This article is brought to you by WellSky. The article is based on an interview that took place during a live Q&A session with Andy Eilert, President of Emerging Markets at WellSky, who interviewed Kunu Kaushal, Founder and CEO of Senior Solutions Home Care and the Founder and Advocate of the Independent Home Care Alliance, and Mag VanOosten, President and Chief Clinical Officer at UnityPoint at Home. The interview took place at the Home Care Conference in Chicago held on December 9, 2021. It has been edited for length and clarity.
Andy Eilert: I’d like to introduce our panelists. First is Kunu Kaushal. Kunu has worked in many different healthcare and home-based health roles. In 2010, he started Senior Solutions Home Care inspired with a motivation to help his own aging grandparents. Mag VanOosten is President and Chief Clinical Officer at UnityPoint at Home.
Mag joined UnityPoint at Home in June of 2016 as VP and Chief Clinical Officer, and then in 2018, she was promoted to president and retained the Chief Clinical Officer role as well. Throughout her time there, she has been committed to driving performance through collaboration, and delivering quality patient-centered care. As we all know the pandemic has changed pretty much everything about life. It certainly has changed healthcare and where healthcare is delivered, when it’s delivered, and how it’s delivered.
As hospitals and health systems began shifting acute care into the home, predominantly based on overcrowding and staffing shortages, CMS added a bit of momentum around this through its Acute Hospital Care at Home initiative, which began about a year ago. As of about a month ago, there were 83 health systems and roughly 187 hospitals operating in that program. In the skilled nursing facility (SNF) space, we’re seeing a significant trend to move care from skilled nursing facilities to home where appropriate, and generally speaking, these are for lower stay and lower acuity needs.
There are certainly different models that are emerging, and we’re going to hear more about that. One thing is very clear, it takes a partnership between the clinical side and the non-clinical care elements to run successful models. Hospitals and SNF at Home are examples of value-based care models because they promise to improve a patient’s experience, getting care where they want to receive that care, improving outcomes, and lowering costs, ultimately driving value. They do require changes to how we’ve traditionally run healthcare, and they require significant coordination between payers, acute care systems, and home-based providers.
Relevant for this conference specifically, is the glue that is increasingly holding these models together which is the non-clinical care and home care providers. There are significant opportunities for acute and home-based providers as they evolve to meet the needs of these models. Also, it’s better for both patients and for our industry. Today, we’re going to hear various perspectives around how these at-home recovery models are viewed from the acute care side and the home care side and address recent concerns that have surfaced regarding the viability or unintended consequences of these types of models.
We’re also going to talk about the counterpoint to that, which is the mounting evidence of the success of these programs. Lastly, we’ll land on the future of these models as we see them. With that, Mag, I thought we would turn it over to you. UnityPoint at Home has been a real innovator in this space.
Pre-pandemic, leaning into both Hospital at Home and SNF at Home models, they’ve had great success and I know you have a lot to share with the group. So we’ll turn it over to you.
Mag VanOosten: Good morning. UnityPoint at Home is an affiliate of UnityPoint Health system. I won’t get into all of the details of UnityPoint Health, but we have a large, currently NextGen ACO going into DCE in the new year, but the reason that we started our non-traditional services really was to support our ACO and those attributed patients. We started originally with the waiver programs, the post-discharge home visits, the care management home visits, and what we recognized was, there was a lot more cost savings if we could keep the patients out of the hospitals.
The patients that we were looking to keep out of the hospitals were still acute, but the lower acute level patients. In 2016, we did a proof of concept around an expedited discharge model, taking patients home after they completed their DRG. We did it that way to prove we could get the supplies they needed in their home, provide that same level of care, and meet the patient in a timely manner. We went back, wrote a business plan, and in 2018, launched what we call, Care at Home. Care at Home is an overview of all of the programs that we run in a non-traditional payment model.
