the right amount of care? Can you identify risk? If you can’t identify risk, can you do anything with it?”

Another thing we hear from a partnership standpoint is that a lot of the organizations managing risk and looking to home health for some type of partnership are struggling because of a lack of transparency.

Mandeville: I completely agree. One thing we heard about earlier is the prediction of more payer-provider — payvider. With the Humana acquisition [Humana’s acquisition of Kindred of Home], we’re definitely going to see more of that because this lack of data flow and interoperability in our industry will take a while to fix. I’m working really hard, y’all. I’m connecting these systems. When you control the data flow from payer down to the actual servicing, and caring for that patient, and that rolling back up, you own the data. Having the right care management on top of that will result in really high-quality scores, and that’s where patients will go.

Wood: They want it. In the conversations that we have, especially with payers who have horrific, arduous authorization processes, they don’t like their authorization process either, but there has not yet been a solution to align incentives. I think, until home health really steps up and takes that opportunity, and a lot of it has to do with data and coordination, you’re going to see more and more third parties introduced into the system that are helping manage PAC transitions and utilization.

You were going down a road towards care coordination, we’ll get to it in a minute. One of the things we’re talking about is using data. Earlier today, there was discussion about how many visits someone will be able to get if it’s prescribed between the payvider or however you phrase it. There’s a certain predictive number of visits and different things. Is it too few? Is it too many?

Elliott, what’s your point of view on getting the clinicians and frontline teams engaged with these predictive analytics versus their professional judgement?

Wood: It’s a multi-step answer. We have a product in both home health and hospice, where we’re making recommendations on utilization. Based on the acuity of the patient and all the data the clinician has accepted about the patient, how much utilization should each patient receive? That is a very sensitive conversation with the clinician. You’re starting to get into existential territory of what they do. I have two clinicians on my team in the back of the room who I want to have this conversation because the customer doesn’t want to talk to me. I’m an informaticist, I’m not a clinician. I don’t need to be having that conversation. I think this is true with most technology, generally, but especially when you’re starting to do things that influence clinical decision-making.

The first requirement in every implementation we’ve ever had is leadership. Do they have good clinical leadership? Someone has to step up in front of them and say, “Hey, this is why we’re doing what we’re doing. This is why this is going to make us better as an agency, and this is how we’re going to take better care of our patients as a result. ” That’s number one. That always has to happen.

Number two is — and I think most of us here are vendors — we have to create good products. It just is what it is. If we create crappy products, they’re not going to want to use them. If we’re making their life harder, they’re not going to want to use them.

Three, assuming that you have the first two, the clinician still has to experience it. We have a handful of cases where there are high levels of skepticism, then with time they see, “Oh, this actually does work. This actually does allow us to take better care of our patients. It hasn’t taken away my decision autonomy, it’s actually supported it, it’s augmented my decision.” It takes that progression in order to win clinicians over.

Mandeville: One thing I learned early in the business is, I’m a technology guy. I could have the best idea in the world, but if I develop it and deploy it without interaction with our customer, it typically flops. I think we see that a lot in technology companies and it bugs the heck out of me.

This is a partnership. We partnered with our customers and got them involved early so that they’re dialed in. Being there in their offices showing the technology and having them use it goes a long way. We’re in the business of saving time. It’s cutting administrative time, cutting out all that waste.

Our mission statement is to empower better patient care. Everything we do in the organization is around our customers taking better care of those patients. It’s not the secret sauce, but to me, it’s the true north of what we do. Getting in with our customers and having them help us develop a great product has been a winning solution.

You mentioned there’s a lot of technology vendors at today’s event, talking a little bit about all the different solutions out there. I personally had an experience where I had to encounter a care coordinator for the first time in my life, and I was required to download something on my phone, then I had to call 1-800 number. It was confusing for me as a consumer.

What do we as an industry do to help facilitate this care coordination? There are lots of tools out there. Where are we going? Because from my experience, it’s rubbish at this point. You go first.

