At the beginning of the second day of the workshop, two of the moderators for panels presented on the first day of the workshop reflected on the key messages they heard regarding what it will take to get to the ideal state of home health care. These included the panels that addressed workforce considerations and new organizational and payment models.1 Then, in the final session of the workshop, three individuals presented their reactions to the workshop overall. Some of the recurrent topics identified by these individuals are highlighted in Box 9-1.
The following sections are the reflections and reactions of the members of these two panels.
1 For personal reasons, Barbara B. Citarella was unable to present her reflections for the panel on key issues and trends (see Chapter 4).
Highlights from Individual Speakers
The following are topics identified by individual reactors as being recurrent topics from the workshop’s presentations:
- A focus on the sickest, highest-cost patients (Bowles, Lee)
- The need for quality and outcomes measurement (Labson, Lee)
- The potential for cost savings (Bowles, Lee)
- The need for better transitions of care and better coordination of care (Bowles, Labson, Lee, Stein)
- The appropriate use of technology, including information technology and telehealth (Bowles, Labson, Lee, Stein, Taler)
- Support for family caregivers (Bowles, Labson)
- Improved training for and use of the home health care workforce (Bowles, Labson, Taler)
- The need to focus on an individual’s level of function (Bowles, Labson, Lee, Taler)
- The need for flexible payment approaches (Bowles, Lee)
- The need for patient-centered goal setting (Lee, Stein)
- The need for better connections between health care and social services (Stein, Taler)
Margherita C. Labson
The Joint Commission
Among the points emphasized in the workforce panel, Labson said, was the compelling need for robust methods of analysis of workforce topics. Thomas E. Edes, in particular, she said, demonstrated how helpful information can be in program development. Targeting of high-risk, high-cost, and vulnerable populations for home-based primary care unquestionably requires a more diverse and skilled workforce, and his data showed “how much better it is to approach these clients at the primary care phase rather than waiting until they need restorative care,” Labson said. In addition to targeting, which all panelists emphasized, Edes discussed the needs for strong transition programs. Labson pointed out that these junctures in the health care continuum are places where the risk of error is highest.
The U.S. Department of Veterans Affairs (VA) has the advantage of having a system-wide electronic record system, a capacity that is “woefully lacking in the industry at large,” Labson said. However, several other
presenters during the day mentioned that although many of the delivery systems may have a single record, their hospice or home health care services do not, at least not yet.
As noted by Gail Hunt, the willingness as well as the ability of family caregivers to provide home health care is important to a successful home care situation, Labson said. Caregiving responsibilities change people’s lives, and some of these changes lead to better organization. This is perhaps a lesson implicit in health professionals’ training of family members for more specific caregiving tasks. Like Edes, Hunt pointed to the appropriate use of technology in the home, Labson noted, and she emphasized the importance of using patient-reported outcomes as one of the measures of effectiveness of a program.
Robyn I. Stone described some of the different types of health workers in the direct care workforce, with each one having somewhat different, but sometimes overlapping, responsibilities and capacities. According to Labson, Stone provided a realistic appraisal of the future of the direct care worker, which will be affected by the
- shrinking availability of family caregivers,
- changing demographics of direct care workers and their patients,
- availability of career lattices that allow ongoing career development,
- low wages and scant benefits, and
- overall health of the U.S. economy.
Improvements in the performance of this workforce will require improvements in competency-based training, supervision, worker empowerment, wages and benefits, and the potential for career advancement in specialty areas, such as comorbidity care or dementia care, Labson said.
According to Labson, the independence at home and consumer-directed care movements were touchstones for the remarks of Henry Claypool. He emphasized the value of promotora-type care, as opposed to rehabilitative care, for people in their homes and the need for those with clinical training to empower their clients. Rather than a narrow focus on clinical issues, he supported the broader attention to functional issues. With respect to direct care workers, the skilled/unskilled dichotomy is pejorative and may inhibit direct care workers from taking their appropriate place on the interdisciplinary team, Labson said.