Under that we have Hospital at Home, SNF at Home, Palliative Care at Home, Primary Care at Home, and we conduct a lot of annual wellness visits on behalf of our providers. We also have 900 providers within the health system. When we say Primary Care at Home, it’s really more of an urgent care at home, which means a physician calls, and if they can’t get their patient in, they recognize something’s going on, and they don’t want to send them to the ED, our providers will go out and see them.
We’ve been able to avert ED utilization that way. We did all of those services under Care at Home because during our pilot, we realized we could only admit patients on Mondays, Tuesdays, or Wednesdays because we were borrowing staff to make it come together. To have full-time dedicated staff, we needed to do something to create capacity. Being able to do these Hospital to Home visits, and palliative care all brought it together, so our providers could cover that whole gamut.
We did the Hospital to Home model, and in October of 2019, we evaluated our metrics. We weren’t really moving the mark, we were still at about 27% ED utilization, and still about 25% 30-day rehospitalization, although we call it hospital utilization because they’ve never been admitted. We went back and did a couple of rapid improvement events. What we found was the pass-off you have between being discharged in the hospital to home health, was the same pass-off we were using from hospital to home to home health.
If we could better coordinate that handoff, we felt like we could really make a difference. We wrapped a 30-day bundle around our hospital home episode and dropped our ED utilization to about 6% in 30 days, and about 10% for a 30-day rehospitalization or hospital utilization. We’ve been pretty successful in keeping patients in their home. Then in November 2020, CMS called six of us and said, “We’re going to put through this waiver, we’d really like you to consider joining it.” We were one of the first six to get in on the CMS waiver and took our first patient home.
Eilert: I’m sure that was an exciting moment for you. Where did you go from there?
VanOosten: In February, and I know you’re saying why did it take so long, but it was completely different from what we were doing. We now had to set up a virtual floor of the hospital. We had to change from documenting an Epic ambulatory to the Epic inpatient medical record. We had to change how we were billing because we weren’t going to bill the fee for service, we were going to bill DRG. I’m proud of the system for pulling all that together in three months and being able to get it done quickly. We now currently run those two models.
Also, in 2020, what happened was our hospitals were getting bottlenecked with patients that needed to quarantine before they could go to the SNF, and we’ve been talking about SNF at Home but paused because of COVID. We didn’t have a private care partner and we knew we needed that for SNF at Home to be successful. In 2020, people were furloughed, we had a lot more caregivers at home and we said let’s do a proof of concept around SNF at Home, much like we did with Hospital to Home, and let’s start taking those patients home in that level of care. We were able to take patients home under a pilot SNF at Home, and then we launched officially earlier this year with the help of WellSky and their personal care platform.
Eilert: Thank you. Kunu, I know you have equally embraced innovation from a home care perspective. What are your thoughts on these models?
Kunu Kaushal: I would say the value proposition for personal care, if you follow the home and community-based services model, we’ve been a nursing home deferment program for quite some time. In Tennessee, where we have most of our operations, we’ve partnered with those managed care organizations, we’ve partnered with the state, and the thought process there is we can deliver care to individuals at a much lower expense.
Everyone knows and sees that parallel, and yet, what we’re also seeing thematically is that the payers and everyone else wants data collection. They want information, they need to know what’s going on with what we call a client, someone else may refer to as a patient. They want eyes and ears in the home. Personal care tends to be there for the longest amount of time. We are standing for the family many times, and we are the ones that understand the care plan and what’s happening in and around it.
At the end of the day, home is where people want to be, but personal care agencies or a formal model that requires partnership with technology, and our payers along the way, is really where innovation has to come up anyway. The caregivers are going only going to be as powerful as the tools that they’re given. I think as agencies, we need to know what the end goal is. An interesting element in personal care is the entire industry has a hard time defining value.
I think ultimately, if you can find a payer or a system that understands the value of essentially having that deferment, with having them be at home and the cost savings along the way, that’s a form of value that is very much realized. Personal care agencies have a pretty easy model. We just want the client to be happy. We want them to be home, we want to service them.
We’re seeing pilot programs with other tech organization partnerships as well. This allows us to ask questions like, “Hey, we can get you some data along the way. Can we use your personal care worker to help with a survey? Can we get your personal care worker to document a changing condition?” How powerful that information can be is really up to the rest of the partners to figure out.
