How Amedisys, SSM Achieve Success With Disease-Specific Care Models

This article is a part of your HHCN+ Membership

As the demand for personalized and effective health care solutions grows, home health care providers are implementing more sophisticated approaches to particular diseases.

Today, home health care professionals can manage conditions such as strokes, heart failure and cancer, achieving successful patient outcomes and bottom-line benefits; however, reimbursement cuts pose a challenge.

“We determine which conditions to focus on for our disease-specific care programs through evaluation of high-volume conditions or those that we’re seeing patients re-hospitalized frequently for,” Jennifer Conley, system director of home health at SSM Health at Home told Home Health Care News.

Advertisement

SSM Health at Home offers home health, palliative care, hospice and home care services in Illinois, Wisconsin, Missouri and Oklahoma.

“We believe that by integrating standardized best practices specific to each disease into our care delivery, we can empower our patients with the knowledge and tools they need to recognize and manage early symptoms,” Barbara Andazola, vice president of clinical practice, strategy and programs at Amedisys, told HHCN. “This approach helps prevent acute exacerbations, avoid unnecessary hospitalizations and minimize long-term complications, ultimately improving their overall quality of life. Each program includes a disease-specific emergency medical record (EMR) pathway, patient self-care guides, informational placards, success logs and educational resources for clinicians.”

Amedisys (Nasdaq: AMED), headquartered in Baton Rouge, Louisiana, provides home health care, hospice, palliative care and high-acuity care services in 38 states. The company offers specialized programs for managing diabetes, heart failure and chronic obstructive pulmonary disease (COPD), as well as a safety program focusing on fall prevention.

Advertisement

Disease-specific care offers patients improved quality of life and greater independence, according to Andazola.

“A key component of our program is recognizing the uniqueness of each patient, family and caregiver,” Andazola said. “We begin by identifying the patient’s goals and their understanding of their disease process. This allows us to sequence our interventions and develop an individualized plan of care tailored to the patient’s specific needs.”

Developing disease-specific caregivers

The caregivers involved are also carefully selected and trained for their roles, both Conely and Andazola said.

“Our staff have ongoing education annually through our online learning platform at a minimum,” Conley said. “Throughout the year, we watch our patient populations and elicit information from our clinicians about what education they feel would be most beneficial to receive. In prior years, we have developed chronic disease modules, which remain excellent resources for our staff.”

SSM Health at Home also partners with educators and uses online education portals and resources from organizations like the American Heart Association.

“Each clinician must complete mandatory learning and relevant skills validation both upon hiring and annually thereafter,” Andazola said. “Our disease-specific program materials are reviewed and updated as needed by our corporate clinical multidisciplinary team at least once a year and whenever advancements in care or standards are published. We provide supplemental training for clinicians and patients when updates are necessary. This typically involves live training sessions and skills validation for clinicians, which may include partnerships with product manufacturers or service providers.”

This type of specialized care is just one aspect of the continuum of care that patients require for optimal outcomes. SSM leverages local liaisons to help coordinate disease-specific care across patient populations, involving leaders at care centers and in regional roles to help develop strategic plans, including care protocols and reporting parameters.

Andazola noted that Amedisys’s disease-specific protocols can be customized to meet the needs and preferences of the ordering providers.

“For each program, we routinely monitor key clinical outcome measures, including emergency room or urgent care usage, hospitalizations, increased patient participation in activities of daily living and overall patient satisfaction,” she said. “Key factors in the success of disease-specific care include identifying patients’ current health status and goals. We need to actively engage patients in developing their care plans, even if that involves coordinating with or transferring care to another provider or setting.”

Financial benefits and challenges

Reimbursement is one of the most significant challenges for disease-specific care right now, Conley said. Cuts in reimbursement from the Centers for Medicare & Medicaid Services (CMS) and other payers lead to an imbalance between the cost of care and the reimbursement received.

“CMS initially proposed a 4% cut in home health payments for 2025 and has been consistently cutting home health reimbursement since 2020,” Conley said. “This has been detrimental for home health agencies and led to fewer visits and even closure of hundreds of agencies. We must be creative in providing exceptional care with diminishing reimbursement.”

However, she emphasized that patient experience and care should be prioritized before considering economics.

“It is in the patient’s best interest to have [their caregiver] focus on disease-specific care so they can be empowered to manage their own health,” she said. “Economically, however, there is a benefit through preventing readmissions to the hospital, [as readmissions] could lead home health agencies to receive financial or quality penalties, as well as helping patients participate in managing their illness.”

When it comes to keeping patients out of the hospital and avoiding readmission, Conley said her agency maintains connections with hospitals and long-term care high-performing networks (HPNs) to ensure that patients receive the highest level of care appropriate for their disease management.

“Communication about patient care across the whole care continuum is key, and our home health teams routinely participate in hospital-led, long-length-of-stay and readmission committee meetings, as well as connect routinely with our HPN partners around key performance indicators,” she said.

A primary metric for SSM Health is the rehospitalization rate, according to Conley. A key focus is onpatients who are hospitalized once and at high risk of being readmitted for the same reason within 30 days of discharge.

“We look at our patients who re-hospitalize and try to find out the why behind that and prevent it from reoccurring,” she said. “We look for trends and preventable occurrences and learn from them. We also look at the patients who do not return to an inpatient setting and learn from what went well in that instance.”

Broadly, chronic conditions and fall-related injuries significantly impact annual spending for Medicare, Medicaid and private insurance. For the health care system, a focus remains on reducing overall costs, enabling a limited workforce to manage acute illnesses and prioritizing wellness and prevention. So, value-based care models and Medicare Advantage payers reward home health providers that achieve quality outcomes while managing costs, including through the reduction of expensive interventions such as hospital readmissions.

“Improved patient self-management and participation in wellness and illness prevention will naturally decrease health care costs for an overburdened health care system,” Conley said.

Companies featured in this article:

,