Inside the Future Of Contessa Health And High-Acuity Care at Home 

When Amedisys Inc. (Nasdaq: AMED) acquired Contessa Health for $250 million in 2021, it changed the home-based care landscape. While other companies had been toying with high-acuity care in the home, that deal sent a clear message: Home-based care was becoming more than just Medicare-certified home health care and personal care services.

Since that point, Contessa Health has had to fight an uphill battle. With any newer service, health systems and payers need to be convinced of its worth.

The company has built up enough data now to prove the value of services like hospital at home and SNF at home. Contessa has additionally invested in palliative care, which is also becoming an important service now that value-based payment models are emerging.

Amedisys leaders have been mostly quiet over the last year and a half due to the pending deal with UnitedHealth Group (NYSE: UNH). But they’ve still released quarterly earnings because of their status on the public market.

Those reports show that Contessa has been growing census and revenue considerably over the past couple of years, and looks as if it’ll be one of the best examples of success when it comes to alternative care models within the home.

I recently caught up with Robert Moskowitz, the chief medical officer at Contessa. We chatted about the immense potential of those alternative models, the need for more buy-in from a payment perspective, and, ultimately, what could make or break the future of high-acuity care in the home.

For this week’s edition of the members-only, exclusive HHCN+ Update, I dive into the future of Contessa and home-based health care with Moskowitz. The conversation has been edited for length and clarity.

Donlan: On the SNF-at-home front, that was a model that many were excited about in 2020 and 2021, but that excitement seemed to dwindle over recent years. What are your thoughts on the future of that model? 

Moskowitz: When you look at traditional brick-and-mortar skilled nursing needs of the industry in general, the landscape continues to tilt toward needing more acute services in the home, specifically skilled nursing services.

From a patient’s perspective, why is a patient interested in getting their skilled nursing services at home? There’s a couple of different reasons. One is, I think, the historical attitude towards SNFs – you’re away from the home. You’re outside the comfort of your home. There’s burdens on your family; they sometimes have to travel long distances to see you. And as we see closures of skilled nursing facilities, they’re having to travel farther and farther. That is becoming an increasing burden, where patients–when given the opportunity–still want to receive their care in their home.

I think that care-at-home interest is now extrapolated into hospital at home and other services. From a patient’s perspective, I want to be in my home as long as I can.

From a hospital perspective, it also continues to be a need. They have a bottleneck when it comes to getting patients into skilled nursing beds. And what hospitals are traditionally looking for is a reliable discharge location or locale, and brick-and-mortar SNFs are not–across the board–a reliable opportunity.

You also have more hospitals that are entering into more risk-based structures, and as they do that, they’re looking for more insights into the patient’s full continuum of care. It used to be that, when they were discharged from the hospital, it was no longer–for lack of a better word–the hospital’s responsibility.

I actually don’t believe there’s been a pullback on SNF at home, because there continues to be more of those brick-and-mortar closures–87% of SNFs recently reported moderate to high staffing shortages. They’re finding it very difficult to hire and retain staff.

By their own account, purely from a staffing perspective, they continue to face challenges, and that limits admissions and increases their cost.

There’s always a place for brick-and-mortar skilled nursing, as there is for brick-and-mortar hospitals. But the landscape continues to point in the direction of skilled nursing in the home. There’s a subset of patients that – like hospital at home – do better in the home, and the forces are all aligned. So I think that’s why we’re continually bullish on that.

Do you believe staffing will be easier in a SNF-at-home model? 

The harder answer is: It depends.

When we enter those partnerships with health systems, and there’s a longitudinal picture of the patient’s journey–hospital at home, skilled nursing at home, palliative care at home–there’s an efficiency play, right? You’re building a chassis of services for hospital at home. It’s the same services for skilled nursing at home.

You need nurses to go in the home–physical therapy, occupational therapy. You need physicians to round on that. You already have created that infrastructure, or we have already created an infrastructure of those services, with hospital at home.

So when you say, “Hey, we’re going to do a hospital at home and the skilled nursing at home,” there’s the efficiency that you’re using that same chassis of services for these programs. You’re getting those same subset of providers, vendors, nurses, to service both of them. And that’s, I think, where you can overcome the staffing challenges, because the traditional mindset of a brick-and-mortar SNF is, “I have to hire X to be in my building and only service that population.”