Models of Care and Approaches to Payment
Teresa L. Lee
Alliance for Home Health Quality and Innovation
Key themes from the panel, which included the overview by Peter Boling and descriptions of six diverse programs, were presented by Teresa L. Lee. She noted that most of the discussion focused on the very sickest, highest-cost patients, defined by the use of different definitions for classifying such individuals by different programs. These patients were described as having multiple chronic conditions and functional limitations; being treated with multiple (sometimes conflicting) medications for multiple conditions; and being frequent users of hospitals, emergency departments, and nursing homes. To identify these patients, Lee noted, most of the models use various types of risk stratification, which requires health information systems sufficient to perform such stratifications, adequate patient assessment protocols, and data analytics.
Lee said the diverse care delivery and payment models described encompassed everything from advanced illness management to bundled payment arrangements, accountable care organizations, home-based primary care, and hospital at home, all with home health or home-based care components. Despite this variation, Lee noted a number of common elements among the home health care models discussed:
- Home health care services are integrated with primary care, specifically physicians and advanced practice nurses, and palliative and end-of-life care programs.
- Home health care services focus on care coordination, care management, and care transitions.
- Most models include post-acute care, and all models are working toward proactive, preventive maintenance care.
- Nursing care and physical or occupational therapy play critical roles, and in some models, the role of home health aides is being strengthened.
- The models use telehealth and remote monitoring (even low-tech approaches) to engage patients and increase program efficiency.
Person-centered goal setting and the integration of family caregivers into care teams were also important themes raised by panelists, Lee said. In particular, the Community Aging in Place—Advancing Better Living for Elders (CAPABLE) model presented by Sarah L. Szanton emphasized the use of the priorities of each individual receiving care to establish goals for that person. These goals may not be related to health or medical goals or needs, Lee said.
Lee further noted that although a number of the models that were described are emerging, some already have data on their impact on quality and cost outcomes over different time frames, although they include different populations and use different evaluation methods. Nevertheless, the patterns in the data were similar, showing dramatic reductions in hospitalization rates; the numbers of rehospitalizations, emergency department visits, and days in intensive care units (ICUs); and total costs per enrollee.
According to Lee, the policy and payment reforms that would strengthen these models and allow their expansion included the following: appropriate reimbursement for services geared to the stabilization or improvement of patients’ functional status; approaches to the use of bundled payments for post-acute care that allow more flexibility in the delivery of care through the use of a waiver of the Medicare requirement that patients be homebound and improved coordination with primary care; encouragement of the use of capitation, which also facilitates flexible payment approaches; and the use of value-based purchasing.
The vertical integration of a number of the models has led to the alignment of incentives by payers and providers, enabled a consensus on a financial bottom line, and improved communication among payers and providers, Lee said. For programs operating on a smaller scale, panelists recommended that a focus be placed on best practices, protocols for the tracking of quality and costs metrics, and the avoidance of expansion faster than the program can deliver positive results.
Finally, Lee raised the unasked question about the extent to which the new models are able to improve rates of diagnosis of certain specific diseases or conditions (e.g., dementia) and ultimately reduce preventable hospitalizations.
This section presents the remarks of three individuals who reflected on the workshop presentations overall, including their individual thoughts on themes that they heard throughout the 2 days of the workshop. In addition, after these formal remarks were provided, several workshop participants contributed some final thoughts.
Kathryn H. Bowles
Visiting Nurse Service of New York Research Center and University of Pennsylvania School of Nursing
In summarizing what she considered to be the main themes during the 2 days of the workshop, Bowles began by emphasizing the opportunity to shift care from costly acute and institutional care to the home and com-
munity. She noted many examples showing that home health care costs less. She found the frequent emphasis on patient function to be well received, including the need for exercise, physical therapy, and other interventions attempting to support patient function.
