Independence at Home

 Care Coordination 
 CMS Demonstration 

Agency
Christiana Care Visiting Nurse Association in New Castle, Delaware.

Agency Description
Christiana Care Visiting Nurse Association (VNA) is a full-service home health agency and a wholly-owned subsidiary of the Christiana Care Health System in Delaware. Average daily census is approximately 1,600 and approximate annual revenue is $45 million. The Home Visiting Provider Program is included as a component of the Christiana Care Quality Partners ACO.

Demonstration
This is part of the Center for Medicare and Medicaid Services (CMS) Independence at Home Demonstration project. This project is authorized under section 3024 of the Affordable Care Act.  

Population Impacted
Frail elderly patients residing in the greater Wilmington area.

Strategic Partners
Close collaboration with the system's physician home visit program, community hospice providers, community PCPs and specialist practices, community hospitals, and numerous other community-based services.

Project Description
Christiana Care VNA has completed the first three years of a five-year "gain sharing" model. Much of the focus has been in recruiting and enrolling the required number of patients to meet the CMS-required level of 200 patients. Christiana Care has focused efforts on the five key quality indicators that are required as part of this project. Finally, Christiana Care's focus has been on integrating the efforts of its home physician visit program and VNA care to optimize quality, patient experience, and the impact on reducing overall costs of care by reducing avoidable readmissions and other non-value added services.  

Results
Results will be tracked over the next two years and will include the numbers of patients, key quality indicators, and various other quality indicators and costs of care. The Independence at Home demonstration was extended by Congress in 2015.

Outcome Measures
As of the first year, Christiana Care VNA has seen an approximate 20 percent reduction in the rate of hospitalization of patients enrolled in the program. CMS is analyzing results and will share the first three years worth of data in the Spring of 2017.

Barriers to Implementation
Key barriers include lack of interoperable IT systems, a requirement that patients discharge from a home visit practice (requirement since relaxed by CMS), a need to develop a more robust home-based palliative care program for patients, and an inability to cover costs of home visit physicians and Nurse Practitioners (NPs) under current reimbursement levels. Additional barriers include a need to develop stronger working relationships with community emergency departments, and a need to develop improved 24/7 capabilities in order to respond to patient needs as an alternative to emergency departments.