And what we’re seeing with our partnerships with health systems … it’s not like they’re looking to hire nurses for hospital at home, and then a different set for skilled nursing at home. It’s their same set of nurses. And for a lot of our partnerships, it’s the same set of physicians, meaning they have hospitalists that are virtually rounding on the hospital-at-home patients, and the same group rounding on their SNF-at-home patients.

So, they gain efficiency of scale, and that’s where I think [SNF-at-home] can overcome a lot of their staffing challenges.

There’s a lot of home health providers interested in getting involved in high-acuity care in the home, and some already have. But do you think there’s still a lack of understanding there, in terms of what all goes into that? 

I think they understand it. I don’t think it’s an issue of them not understanding it. I think it’s them looking to make that a part of their longitudinal strategy. Because there will be things they will need to adapt to. And I think there’s a lot of home health agencies that have started to do this, and do this well.

Because, to a certain extent, what they’re adapting to is a higher-acuity level of the patient than a traditional home health patient.

I think the learning curve is, if I’m a home health company and I’m staffing with nurses, some of which have a comfortability with the higher-acuity patients, you start saying, “I already have this staff.” Because there’s going to be a subset of the staff that just don’t have the clinical chops, it’s not what they went into for, or they don’t have that experience, you need to either have that subset of nurses or create it.

So, again, I don’t think it’s a lack of understanding, as much as it is about where this fits into their strategy. Because for them to want to do it, they have to have a partner. They have to have someone who needs these types of patients to be cared for–and a good partner overall.

Are there home health nurses for Amedisys working for you on these high-acuity cases? 

We leverage our Amedisys care centers and our partnership, so they can have a subset of nurses that are for high acuity care, while they retain their traditional home health nurses to do those traditional home health services. And they sort of carved it out that way and have grown it.

There’s a smattering that overlap. But for all intents and purposes, there’s a subset within our care centers that are those high-acuity care capable nurses.

It also appears that CMS is moving toward these bundled payments, with visibility from the hospital on down. So now seems like a better time than ever to have these solid partnerships with health systems.  

It is.

And whether it’s a health system or a payer, there’s more system accountability to their patient and that longitudinal journey–and having line of sight to all of that. That’s why there’s a lot of integrated health care systems where they have their PCPs, they have their ACOs, their home health entities.

And as they get into a larger strategy, they want a line of sight into the outcomes. The best way of not losing sight is to create that ecosystem. That’s also why you need a trusted partner, because it’s complicated.

The hospital-at-home and SNF-at-home models are still new to the health care lexicon for many. Therefore, do you believe the success you’ve had proving those models out thus far will help beget more success over the next couple of years? 

For new people that are going to enter the arena, or new partners, it’s still about, “What can I reflect back upon? Can you show me what you’ve done?”

And so success breeds success, absolutely. I think currently, the only rate-limiting component to this becoming more exponential is payment uncertainty. We’ll see how it plays out in Washington, D.C. That’s one part that’s keeping growth from being exponential.

And then it matters what you’ve done. People want to look at what you’ve done, how you’ve done it, and what you’ve learned. Specifically for SNF-at-home there is, ironically, less of a runway there right now than there is for hospital-at-home. It’s newer.

And I think the way that health care systems are analyzing it is in two separate ways. One, it is part of a larger high-acuity strategy in the home. “Hey, I’m doing a hospital home. Let’s do skilled nursing. Let’s do palliative.” Two, they may look at it as an isolated component. Is it just skilled nursing in the home? That second approach is a siloed approach, and I think those take forever to move along.

But I’m really excited that some health systems are investing in SNF-at-home. Because the more that do it, the better you get at it. That opens up the opportunity for more to do it, with more frequency, and get better and stronger at it. Then you have more things for the industry to look back on and say, “Okay, I now see what you’re doing.”

What are you most excited about at Contessa in the near-term future?

My focus, passion and biggest interest right now is getting better and overlapping these services to make them more seamless. I mean, again, we go back to the concept, this is a longitudinal journey.

We’ve adapted to adding these sequentially over time. And while we can overlap them, there’s a learning curve to that as well. So how do we overlap them more and more? Again, we want this to be a seamless journey for the patient.

I just came from visiting one of our markets, and they’re admitting a SNF-at-home patient who is one of the palliative care patients in that market, and they have another patient who is a hospital at home that has palliative needs, and now we’re introducing them to the palliative care team.

That’s where it really gets exciting.