Bowles thought that Steven Landers’s key ingredients needed repetition: the use of physician- and nurse practitioner (NP)-led holistic care plans, an enhanced capacity for an acute care response, thoughtful use of information technology to fill gaps and to communicate, and enhanced support during transitions. She also reiterated his message that home health “must rise to the occasion and embrace value creation.”
Bowles indicated that speakers also emphasized the importance of the provision of care by interdisciplinary teams and occasionally mentioned the importance of including the patient and family caregiver as part of the team. Bowles noted that it is important to consider the home health and personal aide workforce to be members of the team, especially in their role as the eyes and ears for other team members.
The movement toward team-based care suggests the need for somewhat different training in medical and nursing schools and in other health professions schools, she said. “We need to be in class together, in the clinic together; we need to be problem solving together from the beginning.” Training programs need to add content about the role of home- and community-based care and the excitement that can come from that type of care, she said. Home health care providers also need continuing education and updating of their training and tools. Bowles also noted the need to improve the efficiency of the processes within home health care, including intake procedures, prioritization of new cases, and the frequency of home visits.
Further, Bowles said, care should appear to be seamless to patients and providers, but hard work will be required to make that happen. Information technology can increase opportunities to communicate, share information, monitor patients, teach, support the work, and evaluate outcomes. These information systems need patient portals that allow information gathering and sharing and that improve self-care. The VA’s information system can be examined for lessons, she added.
Standards facilitate the ability to share information across systems. Bowles noted that the American Nurses Association recognized a standardized, point-of-care terminology, the Omaha System for documenting in-home care and other care in four domains: environmental, psychosocial, physiological, and health-related behavior.2 Multidisciplinary clinicians use that system to document problems, record signs and symptoms related to
those problems and their interventions, and rate outcomes, she said. In 2014, Minnesota approved a statewide electronic health record and data exchange initiative and recommended that the Omaha System be one of the standards used. Such standardized data will help with the identification of best practices and the development of evidence-based protocols, Bowles suggested.
According to Bowles, a number of barriers to the greater use of technology needs attention. The lack of multistate professional licensure and restrictions on NPs inhibit their ability to practice at the top of their license; another is the integration of telehealth and other technologies into daily work. For such integration to happen, Bowles said, technologies must be easy to use and produce timelier results, and telehome alerts need to be smarter and produce fewer false alarms. Technologies are needed that support medication administration, reconciliation, and reminders; that send information to clinicians, including decision support, at the point of care; that can take on some of the inefficient, repetitive teaching in home health care; and that can provide support through the use of social networks. Although telehealth may be a useful tool for the field, she said, much more needs to be learned about it so that it may be used effectively and efficiently.
Identification of the right levels of care for patients coming out of the acute care setting is still not easy, Bowles said, particularly because discharge planning is not standardized. Patients not infrequently refuse post-acute care services because they do not understand their importance. Another need is to increase support for people to age in place and to help them focus on their goals and the care outcomes important to them.
“Our greatest barrier,” Bowles said, “remains the payment models.” The following were some of the ideas from the workshop that she noted were more thought-provoking:
- The emphasis on the most costly 5 (or 10) percent (What about everyone else, she asked?);
- The suggestion that the number of chronic illnesses is less important than the effects of the chronic illnesses on patient function;
- Reconceptualization of community care as pre-acute care and a focus on keeping people healthy and out of the hospital rather than the reverse; and
- The VA’s medical foster home program as an innovative concept.
Center for Medicare Advocacy
Stein, as an advocate for Medicare beneficiaries having difficulties with the current health care system, pointed to several presenters’ emphasis on
patient priorities, agreeing that people want to set their own goals and priorities and that “priorities” may be a better word for this than “goals.” She said, “I don’t think I’ve ever heard, when I’ve spoken with the people I was trying to get services from, ‘Well, what does the patient want?’” She went on to emphasize a number of themes.
