Insights from the Future of Home Health Care: IOM-NRC Forum on Aging, Disability and Independence Workshop
(Written by Merrily Orsini. Reposted with permission from Axxess.)
The first step in any recovery program is to admit that you have a problem. The health care system is no different. It has to admit it has a problem in order to recover. So, here is the problem: Medicare was designed to help pay for health care costs for the elderly. Currently, and since its inception, Medicare has focused on reimbursing costs incurred when an older adult utilizes the services for post-acute care. Those services are not only expensive, but designed to be short-term solutions, and in the case of nursing homes, not where older adults want to be. They would rather be at home.
That doesn’t mean post-acute care needs to go away. In fact, the need for short-term post-acute care will remain. However, America’s aging care issues are much different today than when Medicare was conceived. Adults now become “seniors” at the age of 55 and stay “seniors” well into their nineties and beyond. This new longevity brings with it a number of chronic health conditions that will require management over time – not in a post-acute care setting where an older adult will quickly exhaust all of his or her resources, but in an older adult’s home through the use of home care.
And, what about the money that is being thrown at the problem? Did you know that Medicare and Medicaid are second only to the national defense in spending? If so, you realize that we are on an unprecedented spending trajectory that is unsustainable.
When we look at the future of healthcare through this lens, it is clear that the problems are how we created our health care delivery system and how we have failed to advance it – until now. Instead of skirting the issue, both providers and consumers are beginning to take a stand, take action, and search for solutions. Axxess has funded a study through the Alliance for Home Health Quality and Innovation (AHHQI) that was instrumental in creating the platform for the hearings on the future of home health held September 30 and October 1 at the Keck Center in Washington, DC, and convened by the Institute of Medicine and the National Research Council.
It is this type of support that will make the difference for the future; because in order to solve a problem, you first have to admit and understand the problem you have. You also need to understand where you are in the continuum of problem to solution; and then take the necessary steps to correct the problem or start over. You then need to measure, evaluate and repeat.
CMS has been awarding grants for innovative projects. The Veterans Administration has been using telehealth, among other focused coordinated services, to serve the five percent of the population using most of the resources. Barbara McCann, from Interim Healthcare, phrases the issues clearly: “Medicare is an acute illness benefit in a chronic care world.” The main question most people ask when they become frail is: “Can I live in my habitat longer?” Care transitions are not just for a post-acute setting; rather, there are care transitions at each touch point in receiving care in the health care delivery system; and ensuring proper care for the elderly or chronic disease patients at home can reduce costly transitions and rehospitalizations.
Steven Landers, an MD and MPH who currently works for the VNAA Health Group and is President of the Alliance for Home Health Quality and Innovation (AHHQI), has some ideas for how to better address the long-term needs of our population. He feels that home care can cost less, is more desired and is safer. He also says that it can be vibrant and impactful. His ideas are to create home-centered health strategies and focus on home-centered care that will reduce undue suffering and eliminate undue spending.
As stated in Dr. Landers’ presentation, “In building the future, let’s not forget some of the basic, common sense advantages of home care that are as true today as they were when Lillian Wald and her colleagues from the house on Henry Street ventured out into the squalor of the lower east side of New York City at the end of the 19th century. When we take care of patients at home, there’s an enhanced view of patients and caregivers that leads to a better understanding of important issues like how they manage medications and nutrition. Home visits are an access intervention that is most relevant to patients with physical and socioeconomic barriers to care. During home visits, a more intimate, clinician-patient relationship can be established. Home care clinicians sit beside their patients in their bedrooms and at their kitchen tables. The home visit is an act of humility that demonstrates to the patient the clinician has left their comfort zone to be on their turf, that they are worth being truly known and visited. Home care can cost less while being desired more by many patients, and care at home is sometimes safer for frail elders.”
Dr. Landers says there are four main clinical ingredients for the future:
- Physician and advanced practice nurse developed and overseen interdisciplinary home health care plans; plans informed by the well-proven concepts of holistic geriatric medicine, palliative medicine and rehabilitation medicine assessment.
- Enhanced support around care transitions; support that addresses self-management, care coordination, information transfer and clinical stabilization.
- Advanced capability for escalating intensity of medical care and palliative care at home in times of decline or exacerbation (including escalation to hospital-like services at home).
- The thoughtful use of advanced information technology to fill the white space between encounters, to aid in the management of unscheduled home care patient problems, and to improve triage and the overall efficiency of care.
Histories are often fraught with mistakes and missteps, which seem troublesome and even overwhelming at the time. It is, however, past mistakes that can serve as meaningful lessons in how to improve the future. The history of health care delivery is no different; our past issues or shortcomings can help us pave the way to a brighter, safer and healthier future, with more care centered in the home.
