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Home-based care executives are increasingly turning to alternative reimbursement models developed by the Centers for Medicare & Medicaid Services (CMS) Innovation Center to deliver care and be reimbursed for it in new ways.
Alivia Care CEO Susan Ponder-Stansel is among the executives embracing these new models with open arms and has found that they create a more comprehensive experience for seriously ill patients.
Jacksonville, Florida-based Alivia Care is a nonprofit that operates across Northern Florida and Southern Georgia. Its services include home health care, hospice care, personal care, palliative care and Program of All-Inclusive Care for the Elderly (PACE) care.
The leader has also identified that home health plays a key role in the organization’s value-based care push, as well as ensuring it can continue to care for palliative patients. Still, the service line is “under siege,” she told Home Health Care News.
The interview has been edited for length and clarity.
What key initiatives are happening at Alivia Care?
Our big initiative is really to be involved in the needs behind ACO REACH. This is the last year of it. And we got involved in the GUIDE program. We got to do it right away, we didn’t have to wait a year. And we’re looking at some of these other great models that are coming out of [the CMS Innovation Center] (CMMI), which is really nice because we sort of built Alivia Care to be able to do these kinds of things that help people have a more comprehensive experience when they’re having a serious illness, instead of such a fragmented experience.
[CMMI] is coming up with really good programs to address this population. We’re excited to do the high needs this year, and then we’d like to be part of LEAD 2.0. That’s the big excitement for us.
What opportunity do you see here?
I always look at who isn’t in the hospital sphere, and I also look at our length of stay. And obviously, we’re a nonprofit. So when you look at length of stay for nonprofits, nationally, we all tend to get more of the adverse selection. We get people who should have been in a different care situation and come to us very late. Our median is 12 days. Think about that, half of our patients don’t even make it 12 days.
Part of our motivation is to be able to have these programs that help people access the kind of care that we do, to integrate that palliative care management, care navigation approach through our individual service lines, like home health and palliative. But also then to have that, that broader view, where care navigators are really helping people.
What are your home health priorities for 2026?
Because we take a large percentage of our patients who are what we would call palliative, because that’s really why we brought home health into our business, it’s to get a little more volume in the non-palliative. Because the way OASIS is skewed, when you don’t have a big rehab potential, if you’re just preventing declining or palliating, your scores are going to be problematic.
We don’t want to be a generic home health agency. We’re really looking at dementia certification and some of the care-focused programs we’ve implemented on the hospice side, like COPD, CHF, Age Friendly, to really integrate those best practice protocols into our practice in home health to help support the serious illness population. That was our big play with home health, as we begin to serve our patients through the ACO or PACE program, to have a home health agency that understood the population.
We have a little different mindset, but to get those excellent clinical certifications, and to really watch how they drive the outcomes that we’re managing, as well as figure out how to play the OASIS game so we can keep our palliative patients, because that’s so needed.
Home health is under such siege now. It’s like Maslow’s hierarchy. They’re looking at survival, but if we were going to do a little more of self-actualization, just understanding that home health has a real utility to help people not decline further in the home and be able to receive care in the home, instead of them ending up in a nursing home or a hospital bed. That should be rewarded as well. It’s not just all rehab, because some people don’t have a good rehab potential, but they need care or they’re going to end up in higher levels of care and probably receive low-value care when they do.
Does your distinct approach to home health, in addition to improving the continuum of care, help you stand out from your peers?
It should. That’s going to be what we focus on. It helps us internally, honestly, because, again, we have other hands. If we have a hospice patient who says, ‘I’m not ready,’ even though they’re medically ready, we don’t have to say, ‘Okay, see you.’ Many of them are being discharged from the hospital. They need wound care. They need some PT or OT because they still have time. We can help with that. And then our palliative service also sees people who need care planning and a comprehensive plan of care. A lot of those are discharged from the hospital with home health, but the home health that they have is, again, very focused on what you get paid to do. Internally, it helps us have a better patient journey and for value-based care, it will serve us really well. That’s our play there.
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