Many workshop presenters discussed the provision of as much patient support as possible in the community, she said, which means that the location for the provision of care is not limited to the patient’s home. She believes that more discussion of collateral issues like transportation and housing is needed. The intervention from individuals who can help make repairs around the home was welcome, she said, because in her experience, simple issues prevent people from being able to stay in their homes, for example, needing a safety bar for the bathtub or a ramp to get up to the porch.
Coordinated care was another theme that Stein identified. Coordination of all aspects of an individual’s care, including skilled, medical, and nonskilled services, is key to successful outcomes, she said. She expressed concern, however, that although Medicare Advantage strives to manage the costs of care, it has not proven to be able to coordinate care. Coordination of care means to “coordinate the services, the transportation, the housing, the physicians,” she said. “[It] does not mean to ‘manage the dollars, save the dollars.’”
Although the need for a willing and available caregiver received attention, “a willing and available patient” is also needed, Stein said. People sometimes refuse services because they do not understand them or the need for them, as was mentioned regarding post-acute care. “How you communicate is incredibly important,” she said, and there also needs to be sensitivity to what individuals are comfortable with. For example, mothers do not necessarily want their daughters or sons to tend to their bathroom needs, she explained.
The workshop participants were rightfully focused on what technology can mean, she believes. However, she noted that at the Center for Medicare Advocacy, staff members have encountered denial after denial of Medicare claims for durable medical equipment, prosthetic devices, and speech-generating devices. The implication, she said, is that creative uses of technology that are most useful to beneficiaries may run afoul of coverage rules. This is short-sighted and counterproductive for beneficiaries, providers, and the Medicare program, Stein said.
The interpretation of Medicare rules that limits home health care to post-acute care situations remains a serious problem, despite the Jimmo v. Sebelius decision, Stein said. For these and other reasons, she said, “we need a 21st century Medicare program” that addresses contemporary patient and caregiver needs and considers medical and technological advances.
MedStar Washington Hospital Center and
Georgetown University School of Medicine
All aspects of the U.S. health care system have been based on the medical model, focused on the illnesses and disabilities of the individual, and “we need to move it much more towards an emphasis on healthy communities,” said Taler. He cited the conceptual shift, suggested by speaker Wendy J. Nilsen, from the consideration of home health care as health care in the home to consideration of the home as a place to be healthy and safe and was the central locus of care.
He sees care in the home to be a proverbial three-legged stool, supported by health care, social services, and function. In his model, health care is not about a set of consultative clinicians and supporting professionals; it is about an interdisciplinary team working for a population “to whom they are responsible personally and accountable to society.” The social work leg of the stool should involve not just the brokering and pulling together of services, as they are now mostly used, but also counseling of patients and family caregivers and provision of a community organization function, he said, enjoining family, friends, and local agencies, such as the neighborhood village movement. Housing and function work together, are intimately related, and either limit or facilitate what can be accomplished in the home. By enlisting the help of neighbors and volunteers and with the aid of small grants and donations, older adults can age in place, which promotes age-related diversity in the community and maintains property values that benefit all.
Taler then suggested that the workshop participants conduct a thought experiment. He asked them to envision a matrix. Down the left margin, they should list functions (activities of daily living, instrumental activities of daily living, patient goals, and so on). The next columns are used to answer a series of questions from left to right:
- What is the patient’s current status? Which of those activities and goals are they able to accomplish (determined by the use of whatever assessment scale is convenient)?
- Where is the patient likely to go, relative to those activities and goals, with the help of medical care, devices, rehabilitation services, and so on, including patient motivation?
- What is the caregiver willing and able do to fill in the gaps?
- What can the formal care system do to train the caregiver, provide additional assistance, or provide devices to fill in the gaps a little better?
- What can secondary caregivers—neighbors, friends, relatives, or paid assistance—contribute?
This exercise begins to create a care plan that focuses squarely on function and sets priorities, he suggested.