Eilert: Thank you, Kunu. There’s a lot of promise in these models and we’re clearly seeing results. There’s been some recent chatter in articles questioning the viability of these models, and maybe not viability as much as unintended consequences of these models. Number one, can you truly provide the same level of care in a home setting as you can in a facility?
Number two, is there an impact on nursing in that transition? You see concerns as to whether or not this is going to lead to nursing cuts and so forth, which is a really interesting perspective. Then lastly, as you shift from a facility-based care model to a home, what kind of undue pressure do you put on those around the patient, the family, the caregiver, a family member in those scenarios? Mag, you obviously have had great success in your program. Any thoughts on these criticisms or questions that have been called out?
VanOosten: Yes, I would say I’ve had quite a few thoughts. I actually have an easier time recruiting nurses to our Care at Home program. It’s transformational. It uses the top of their license and they really work closely with their provider. I can recruit to that much easier than I can recruit to traditional home health. I would also say along that line, we’re never going to have enough nurses.
The last thing we want to do is burden a family or caregiver with taking the patient home. Part of that criteria is, is it safe for you to be at home? Do you want to be at home, and do you have help at home? Either the caregiver or the patient can opt- out. We actually have patients who come into the emergency room and ask to go into Care at Home because they’ve heard such great things about it. That’s pretty exciting. Some will ask, can the care be delivered at home? I’ll say, we started out with more of the less acute diagnosis. We wanted to make sure we could do it.
We also have criteria stating they have to live within 25 miles of a hospital because if something happens, we need to get them out fast. We’ve had patients that we’ve had to send into the hospital and they’ve been vented. We’ve had some of our more recent COVID patients that could not manage that oxygen level in the home, and we’ve had to get back to the hospital. Again, we’re talking about less than 10% of our patients. I would say we can very well manage those patients at home.
The one thing I will brag about is our patient engagement scores are over 99%. We know we’re doing it well for our patients.
Eilert: Sounds like the value prop. Are there any risks that are far outweighed in your opinion by the success of the month?
VanOosten: I don’t think we’re ready for ICU at home, but we’re definitely ready for CHF, COPD, and wound care.
Eilert: Kunu, anything you’d like to add?
Kaushal: To summarize, any of these programs are for some people. It’s for the right population. What you’re trying to do, I think, is impact the population. You can help to the same extent from a nursing home deferment program type model for us, we don’t take on everyone as a good client. People also graduate out at some point because their needs get to a spot or the family dynamics change. I would say like any other thing, you hope to make an impact with the population you can, and it’s certainly not an all or nothing type of proposal.
Eilert: We’ll talk about the payer’s role in this, and having spent some time at both UnitedHealth Group and Cigna, I think I can speak to their thought process. Let’s take a step back and talk about what they are looking to accomplish. Generally speaking, they’re trying to control and influence evidence-based care which is used more unilaterally across providers because there’s a great variance in care.
It’s critical we continue driving the consistency of care based on evidence, where possible, and also driving away from the restrictive environment of care. If you think about hospital to home to the surgery center, these are all areas where care can be delivered appropriately, but in a less confining and more cost-effective structure.
The last piece is member satisfaction, which was alluded to from a patient satisfaction perspective. Number one is the retention of those life-long members.
Assuming these models deliver on the promise of more efficient care and a better patient experience, then payers should really be lining up to embrace this. Payers and health plans are not designed for this model. They’re designed for traditional models, historical definitions of a hospital, a DRG payment, and the claims. When you blend these things, it can create some challenges in the models. Would you agree?
VanOosten: I would definitely agree.
Eilert: I thought you might. I think if there’s one thing that might slow adoption beyond ACO into the general payer landscape, it would be, can the systems keep up and the processes keep up from a payer perspective? I do think it’s possible because there already are emerging intermediaries. There are others that are bridging the gap between providers and payers trying to enable them on their way to value-based care models.
