HHCN FUTURE: Addressing Home Health Agency Readiness for Potential Payment Cuts in 2024

This article is sponsored by nVoq. This article is based on a Home Health Care News discussion with Jason Banks, VP of Post Acute Business Development at nVoq and Jennifer Maxwell, CEO of Maxwell Healthcare Associates. This discussion took place on August 30, 2023, during the HHCN FUTURE Conference. The article below has been edited for length and clarity.

Home Health Care News: Can you provide a brief background for the audience on yourselves and your company? Jason, we’ll start with you.

Jason Banks: I’m the Vice President of Business Development for nVoq. nVoq is a speech recognition provider in the home health and hospice space. My background is in technology in the post-acute care space. I’ve been in the space for a little over 20 years. Having run a provider for about two and a half years I know how difficult it is for the folks here at the conference in the room. I’m excited to talk more about how organizations survive and thrive under some of the headwinds that they’re facing and look forward to the conversation.


Jennifer Maxwell: I am co-founder, CEO and a counselor in the mental health acute hospital space. From there I moved into home and community-based services, all the 1115 waivers in the state of Colorado, and oversaw the Adult Protection Area Agency on Aging and other adult services programs. From there, I moved into the trade association space and was the CEO and executive director for the Minnesota Home Care Association.

For about three and a half years after that, my husband and I became business partners. I did a small stint in sales in corporate, and we decided to start Maxwell Healthcare Associates. We are a post-acute care, home health, hospice, and palliative care consulting firm. We cover all 50 states and all payer sources as well as private equity and technology.

HHCN: Given the tightening of the belts, everyone’s trying to become more efficient, but also trying to cut back on cost. What is the value proposition? How do you convince someone that it is the time to invest in a tool like nVoq?


Banks: We’re in a cycle. The cycle never really stops, right? You’re going to have up periods, down periods, you’re always going to face reimbursement challenges and regulatory challenges.

The interesting thing that I see is that there’s always an uproar when it comes to payment cuts. No matter what, if there’s a payment cut or even an increase, that’s not to the level that the organizations in our industry find acceptable, which I don’t think there’s ever been one that’s been acceptable, then there’s a huge uproar about it, right?

There’s not the same uproar as it relates to regulatory compliance and regulatory burdens that CMS continues to come out with, and I find that interesting. I know we have comment periods on some of the proposed changes to regulatory. I don’t see the same level of outrage on the regulatory changes that are occurring.

I think there’s so much there in terms of burden that’s put on the individual clinicians from a regulatory perspective. Let me just give you one example. When we had to comply with the addendum on uncovered services, it placed undue burden on the provider, on the clinicians, on the entire system. We were covering much of the non-primary hospice diagnosis stuff anyway.

I feel like there’s just not enough visibility put on the regulatory compliance, and I know there’s a whole cottage industry there focused on OASIS answers and how we answer those questions and staying aligned with care plans, and if you watch a clinician, whenever you say the word care plan, their eyes start to roll in the back of their head.

I think that nVoq has a value proposition in multiple areas, making clinician workflow more efficient and improving the quality. Most of the technology that is out there, and the EHRs do a great job, we’re partnered with most of them, they do a wonderful job at keeping the organization in regulatory compliance as it relates to the documentation. There’s a gap there in efficiency, right? A lot of times with technology, there’s a trade-off.

The more efficient you make the clinician, quality suffers or the higher the quality they suffer from an efficiency perspective. nVoq is unique in that we’re making it faster for clinicians to document, which ultimately will result in less burnout. There are studies out there that state after-hour documentation is the number one cause of clinician burnout. We feel like we make a significant difference there, but also in the quality of the data as well. Those are the main value propositions that we’re looking to drive.

HHCN: From the consultant perspective, how do you explain why investment matters even in times like this where cuts are occurring?

