HHCN FUTURE: From Crisis to Success – Unlocking the Power of Outsourcing, Insourcing, and Technology in Home Health and Hospice

This article is sponsored by CareXM. This article is based on a Home Health Care News discussion with Mike Kearns, vice president of sales at CareXM and Ellen Kuebrich, chief governance officer at CareXM. 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: What do you see as the main challenges right now in the home healthcare space?

Ellen Kuebrich: We’re in a pretty unique time, where we have more people than ever that are aging into care. We have fewer people able to take care of those, both currently with the staffing crisis. I think, demographically, we’re going to continue to have this problem because children of baby boomers have fewer kids than baby boomers did. Even if you look at the last 20 years, there’s going to be less people entering the workforce.


Even if the same amount want to get into healthcare, we’re going to have fewer people able to take care of our patients. While our payment system and our government are saying that they really value, and they see care moving to the home, we’re not getting paid as if we’re valued that way. I think the biggest problem, if I had to summarize it, would be the age-old adage that you hear all the time is we have to figure out how to do more with less.

Mike Kearns: Yes, I’d agree. Certainly, we’ve heard a lot today about the workforce shortage and the challenges of retention. That is certainly something that is weighing on everyone. We heard today that the delta right now between the pre-pandemic levels and today is around 900,000, I believe. That continues to be a significant pressure for home health organizations. Many of the customers that we talk to, that’s what they’re dealing with. The biggest challenge is how do we do more with less?

HHCN: As we’re dealing with these pulling forces of patient outcomes, staff retention, and squeeze margins, how do providers not only survive but thrive in this environment?


Kuebrich: That’s a challenge. I think if you are expected to do more with less, the only possible way that you can achieve that is through becoming more efficient. We have to find ways to create efficiencies that weren’t there before. Joyce, you said a little blurb about us in how we help providers transform how they treat the function of triage, it’s really when in what happens when your patients are calling in. We do that through a pretty unique combination of a technology layer that’s coupled with our services.

We’ve got over 100 RNs, over 450 non-clinical patient care advocates to help providers reimagine how they’re handling when a patient calls in. When we talk about how we create efficiencies that weren’t there before, I think the easy answer that comes to everybody’s mind is technology. That’s got to be our savior. AI’s coming, and it’s not going to really just figure everything out for us on its own.

I think technology is going to be a critical piece in how we address this crisis, but I don’t think it can be technology alone. There’s never going to be care that’s delivered without a human element. What I think we need to do is really find a marriage between technology innovation and that human touch to help create those efficiencies.

My suggestion, if you want an actionable place to start, is to go back, talk with your operational teams, and start looking at all of the functions of your business, all of the operational functions, and how are you treating each of those functions. Then start to organize those actions into different buckets. Where do I say I absolutely want one of my clinicians on this? There’s not a day where I don’t want my clinician touching this part of the patient journey.

Where could I use technology to handle this function? Where could I look at outsourcing somebody else to handle this function? What that exercise is going to do is allow your clinicians to breathe. We’ve got to take care of our clinicians if we want to take care of our patients. It’s going to give them the room to practice to the top of their license. It’s really going to start to create efficiencies again that weren’t there before so that we’re able to scale without having the linear function of labor backing us up. We don’t have that luxury.

HHCN: We’re focused on home health today, but this, obviously, applies to hospice as well. I’m sure some of the people in the audience as well as a lot of the attendees do both home health and hospice. Do you want to talk a little bit about that?

Kearns: Yes. Obviously, many of the customers that we talk to and that we work with are doing both hospice and home health. There’s certainly a lot of similarities and differences between them, from a patient volume and the acuity of the patients. That certainly varies across the different organizations. In order to thrive, whether it’s hospice or home health, utilizing resources, like Ellen is talking about, is important as well as focusing on quality outcomes. I think that’s really the differentiator for a hospice or a home health organization.

That’s what can help them thrive because, as you focus on those quality outcomes, the patient experience improves, obviously, their health improves, their satisfaction improves. That leads to more referrals, and it really helps you to grow in a market where maybe organizations are focusing on something else. I think quality outcomes are very important for hospice organizations to focus on.

