How A Home-Based Care Provider Weans Itself Off Fee-For-Service Reliance

Not even two years ago, Alivia Care CEO Susan Ponder-Stansel was open and honest about the challenges her organization would face on its journey toward risk- and value-based care.

Now, it’s still on that journey, but much further along. The company’s story is one of promise, one that shows home-based care providers can become risk-bearing entities that have a larger control of their financial futures.

“We really believe that that’s going to be the way that you succeed financially,” Ponder-Stansel told Home Health Care News. “And, also, how you succeed in being able to deliver better outcomes to seriously ill patients.”


The Jacksonville, Florida-based Alivia Care provides home health care, hospice care, personal care, palliative care, advanced care planning and other services across Northern Florida and Southern Georgia. The company has its own Program of All-Inclusive Care for the Elderly (PACE), and plans to open another in due time.

Ponder-Stansel sat down with HHCN and its sister site, Hospice News, to chat about that value-based care journey – and more – last month at Home Care 100 in Scottsdale, Arizona.

The conversation is below, edited for length and clarity.


HHCN: What are your company’s biggest focuses for 2024?

Ponder-Stansel: What we’re really focusing on is standing up value-based care.

We really want to be behind those at-risk physicians in those REACH ACOs, or working with them and figuring out how to be a partner. We’ve been preparing for this for years, that’s what we’ve been doing. And it’s a big opportunity.

So, you’re looking for the best at-risk partners?

That’s right, and we’re also already at risk through our PACE program.

But we’d like to partner with them. We really believe that that’s going to be the way that you succeed financially. And, also how you succeed in being able to deliver better outcomes to seriously ill patients.

And I think that when you’re in any kind of value-based situation, you do need all the components – the private-duty, the Medicare-certified hospice, adult day care, all parts of that care.

Take PACE, for example. It’s a longitudinal service, there’s many mature programs that have had their participants for 10 or 15 years. You’re managing them to keep them in the community and out of long-term care. Now, they may go into long-term care intermittently after a hospitalization, but they’re not custodial. They’re not living there.

You need different tools to do that.

Now, the challenges are that there’s so much consolidation, and so many big companies with a lot of PE investment. We’re a nonprofit regional, so you’re always weighing and balancing how fast you can get your solution to the market without having to merge or take on additional capital. But so far, we haven’t had to go that route.

With some of the cuts coming to home health, and the costs of labor, we’re seeing some margin compression. So we know that the fee-for-service business is probably not going to get us where we want to go.

On the other side of that coin, with value-based reimbursement, there can be lower reimbursement rates there, too. How do you offset that?

It depends on which value-based program, because there’s so many flavors of that.

In PACE, for example. In Florida, Medicaid rates are terrible. That’s why we haven’t had much competition in PACE down there.

But these are dual eligibles. So for almost all of these, you’re looking at their HCC scores. You’re getting your monthly payment – your per member per month – based on their acuity, and then it’s up to you to manage everything, whether it’s a heart transplant or dental care.

That’s the point that I like about it, Special Needs Plans and D-SNPs and the I-SNPS, you get that bucket of money and you get to make decisions based on patient needs without going back for pre-authorization.

It is upside and downside risk, and you really have to have some good AI to help you understand who’s in your population and make sure that you’re meeting that need. It’s about recognizing that risk, and not just giving one visit per week, for example.

We learned the hard way on PACE, and finally have a margin there. It’s year four. If you can manage PACE – because you’re basically a health plan at that point – it really is the best way to manage people with advanced and chronic illnesses.

How specifically are you using AI? Is it table stakes moving forward?

Yes, I think you have to be invested in it. And you have to be intentional about what you need it to do for you.

And part of the challenge is getting the data quick enough.

We want to really be able to stratify risk and create a patient profile. There are certain algorithms that you can develop to say, “Okay, when these particular things happen, you need an extra visit, you probably need to do a med rec.” Because all those things downstream help prevent that rehospitalization, help prevent that adverse outcome. So that’s what we’re looking at.

With the type of risk- and value-based care success you’ve now achieved, does success now beget success, in that you have the proof to show off?

Yes. That was deliberate on our part to do PACE first, because it’s a program that has a structure, a payment system that serves the population we wanted to serve.

We figured if we were going to jump in, we should learn how to do that. And that was a really good decision on our part.

But you have to have a certain scale and the capital to be able to do that in the first place.

This movement toward these at-risk relationships seems kind of necessary to survive in today’s environment. Are you excited about that opportunity? Or are you more worried about it?

Both, obviously. But I really believe that if we have the funds, and do that good, patient-centered care without having to go ask for things from [third parties], we can help people that have these serious illnesses have better outcomes. And that’s the care that gets me going.

You’ll make some margin if you do it well, too. And that’s necessary, but honestly, if you can create that person-centered care based on what you think is best for the patient and build a better system, I think that’s most important.

Because right now, it’s so transactional and so fragmented. You can look at claims data and see what happens to older adults with serious illnesses. And we all lose when there’s low-value care provided. So there’s an altruistic motive too. Plus, I think we’re going to die if we just stay in fee for service.

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