Taler endorsed speaker Robyn I. Stone’s emphasis on the importance of direct care workers as part of the home health care team. They need adequate training and a care plan that helps them know what they need to do, how to be effective eyes and ears for the team, and how to be accountable not only to the team but also for their contribution to the outcomes of their patients, he said.
Meanwhile, he noted, the country faces a dearth of geriatricians. The geriatric NPs have been folded in with the adult NPs, and only a handful of physical therapists with geriatric expertise exist. The future workforce, Taler said, is a serious concern. The chronic care management field needs primary care physicians who are truly engaged in “the intellectual challenges of managing the complexity of [the medical conditions of] these patients, not only because of the joys of working in an interdisciplinary team but also for the emotional satisfaction of dealing with people at this time in their lives.” Remunerative positions will be needed to attract these physicians, and the funds will likely come from shared savings programs under development through Medicare.
Taler also noted that much attention was given to technology issues, including monitoring technologies. Not discussed, he said, were practice management technologies that optimize clinicians’ time, facilitate communication, and utilize point-of-service diagnostic technologies that permit informed decisions to be made on the fly, in patients’ homes. “With about 20 pounds of equipment costing perhaps $20,000, it is possible to do in the home anything that an urgent care center can do,” he said. Going further, he said that with the right financial incentives, within 4 hours it is possible to create a nursing home, hospital, or intensive care unit in a patient’s bedroom. “There’s no need to go to a hospital for the vast majority of problems, except major surgery, invasive procedures, and complex imaging.” Preoperative and postoperative care can be done at home with ICU-level monitoring devices wirelessly connecting to a central telemetry unit. Taler also noted the lack of discussion about the specific technologies that can facilitate home-delivered medications and treatments.
Taler stated that neither hospitals nor primary care (as it is currently structured) can handle the wave of older patients requiring care for chronic conditions. He also said that current home health care organizations are unsustainable, but no one wants to be in a nursing home. For that reason, Taler challenged innovative home health care leaders to stop thinking about themselves as small fish in a large pond and instead “think about us as oxygen in the tank. If we don’t succeed, our health care system dies.”
Amy Berman, The John A. Hartford Foundation, said the current system has many incentives to move in directions that would preclude home health care. When the future is considered, the health care system has a tremendous regulatory burden with respect to what is accomplished in that first home health visit. As a result, she said, home health providers are not necessarily focused on accomplishing what is of the greatest importance to patients until the second, third, or fourth visit. This includes the provision of assistance to the family to help them understand how to handle different aspects of care.
Berman also noted that for many people, caregiving is managed at a distance; that is, children do not necessarily live close to their parents any longer. Information sharing—and the Health Insurance Portability and Accountability Act3—should not be a barrier to this, even though, at present, it often is cited as being a barrier to team-based dialog.
Karen Marshall, Kadamba Tree Foundation, noted that people often come to the issue of care at home in a moment of crisis. People need a bridge between the present and future, she said, so that they have realistic expectations of what it means to have a long-term illness and to age. Some education could take place in the long period of time that exists before a crisis.
Michael Johnson, BAYADA Home Health Care, said that professionals should be interested not in what they are teaching patients and caregivers but in what they are learning. “We continue to talk about teaching, he said, and I just want to be sure that we’re talking about learning, and how we measure that.”
For the delivery of high-level, high-quality care at home, Anthony Sung described a pioneering project at Duke University: home-based bone marrow transplantation. Although this is one of the most advanced technical medical procedures, the Duke team has successfully treated seven patients in home-based settings. Sung argued that it is better for patients in terms of improved quality of life and decreased exposures to infection, and the clinicians believe that it also will improve other outcomes. Home health care preserves patients’ normal microflora, he said, and in that way can improve homeostasis and health.
The workshop concluded with a final comment from Judith Stein: “I just want to say, we should unite. We have nothing to lose but our silos.”
3 Health Insurance Portability and Accountability Act of 1996, Public Law 104-191, 104th Cong., 2nd sess. (August 21, 1996).