HHCN: How can the strategic utilization of outsourcing, insourcing, and technology revolutionize the delivery of care in both home health and hospice?

Kearns: Each of them have benefits and certainly, risks and challenges. If you start with outsourcing, certainly, there’s real benefits to that. It can be a cost savings model. If you’re able to outsource some of your non-core competencies to another vendor and alleviate that pressure from your staff, that can be a huge win. Really, that is what we are positioned to do. Outsourcing also provides flexibility and scalability so that you can fluctuate up or down, depending on the needs and the demands of your patients. We do see that there are benefits to the outsourcing model.

Insourcing is a little bit different. Obviously, you have more control. As you build your team internally to solve whatever problem it may be, you maintain that quality control. That’s a real benefit to the insourcing model. One pattern that we’ve seen at CareXM is that many look at insourcing and outsourcing as a trade-off. They’re really, they’re not if you’re working with the right organization.

As Ellen mentioned, at CareXM, we’ve brought them all under one roof. We have some customers like LHC that are using a hybrid model, where they’re insourcing their core competencies, and they’re outsourcing those that aren’t. We work with them to be able to do that. We have technologies like remote patient monitoring and patient engagement to where they can utilize our technologies as well to improve communication and improve coordination across the different specialties.

That’s definitely a big challenge for a lot of these organizations because home health, for example, is multidisciplinary. It requires a multidisciplinary team that is working, in some ways, feels like silos. Having that coordination and communication, having those tools in place to be able to do that, whichever model you’re going with is critical to the success of it.

Kuebrich: I think Mike hit the nail on the head, there’s no one-size-fits-all all solution, but we have seen time and time again that pairing these together as a function, saying we’re going to insource some functions, outsource some functions, and use technology to handle some functions is consistently the most effective way. It’s going to be a combination, and it takes a little bit of work to see where it is. There’s trade-offs with all of them.

For example, if you need just some pressure to be relieved off of your staff, you may want to just straight outsource functions of your business, and that’s okay. That may be where you start. It’s always good to have an eye on a path to the future of, I just need to relieve the pressure on my staff today. I know that overall and over time, that I’m going to lose some control, I may lose some quality there, so here’s our plan to potentially insert some of that function later or to handle it with technology, so it’s more consistent.

HHCN: How long does it take investments in this area to kick in for providers? Are we talking instantaneously, two years, three years?

Kearns: It really depends on the complexity of the model that you choose. Most solutions, you should start seeing a positive impact in year one. I would say, if you’re not, then it could be a bad fit, could be the wrong solution, could be the wrong vendor, could be a number of factors. You should start to see some positive impact within year one with growth in year two and going forward. In some cases, it could be instantaneous.

As Ellen mentioned, we have customers in some cases that just want to outsource everything to us, and that has a very quick effect. There are factors that go into determining that the vendors know– you want to make sure that whichever model you’re choosing to go with that the vendors that you’re working with have a good implementation plan.

We’ve had a really strong team that can implement all of their locations, all of their patients, get them up and running. It’s critical that you have that in place. Then having the proper training for your staff. We know in healthcare that people don’t change, right? Most industries don’t love change. Having good training in place will help mitigate some of those challenges and help you get to that ROI even quicker if you can get them up and running.

Kuebrich: I would say that for all of your partners out there, your vendor partners, ROI, and demonstration of that is table stakes these days. I think we’re partnered with a lot of the vendors out there and integrated, and they fully believe that as well. Everybody knows how hard providers have it right now, and everybody is striving to help you to relieve burden on clinicians and improve the patient experience. They should all be doing that through some type of an ROI for you.

I think most of the really good ones, and there’s tons of good ones here are. Don’t be afraid to ask and push them for that.

HHCN: Ellen, we’ve talked a lot about patient engagement in past years. Why is this such an important topic at this point in time?