Maxwell: That’s a great question. A lot of the work that we do, we’re going into organizations and we’re figuring out how to strategically align the innards of the organization, all the operations, the people, the workflows, also quality and bottom line is your DSO and cash flow, right? When we think about all of those things, timely, effective, efficient documentation that meets, as Jason said, the regulatory requirements, that gets into the EMR in a timely fashion and is up to date, provides a much better reimbursement potential and a quicker reimbursement potential.

If you know that your clinicians are working off of narratives that are highly detailed and using an assistive technology that helps to maybe remind that clinician, “Hey, did you ask that question? I don’t think that one was finished in the OASIS set.” Those are some of the things, and especially on the home health side, that really help.

I would also say to the point of documentation outside of the home, if you’re documenting after-hours and you’ve had six or eight visits throughout the day, and you’re coming back and trying to remember what you did with your first patient of the day at eight o’clock at night, after homework, after swimming lessons, and whatever else it is, that quality of documentation, and what you remember is not going to be as accurate as it should be.

Which increases your issues with, is the plan of care being followed correctly. Are you seeing things that potentially this patient might need sooner than later? Then the care teams are not aligned either. When you think about being able to bring in that technology to document quickly, being able to be less distracted when you’re at the patient’s bedside as well. Then my last piece to that is quality of care goes up, and patient satisfaction.

We all know that patient satisfaction is going to be a big deal because that’s your star rating. That’s what CMS is looking at the end of the day. If you don’t have good satisfaction scores, you’re also going to have the issues with payment as well down the road.

HHCN: Jason, you said earlier that you admitted that you were biased. Can you provide evidence of how this can make home health agencies more efficient during a cut period?

Banks: We’ve actually done a number of formal and informal studies over the last two to three years in working with organizations around improvement in DSO. How quickly are we moving from care to the bedside to reimbursement for that care? We’ve been able to improve DSO in a lot of cases by speeding up the documentation, but also moving it closer to the actual patient visit itself. You see things like NOAs getting sent out earlier, QA processes getting sent out earlier, and the QA process not being as back and forth so it can lower QA costs.

Then, ultimately, we’re seeing a tremendous impact on clinicians’ satisfaction, which ultimately we’re tying to retention. We just recently worked with an organization that saw the clinicians that were using our speech recognition engine tool about a 20% reduction in turnover. As I look across the industry, there are a number of things that organizations can do to help with clinician shortage and clinician burnouts. Not a lot of them, though, have a direct impact to the clinician the way that speech recognition does.

We have organizations today that are producing video testimonials from their clinicians saying, “Hey, with this tool, I’ve been able to save 20%, 30% of my charting time.” If you look at an industry average of home, health and hospice, the average amount of documentation as compared to care, is about 20% to 30% for a routine visit and upwards to 50% to 60% for an admission visit.

It’s a significant amount of time, which also means they’re saving a significant amount of time. Those organizations are using those clinician testimonials as recruiting tools. I don’t think saying, “Hey, we’re investing in our clinicians.” Again, I don’t think speech recognition is the panacea for everything, but it is an important thing to directly impact one of the biggest burdens that clinicians face, which is the documentation time.

HHCN: Sometimes it’s a better place to start with retention than recruitment, trying to keep the clinicians that you do have. Do you see this as something that can really be leveraged to help home health providers hold on to their clinicians longer-term?

Maxwell: Absolutely. What we’re seeing when we work across organizations, some of you have obviously state regulations and overtime and a half after hours for documentation. Some of our larger clients out in the California area, anything after 5 PM is paid at time and a half. Also, they are struggling to be able to get their family life and work-life balance into play. What we’re seeing is if they’re doing it during the workday or even as much as you push the button and you’re talking into the microphone in your car, into the mobile device.

Being able to get that taken care of before you get to the next home is a greater level of satisfaction to clinicians, is what we’re finding. Those that leverage speech-to-text technology such as nVoq really do save that time throughout the day. We’re able to bring in more admissions, be able to move clinicians quicker through different processes without them feeling the stress of, “Oh my gosh, I have all of this paperwork to do, and all of this documentation.