Insights from the Future of Home Health: IOM-NRC Forum on Aging, Disability and Independence Workshop
(Written by Merrily Orsini. Reposted with permission from Axxess.)
Ecosystems work together so that all members can survive, change and grow, in accordance with the availability of resources to foster growth. Health care is also like an ecosystem, with different but crucial members that require collaboration for survival and growth. How does this apply to home health?
According to the Centers for Medicare and Medicaid Services (CMS), annually, Medicare accounts for $572.5 billion of health care costs, and Medicaid for $421.2 billion. Yet, the home health care portion of that expenditure is only 6-7 percent. Historically, Medicare and Medicaid have reimbursed more for managing care in facility-based settings, such as hospitals and nursing homes, instead of home-based care. Nearly 50 percent of that current, enormous national expenditure is for the 5 percent of citizens who are considered “frail” and have multiple chronic health issues. The Organization for Economic Co-operation and Development’s (OECD’s) 2009 health data report shows that, compared to the other industrialized nations, the U.S.’s expenditure per capita is far greater, yet our quality of care is less. Now more than ever, it is time to revamp, refocus and revise so that the burgeoning baby boomer generation will have access to care in the home that our system can both afford to provide and deploy in cost-effective ways that assure better outcomes and provide greater value.
A recent two-day workshop held in Washington, DC, at the Keck Center by the Institute of Medicine and the National Research Council is the first meeting to take place at a national policy level on the future of home health – the part of the health care ecosystem that all should focus on with greater urgency. Presenters revealed a wide range of options to be considered as possible ways to move home health to the center of the conversation with the goal of assisting the nation with caring for its own aging and disabled population, so that they can remain independent for as long as possible, and live safely and securely in a place that the vast majority want to be – at home.
So, what are the key issues? What is our vision for the future of home care? How do we ensure the survival and growth of the home care industry? There are certainly multiple issues, and right now they’re all a component of the current ecosystem of healthcare: workforce, payments, technology and integration between components of the health care delivery system. Two of those components that are currently missing from the equation – and should be at the center – are the patient and the caregiver.
What is the current spectrum of home-based care? At 6-7 percent of current expenditures, the reimbursement for care in the home is not in line with the desire for that service. The unintended consequences of a reimbursement system that is focused on post-acute care has created an imbalance in service delivery. The creation of specialties within the health care delivery system has also assisted in this silo of services. The patient, who should be at the center, is somewhere in the process, but not in a way that considers the whole of the patient and the entirety of the situation.
The goal of delivering quality health care services should focus on the patient, his or her goals and helping caregivers who assist patients with meeting goals – integrated with the patient at the center. Resources should be allocated with the patient in mind, and the patient’s wishes included in the process. See a theme emerging here? To fix the system, we really have to start over and think of ways to work together, ways to pay for value and not quantity, ways to listen to the patient and his or her family, ways to communicate with each other so that we are all working together to solve the same problem: providing a supportive and coordinated system of care for those in need of care, but in a way that starts with where they are and meets their needs best.
By 2029 (the next 15 years), there will be 71 million baby boomers over age 65, an increase of around 73% from today’s numbers. More and more physicians and hospitals are awakening to the fact that, not only do patients want their healthcare in the home, but home care is significantly less costly than hospital care and oftentimes care provided by a skilled nursing facility.
One study conducted by the Milken Institute projects a 42 percent increase in cases of the seven major chronic diseases (cancer, diabetes, hypertension, stroke, heart disease, pulmonary conditions, and mental disorders) by 2023. The time to discuss the future of home health care is now.
Please join me at this year’s New England Home Healthcare Consortium in Uncasville, CT where you’ll learn how to nurture, market, and grow your home care agency, while facing the challenges and changes of our industry.
My session, The Future of Home Health, will take place on Monday, November 10th at 11 a.m. This session will be a visionary overview of the dynamic forces that are changing the healthcare landscape in the United States, from the perspective of the home health industry. The Future of Home Health is an ongoing project sanctioned by the Alliance for Home Health Quality and Innovation of Washington, DC, and involves the National Research Council, Institute of Medicine, and thought leaders nationwide. AXXESS is a primary sponsor of this incredibly important project, and some insights from the recent 2-day workshop held in DC will be reported. The presentation will focus on technology developments expected to have a direct impact on home healthcare services, policy changes needed to accomplish care for the growing number of seniors in our country, and some results from the innovation projects that are now in their 3rd year.
Please join me for this unique opportunity to stay informed and current in an evolving, dynamic industry.