Kuebrich: We actually refer to patient engagement as proactive triage. We are drowning in data. I know you all are because you all have great EMRs, and you’ve got so much information about what your patients want, what they need, and when they want it. It’s really important that we do something with that data. Patient engagement is a wonderful way to try to pre-empt any event from happening. You can imagine the effect that satisfaction has on readmissions. If we’re reaching out proactively, they’re not heading back or going to the ER.

I think the problem that we see with patient engagement is it’s a really tough job to do manually. I know that any hospice provider in here wants to do a tuck-in call on every patient every night, but we can’t do that. I would love to check the schedule, make sure that everybody knows that I’m coming tomorrow every evening before I leave for work, but that’s an extra hour for my nurse every day to try to follow up and engage my patients that way.

This would be a function where I’d say, I don’t necessarily need a nurse doing that. That’s not practicing to the top of her license necessarily. That’s something I could solve through technology. We’ve got an automated patient engagement platform where you can proactively send out any type of engagement that you want to your patients. Again, we’re giving our nurses back a little bit of time in their day, and we’re just re-bucketing.

HHCN: Potential obstacle with outsourcing, insourcing, and technology implementation?

Kearns: Again, depends on which model you’re going with, but we’ve talked about the benefits of outsourcing and how it can save you money. One of the downsides is you give up some of that control. From a quality perspective, you’re now reliant upon another vendor to maintain that same level of quality. We’ve always said that we believe the best people to provide patient care to your patients are your nurses, it’s your staff, it’s your team, so we really try to live that.

All the solutions that we’ve built are built around that thesis that we want to encourage your patients to communicate with your team as much as possible so that you don’t lose that level of quality. When they’re unable to, when they’re in a death visit, when they’re on a call with another patient, our team can back them up, and that maintains that high level of quality within your group.

Certainly, one of the risks that you see from an outsourcing model when you’re dependent on external vendors, there’s always a risk from time to time of there being a disruption in service, which can have an effect on your patient’s care. No one is without that. There’s a hurricane hitting Florida right now, and there’s going to be disruption in service. That’s definitely one of the downsides of an outsourcing model.

In a lot of cases, you have to overstaff to meet the demands of your patients, and that gets very expensive. Many of the customers that we start talking to, that’s the first thing we look at, is we provide a free consultation for all of our customers before we ever sign on the dotted line as it were. We walk them through what that cost is on a per patient per day basis, so they can compare it to solutions that they’re considering.

Certainly, when you have that level of staffing, you have to make sure that you do have a plan in place to retain that staff, and that is one of the risks and challenges to the insource model. Like we’ve talked about, it doesn’t have to be mutually exclusive. You have the ability to leverage both through the models that we present.

Kuebrich: If you know that the risk of fully outsourcing is that your quality could suffer, I would make sure that you’re getting a lot of data and reporting on that outsourced function so that you can consistently monitor the quality, make sure that you’re using it for quality assurance, performance improvement, put a PIP together if you need to. I also think technology is a way to mitigate some of that risk, where it makes it hard for your clinician or an outsourced clinician to do the wrong thing.

If we can keep them on a straight and narrow path that we want them going down in terms of care, you’ll be able to mitigate some of those risks. I think those are the right risks to consider in any of those models.

HHCN: Can each of you just get into some of the detail around that? Maybe, Ellen, we’ll start with you.

Kuebrich: Elara Caring is one of our customers, and they use us for remote patient monitoring and patient engagement. One of the things that we’ve really found with them is that they’ve benefited through the fact that we believe that there’s not one size fits all, especially when it comes to remote patient monitoring. A lot of that has to do with access to care because you may have a patient that doesn’t have WiFi or one that doesn’t have a good cell signal, one that doesn’t know how to use a tablet and do not make them try to use a tablet.

We have to find different solutions that work within the same platform that meet the patients where they are and what they are comfortable with. That’s how it’s successful when your patient uses patient engagement. They use the model where they use our technology platform, and then they insource the monitoring. Even though they could use their people if they wanted, they really have a tight hold on that. They’ve been able to reduce readmissions by 30%, and that’s been in the last eight months.