They are really feeling satisfied with the work they are doing, and they are feeling like they are providing the care that they set out to be a clinician for and being able to work at the top of their license rather than sitting behind a computer and typing.

HHCN: For both of you, how much time do you think this can save on a daily basis for clinicians?

Banks: It depends. For instance, we’re seeing upwards of 45 minutes to an hour savings on every admission visit from a documentation perspective. Then, on more routine visits, subsequent visits, we’re seeing in the area of 7 to 10 minutes saving per visit on the documentation side. It does result in significant cash flow improvements, ROI improvements, significant savings on turnover, etc.

There’s a very strong ROI component. Usually when we start working with home health or hospice organizations, they intuitively get a lot of head nods from the clinicians and also the IT department, they intuitively know that this is the right thing to do. It’s normally getting over that ROI hump with the financial buyer, whether it be the CFO or somebody else within the organization, if she is focused on how is the ROI going to pay for itself, that’s typically where we are spending the most time, I would say, again, that a lot of the clinical leadership, they just intuitively get this right off the bat.

HHCN: Even if the ROI is there at a time like this when providers are busy, how do you help them get through the burden that is applying any new technology to their business. I imagine that’s not an easy process, especially for some of the agencies that are short-staffed, and don’t have a person on board who specifically has that job. What do you do to help them ultimately get that to be a part of their business without it really hurting them in the short term?

Maxwell: I think that’s where the partnerships come into play. MHA is a partner with nVoq. We actually, in the client life-cycle of working with organizations, to your point, boots on the ground within any one organization to implement a series of technologies. We strategically align the technology at the right time. When we’re hitting an efficiency level within the organization in a specific type of workflow, then we feed in the voice to text.

We get the organization bot on board and trained on what the new process is going to be prior to just slapping the technology on them, because at that point, they haven’t really had a chance to absorb it, be able to talk about it, and have true buy-in, because there is a team focus when we look at organizations as a whole. Then as we work individually with clinicians and chaplains and therapists, there’s a different angle that they’re all coming at, “What is it in it for me? What is in it for my patients?”

They have a smaller ecosystem than the larger ecosystem. We really sit down and walk them through the why, not only the how, and then show them what those results will be, not only for themselves, but for their clinical teams, for the outcomes of their patients, and for just overall work-life balance.

Banks: It’s about getting the most value out of the tool. It’s exactly where they have executive-level buy-in, exactly where they have Maxwell’s help in terms of change management or getting clinicians the information on what’s in it for them. Why is this important? In addition to the how. The how is fairly easy to figure out. I always talk about this.

Clinicians do an amazing job in our industry, but there’s a certain percentage of them that don’t have five minutes to go to the bathroom in a day. Introducing a new technology is like it’s so difficult unless you convince them that this is in their own best interest. Maxwell does a great job of that, but also preparing the organization to say, “Here’s what we need from you in order to be successful as well.” I think Jen put it great.

HHCN: Jason, how do you differentiate yourself from other companies in the industry?

Banks: I think we’re really focused on moving the needle for the individual user, for the provider organization. We really want this to check all the boxes when it comes to technology and how it’s going to produce an ROI for an organization, but also how it’s going to influence that individual clinician. I can tell you that every day when we have these listening sessions that we do with clinicians, they tell us, “It’s changed the way that I feel about my work. I feel like I get to spend more time with my patients, which is why I got into this industry,” and Jen talked about it earlier. These are special men and women that get into home health and hospice.

The whole reason why they get into this industry is because they’re relationship driven. They’re not transactional individuals. When you take that relationship aspect away because they’re so worried about, I’ve got this much charting to do at the end of the day, and I got to get to my next visit, and my next visit, and they’re not really present at that time, it’s taking a lot of that satisfaction away from them. Even if we’re making a dent in that, and I think we’re doing much more than that, it’s really beneficial.

Partnering with leaders who understand the industry like Maxwell is also a differentiator for us. We know that Maxwell understands exactly the needs of these organizations and how to impact change within them. I think that makes us different as well.

HHCN: What does the integration look like in current mainstream EMRs?