Clearly, there’s interest in these models in the marketplace. I’m going to actually quote and give credit where it’s due, the Advisory Board had a recent slide at the Care Shift Summit. Over two-thirds of the healthcare provider and payer leaders that were in attendance at that summit- estimated that by 2024 more than 10% of inpatient volume would actually shift to the home. That’s pretty meaningful. If you think about that goal in 2024, what do you see.
As the evolution of these models? How do we get to that point where 10% of volume is in the home?
VanOosten: I think 10% is certainly reasonable and it would make our CEOs or our hospitals less fearful of it. I think again, to your point, Andy, it’s that we have to get payers on board. We’re not billing it as a hospital, we’re not billing it as a fee for service, how can we bill it so that it’s based around that 30-day episode? How do we convince them we’re willing to take the risk because our numbers are so powerful and that we’re happy to stand in and take that risk? I also think we have barely begun to break the ice with technology usage.
We use remote patient monitoring and peripherals in every home that has our Hospital to Home or SNF at Home patients. I think as the wearables become more available and more robust, and we focus on robust analytics and the information we can get from those patients to see when they are at risk of needing hospitalization. I think 10% is absolutely doable.
Eilert: The use of technology to be more proactive in identifying risks like aging with risk, is a good point.
Kaushal: I would say at its simplest source, we have to find a way for personal care agencies to become good partners with dollars in mind. One of the challenges of personal care is we’re thought of last in the mix, and we know the power of having those individuals in the home. I also think there’s an overlap, when you talk about data collection, we really have to think about what is the app that a caregiver is using to do work, it has to be more than clocking in and out.
We’re already seeing some of that data collection come through, and really taking on everything from their care plan, overlaying it with visit data to care tasks that are being done, but it’s going to have to go a lot further. I also think that our caregivers are going to have a new level of education. They need training, they need to be more than a sitter service, or someone who comes in and impassively does a few tasks. In order for these models to work, they have to understand what the goals are in this home and what we’re trying to accomplish.
We can then focus on education and training for them and the technology they’re going to need. Then from a business plan perspective, for example, we focus on a program in which we have a home health agency that sends us a referral. Now we’re competing against just private pay businesses, and working the market in that way versus a business plan where someone can find the value from personal care agency. This allows personal care agencies to be part of the group instead of just an additional resource that’s thought of after the fact.
Kaushal: I think with the workforce shortages that have been occurring, you’re going to see a tail in the data that comes out through a lot of the state programs that are funded in some capacity. I think the tail of data that comes in the next two years shows nursing home utilization went up, hospital readmission of a certain population went up.
I think between the payers and this population, there’s a lot of data out there, and yet, no one today is actually digesting it. People are making decisions based on things that happened a year or two ago versus more of a real-time understanding of what needs to happen.
Eilert: The other thing that occurs is the growth of these types of models, let’s say it’s 10%. It’s going to put even more stress on staffing in these models. How do you meet the needs from a staffing perspective of that increase?
Kaushal: To Mag’s point earlier, you have to sell the model that you’re providing. I think the workforce for those who want to be part of the healthcare field and want to take care of other individuals, you have to show where these organizations or models are a much more valued partner. Some of that comes with pay. A lot of it comes with the difference of, are you expected to be a sitter today or are you expected to be part of a health program?
Eilert: Got it. Yes, an ecosystem.
Kaushal: Education also goes with that. The work force will stabilize as time goes, there’s no question around that. I have a lot of concern personally about where innovation is allowed to happen and where it is promoted to happen. All of a sudden, it is allowed when the payer decides this is a thing we should do. Yet, innovation from piloting, testing, and trying with different groups needs to be lowered down to the provider level.
Eilert: I want to thank everyone for attending this session. Thank you, Mag. Thank you, Kunu, for your expertise. Hopefully, we’re all walking away with a bit more insight into these emerging, really interesting, and very important models, SNF at Home and Hospital at Home, and maybe specifically the impact of home care and the really important role that home care plays. Thank you all for your time and attention.
Editor’s note: This interview has been edited for length and clarity.
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