Again, when we talk about the ROI and being able to have that come to fruition, it’s really a good marriage when you have an amazing partner like Elara. I will tell you, though, one thing that they’re really good at, and I would encourage all providers to do, is talk to your vendors like they’re your partners and ask them for what you need. Let us know where their struggles are because we’re always wanting to try to cement the relationship and help this be a successful room.

HHCN: I think that’s a good point in just viewing it as more of a partnership. Mike, did you want to weigh in on this as well?

Kearns: For those who were at Home Care 100 earlier this year, hopefully, you had a chance to see when we had Carla Davis from LHC provide feedback on our pilot with them. Since then, we’ve been able to expand our solution across the entire LHC organization hospice, and now, we’re looking at home health as well. This is regarding the triage service that we were able to provide.

When LHC came to us about a year ago, we started working with them in August of last year. We created a pilot that focused on providing services to 17 locations, about 1,600 patients, and it was really that heart of the hospice group that they had acquired. We’re working very much with Carla Davis, and she’s been just a phenomenal partner for us. They were dealing with the same challenges that we’re all seeing, the labor costs, how do we drive down our labor, the constraints of the market. Certainly, the quality was a big concern for them.

They felt like, in an after-hours triage setting, they weren’t able to answer all of their calls, they weren’t able to answer them timely, and the patient experience was really struggling. We implemented the hybrid model using CareXM smart staffing. Many of the groups that we talk to come to us saying, “I can’t hire enough people to cover my calls.” That’s because what they’re trying to do is staff for their peaks. They’re trying to staff for the worst times, Saturday, Sundays, when patients are calling in. You have to overstaff for that. We know this from a decade-plus of experience.

As Ellen mentioned, we have a team of over 100 nurses ourselves. All of the pains that you’re experiencing are pains that we’re also experiencing. We’ve just gotten really good at managing it. They were dealing with that, and they were trying to figure out how many people we needed to hire. We showed them, through a flexible hybrid model, where we can send the call to them using our technologies when a patient needs help, they’re able to get ahold of their nurse. When the nurse is unavailable, we back them up, which happens about 15% of the time.

With our technology, they receive the calls, they take the calls when they’re available, they’re documented in our platform, which has an integration with Homecare Homebase. Then, like I said, about 15% of the time, the call flows over to our team. Because we were able to do that with them and show them how to become really efficient, they were able to see substantial savings.

About a 40% reduction in capacity allocation of nurses, meaning they didn’t need as many nurses to take the calls as they were planning on, so they didn’t have to hire as many people through our time. They saw reduction in actual patients contacting LHC of about 30%. You’re driving down the number of times that patients feel like they need to call in. You’re doing it at a cost savings of close to 40%. That, obviously, led to a significant increase in nurse satisfaction.

They ran internal surveys and saw that their nurses were happier. Then certainly, the patients were happier. A model like that with LHC has been very well received, certainly, but had significant ROI that they were able to see within the first six months. Now we’ve rolled it out across the entire hospice organization, and we’re rolling into home health next. A real win for them, and it really validated a lot of what we had shown them beforehand.

HHCN: Thank you both for going into detail about that. Mike’s really speaks to what you were saying before about when you start seeing ROI within that year. I want to read something that I read from CareXM. “Clinicians need innovative approaches to reduce or eliminate off-hours documentation and restore work-life balance while increasing the quality of documentation, which, in turn, leads to better patient care and reimbursement.” We’ve talked a lot about these things, innovative approaches already. Is there anything else? I want to turn this one to you, Ellen.

Kuebrich: Yes, I would say, integration, integration, integration, get your technology partners to integrate. They all do wonderful things. It reduces nurse documentation when they’re talking to each other. We have integrations with almost over 25 EMRs. We have information flowing one way to them, our nursing notes are going back in, we’re getting patient demographics and medications, and again, anything that you can do to reduce the chance that a nurse or a non-clinician will make a mistake, the better.