In 2012 there were 39 million people over 65, and in 2014 there are 43 million. In fact, 10,000 people are turning 65 each day. Now, turning that magic age does not mean that care is immediately needed. In fact, most care is not needed until a person reaches 80. So, that means that, when the first boomers reach 80 in 2026, the onslaught for care will begin. Understanding what aging means in terms of frailty, functionality, and needs is at the heart of geriatric care management.
The Handbook of Geriatric Care Management, the only textbook of its kind on the subject, will be releasing its 4th edition in 2015. Published by Jones & Bartlett, and compiled by editor Cathy Jo Cress, this comprehensive guide for Geriatric Care Managers (GCMs) is an essential teaching tool, with lessons and guidelines on:
- Supporting clients’ quality of life
- Assessing and supporting family caregivers
- Ethnic and cultural considerations in geriatric care management
- Combining a home care agency and a GCM practice
- Care planning
- And much more
As one of the authors of a chapter in this important textbook, I am pleased to announce that I will be revising my chapter, “Marketing Geriatric Care Management.” In this chapter, geriatric care managers learn how to:
- Market services to the geriatric care population
- Create a solid marketing strategy
- Develop a strategic marketing plan
- Develop their brand
- Target their marketing message to the right audience
- Set themselves apart from the competition
- Use new technology and digital media as a core component to reach those who have a need
- Use education on issues related to aging to reach those in the first phase of the buying cycle
- And more
As a veteran of the aging care industry, my professional background is steeped in home care, geriatric care management, and marketing. My business ownership began with a geriatric care managed in-home care agency, which earned the Ernst & Young Entrepreneur of the Year Award in 1996. I founded corecubed (Aging Care Marketing) in 1998 after selling my home care business. corecubed focuses on marketing aging care companies using strategy, design and integration to get results for our home care and aging care client partners.
The corecubed team has won multiple awards, including a prestigious Stevie Award, and a coveted Webby Award nomination, as well as numerous Aster Awards and Web Health Awards for our home care marketing materials.
It is such an honor to be asked to contribute to this informative and timely book, and I am thrilled to be able to bring my marking and aging care expertise to the Handbook for Geriatric Care Management in its latest edition. To learn more about the handbook and about its editor, Cathy Jo Cress, please visit her website.
If you are interested in having a team with in-depth geriatric care experience working with you or your business to better reach a senior care market, the experts at corecubed know how to do it. Just contact us and we will gladly assist you in better targeting your campaigns, branding your business for success, and communicating with those who make decisions.
At a recent VNAA National Public Policy Leadership Conference, Jim Pyles, one of the proponents of the Independence at Home Project, said, “If you reimburse for visits, a business is going to push making more visits. If you reimburse for episodes, a business will naturally push for getting more episodes.” That was his reasoning behind the ACO model not bringing in as much savings as originally anticipated. However, in a report just released and published in Modern Health, the results are coming in for the Accountable Care Organizations that were set up as one of the trial Medicare models to see if the triple aim can be achieved: lower costs, better patient care and a healthier population.
The Pioneer ACOs showed improvements in three key areas: financial, quality of care, and patient experience. However, the model has not really changed, only collaboration to accomplish the results. The Independence at Home Project, on the other hand, targets that 10% of the population that is the heavy user of Medicare dollars. The following is taken directly from the website explaining the Independence at Home Model, but it really does explain the project and its intent very well:
“There are 3-4 million seniors now living with multiple chronic illnesses such as diabetes, lung and heart disease who are too ill or disabled to easily visit their physician when they need care. These seniors, representing approximately 10% of Medicare beneficiaries, account for two thirds of Medicare’s expenditures.
These seniors are typically unable to access a primary care physician’s office for needed care, instead of going to the ER or being hospitalized. These are the patients who place the largest burden on Medicare, and this problem isn’t going away. The number of people with multiple chronic illnesses will grow to 6-8 million by 2025.
The quickest way to control health costs is by addressing these highest cost patients first. House calls are a solution to the rising costs of helping home-limited patients with multiple chronic conditions. At $1,500 per ER visit, we can show that the cost of 10 house calls more than offsets the expense of an avoidable ER visit. Savings are even greater for avoided hospitalizations.
Improved Care for Patients, Savings for Medicare
Home-based primary care programs have the potential to save 20-40% on Medicare’s most expensive patients by bringing them care in their homes. IAH provides for care coordination across all care settings. Providers are also accountable for good care and reduced cost. Overall this is a win for patients, their families, and Medicare!”
We all know that the boomers are getting older, and as this “pig in a python” population cohort gets older, the system is going to have to change to accommodate the needs. Paying privately for care is one option, but more people cannot afford to cover their long-term care costs than can. It is encouraging to see that we are, as a health care delivery system, looking at innovative and effective new ways to use home care as a low cost alternative and a viable option.