Banks: We are integrated with a number of EMRs. We also are available as a standalone offering. We actually integrate with the operating system, so Windows and Android devices. If your clinicians are using iOS, we would integrate with the EHR side. All of that behind the scenes is very, very simple. The technology is simple to deploy and, operate. We work in SSO environments, clinicians have a real seamless experience. IT can push it out via mobile device management or whatever tools they have to deploy it.

We try to make that as frictionless of a process as possible so that we can focus on leveraging Maxwell to get these in the hands of the clinicians. We don’t have any technical barriers that we have to jump through to get there.

HHCN: Jennifer, what other areas should home health agencies focus on improving or automating through technology?

Maxwell: I would tell you the world of technology and tech-enabled solutions is definitely top of mind, top of priority in our space. If you think about all of the technology that’s out there in different verticals, whether it’s when it comes to technology and automating things, that we’re starting to see more of a flood. I think when you think about technology, you need to think about what it is that you want to solve. What’s the problem you want to solve? What is the ROI that you need out of it?

We’re of the mindset that good technology will pay for itself, right? If you think about ROIs on technology that’s out there, a technology that should cost you a lot of money, but it’s not going to pay for itself and you’re still going to have to have money out of your pocket probably isn’t the technology that you want to use, go forward. We’re always thinking about those types of things that ROIs, the different use cases.

Even when we think of nVoq as a use case, some of the use cases that we’ve come up with is, “Hey, why aren’t you using nVoq for your QAPI program? You can do batch audits; you can automate things even further. I’m a strategic advisor and owner of another technology and data science AI company. When you think about the data that can go in and what the possibilities are coming out of in an automated fashion that really delivers better quality outcomes for patients is really where we’re headed, right?

It’s not about, okay, we’re going to cut a bunch of jobs. It’s about how we don’t have the clinicians coming out of school anymore.

The volume that is required to take care of the people that are going to be needed to be cared for is the numbers that don’t match up. We got to think about technology from a holistic pattern, whether it’s workflows, whether it’s speech to text, whether it’s data science and AI that can do predictive analytics for patient outcomes and visit scheduling.

There’s a plethora of those things that are out there. I always tell everybody, think about it and think about what you want to be strategically in the next one to three years as we see these cuts coming.

HHCN: Jason, does nVoq have any translation services from Spanish to English?

Banks: We don’t at this point in time, we do handle accents and dialects very well though. What I find is, I slur my words together, [laughs] I find that even clinicians with ESL (English as a second language) actually do really well with the tool because they have good word boundaries. Really, it does an excellent job. We work with clinicians all across the country that have various beautiful dialects and accents and the tool does really well with them, but we don’t translate just yet.

We’re also experiencing new models where we go out and we’re doing this with a couple of providers today where we’re implementing speech recognition as a part of their EHR rollout.

The clinicians just intuitively take to speech recognition thinking, “Well. I guess this is how we do our dictation. How we do our documentation, we just do it via dictation.” We’re seeing tremendous value and uptick there. As they’re learning the new EMR, they just roll in speech recognition like it’s a natural part of the process. We’re seeing that that makes a tremendous difference. Versus, again, you’re disrupting them multiple times if you’re rolling out a new EMR and then you’re trying to add things on top of it.

HHCN: Once a home health agency does sign on, what does the clinician adoption rate look like?

Banks: Typically, you’re going to get 60% to 70% adoption right off the bat. Then it’s really about creating that model that is sustainable to get to 80%, 90%, 95% adoption. We have clients today that are well above 95% adoption rate, but that’s where Maxwell comes in. They understand how to organize and get the organization ready and make sure that they have the executive level buy-in, and they have a plan to roll this out. Again, a lot of it is about the why, as you pointed out earlier.

nVoq Incorporated provides a HIPAA compliant, cloud-based speech recognition platform supporting a wide variety of healthcare delivery scenarios including post-acute care with an emphasis on home healthcare and hospice. To learn more, visit: https://sayit.nvoq.com/.

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