Mandeville: I agree. Care coordination is very heavy on the FTE side. You’ve got a massive opportunity for technology to evolve and we can automate a lot of that, especially through AI tools and machine learning. Where we see things fall down is the transition of care. As a patient gets discharged to home health, palliative, hospice or maybe to a SNF, it is a complete download of that patient record. There’s literally no metadata that makes its way into the next system which impacts the patient directly. The lack of information and history of what’s happened makes it very difficult.

These are things we’re working on, that we’re delivering into the post-acute market to connect these systems. We are moving this information fluidly through the transition of care so there’s less FTE proactiveness in terms of following up and empowering you to manage your own care.

Wood: Just to speak from our experience, we do less than Craig does on pure tech-enabled care coordination. We see care coordination happening because of risks that we’re identifying, which is usually creating workflow downstream where clinicians have to coordinate. That is way harder than it sounds, and for a variety of reasons. We’re talking about care coordination, at least at the beginning of this conversation of different verticals of care: physicians, hospitals and post-acute. That is so difficult to do.

Our very first product identified patients on home health with a high probability of passing away. Curative care probably wasn’t the best type of care for the patient anymore. For a lot of patients at the end of life, one is having an end of life conversation with the patient, despite the fact that they’re about to die. We were seeing this happen even with home health agencies that owned hospice.

One of my favorite stories to tell is when we went to do an implementation of a customer of ours in Oklahoma, and we get to this meeting where we’re about to facilitate a discussion between home health and hospice. There’s a giant table in the middle of the room, and all the home health clinicians were sitting at the table, and the hospice clinicians sat at the outside of the table. This was a home health and a hospice that were owned by the same company. They were the same company, but the lack of “team” was evident, much less the capability to actually coordinate care across service lines.

We’re talking about care coordination that is best for the patient — that is very difficult in home health and hospice even when owned by the same company. As a broader ecosystem, we have to take this care coordination effort beyond our company logo. We have a long way to go and a lot of things have to get put in place. We need alignment and economic incentives around philosophies of care. What are the plays? When you’re talking about aligning physician groups and home health, what is the actual care coordination that can happen? There’s a lot to unpack there.

Both of you spend a lot of time with your customers, some of which are very large health care providers and health systems. Tell me what’s the most pressing issue that C-suite comes to you and says, “Gosh, I need help.” What is that? How are you addressing that today?

Mandeville: It goes back to seeing a lot of consolidation, not only in the market, but stratifying that risk across multiple service lines. Many of our customers are using six different EHRs and none of them talk to each other. There’s a lot of chatter like, “Oh, we’re implementing that. We’ve got all these things.” We’ve got a long way to go. That’s definitely a major investment that we’re making.

It’s connecting these systems and moving that patient data across so these teams have really good cultural communication within their organization. They also have to pass this patient data information to other care coordination teams to get a good understanding of what’s happened and why they’re here? “What can I do to make really good decisions to care for this patient?”


Wood: Data. We need data. Not just because we’re a machine learning company, but because we need to understand how we’re doing. When you’re implementing technologies, these customers spend a lot of money, not just on the tech itself, but also on the implementation, on the focus and on aligning their teams.

I think some of the most frequent feedback we get specific to our products are, “Hey, we need to understand more and more and more, where are we getting this right? How can we do better?” Part of our responsibility is to be good vendors and partners, quite frankly. Outside of that, the product-specific stuff, it’s all staff. There’s a shortage in the market.

This article is sponsored by Forcura. Forcura is a health care technology company that facilitates care coordination for providers across the continuum to reduce administrative expenses, optimize revenue cycle management and deliver better clinical outcomes.

Based out of Jacksonville, Florida, Forcura serves over 600 clients and 7,000 locations nationwide. The company has been recognized in 2021 as the Best Healthcare Technology Solution, ranked for the fifth consecutive year on the Inc. 5000 and is a top-20 ranked Fortune Best Small & Medium Workplaces™. Learn more at forcura.com.

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