I think that technology is a really good way to solve that and keep them on a path, so these clinical pathways that we have developed. I also think that we will always say, there’s a human element to care, and technology will just augment your team in the best way possible. I think it’s also really important for us to not just put a focus on how we’re getting paid through value-based purchasing with readmissions and patient satisfaction, but also, just consider how clinician satisfaction and care of our clinicians impacts that patient care and our patient outcomes.

If we can give them the bandwidth to not feel like they’re pulling their hair out, or they’re elbow deep in wound care and their phone’s buzzing in their pocket, and they don’t know which choice to make and which patient to prioritize, a happy clinician is going to give worlds better care that you will want that for your teams as well. I’d say, anything that we can do through technology to eliminate parts of their job that you don’t need them to do is great.

HHCN: What current crisis have we talked about today that you see as the industry’s biggest opportunity?

Kearns: I’d be curious if everyone agrees, but I think it is the workforce shortage and retention that’s putting just increased pressure on every organization, and there’s no end in sight, as certainly as the population is aging, as disease prevalence continues and a chronic setting, it becomes very difficult to manage for this increased population that we’re seeing. It’s important that whichever model you choose, or a combination of models, that the organizations are well positioned to do that.

As we’ve mentioned, we have a team of 100 nurses. We have a tech-enabled service that we can provide. As you’re talking about just the benefits of the different organizations, certainly, one advantage to CareXM is we brought it all under one roof, and there’s a lot of those challenges we solve for. That is going to have a positive effect on your workforce. Again, we have our own team of nurses and we’re listening to them, and we’re innovating based on what they’re telling us.

We’re building platforms by nurses, for nurses, by providers, for providers so that we can help solve those problems that you’re experiencing. I think that that does help with retention. That does help as you’re hiring. We’ve heard from some organizations that one very large organization, actually, said that they feel like that because they’re using our platform, they’re shaving off up to two hours of unnecessary repetitive admin work, logging into this system adding notes, logging into the system adding notes.

There are real efficiencies gained from having the right technology partner that can benefit your organization. I think that that helps mitigate some of those challenges that we’re seeing from a workforce shortage.

HHCN: We’re at the point where I want to start wrapping the conversation up, but before we do that, Mike, can you tease some of your company’s main priorities for the year ahead?

Kearns: Yes. Similar to what I just said there, we are constantly innovating. Patient engagement was a big rollout for us this year. We worked on certainly improving our technology to meet the demands of Elara and Inhabit and other organizations that have started using our platform. We have technologies that are built by nurses, for nurses. We want to make sure that our solution fits within hospice and home health. Next year, we are rolling out even more technologies that will, hopefully, improve that and make the experience better for your patients.

Then we also work with many of the vendors that you see here today and really improve our integrations, so we’ll continue to do that as new technologies are developed outside so that our customers, that work with CareXM, have access to others as well.

HHCN: Ellen, what’s the overarching message that you have for our attendees today regarding where their priorities should be headed as we look on to 2024?

Kuebrich: I agree with Mike that the elephant in the room, the biggest crisis is the staffing crisis. Taking a good hard look at ways that we can address that, I’d say, treat everybody that’s here at this conference or any of the conferences that we all go to as your ecosystems. While I realize, there’s competitors on the vendor side and competitors on the provider side, we really are all trying to innovate into the same direction.

I’ve seen so much good come from leaders in the industry that are collaborating together and really putting their heads together on how we solve this problem from marching on the hill, which we heard a great talk earlier about that on how we can all be better advocates to supporting these associations that are advocating for us, but I would say, take a look at technology, where can that augment my nurses time, where can it take something off their plate?

Take a look at insourcing, where do I definitely not want to take this function away, and then take a look at outsourcing is, where would I feel comfortable? If I had control, and I was monitoring them with data and solidly integrated programs, I could trust a partner to take on this function for me.

CareXM is a patient engagement platform that acts as an intelligent, virtual nurse call button whose mission is to care – about the patients, staff, and business of healthcare partners. To learn more visit: https://www.carexm.com/.

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