Advanced Home Care
|Background||Advanced Home Care successfully applied to participate in CMS’ Bundled Payment for Care Improvement initiative. The first patients were assigned to the program in Spring 2015.|
|Organization Type||Not-for-profit, hospital-affiliated home health agency|
|Population||Medicare patients with Heart Failure, COPD, or Pneumonia who meet program criteria|
|Incentive Structure||Shared savings against target spend for all related services during the 90 day period post hospital discharge|
|Performance Measures||– Patient experience of care (survey conducted at the beginning and the end of the 90 day bundle):|
+ The interview tool asks the same questions at the beginning and end of the bundle. Questions address issues such as healthcare utilization (hospitalizations, ED use), patient’s ability to independently performing daily tasks; patient level of energy to conduct certain tasks; patient and caregiver confidence level with ability to maintain safety at home; confidence in taking medications as prescribed; patient’s breathlessness based on certain activities; patient’s confidence in ability to notice change in health status and call for help; among others.
– Readmission rate
– ED visit rate
|Challenges||– Knowing which patients meet the criteria for the bundle|
– Knowing which services are related to the diagnosis that triggers the bundle (and therefore whether the HHA will be held accountable for the costs of those services)
– Access to real-time data for analytics
– Understanding patients needs for the last 30 days of the bundle if no longer in need of home health services (30 days beyond the traditional 60 day home health episode)
|Competencies for Success||– A new Department of Population Health with the following:|
+ Population Health Manager: Develops relationships with other providers and conducts education, particularly of the hospital
+ Patient Navigators: Manage up to 120 patients each. Navigators assist the patient in complying with their care plan. Navigators spend a significant amount of time on the phone with patients listening, assessing, teaching, and doing teach back.
+ Business Intelligence Team: Monitors cost and clinical performance.
+ Care Redesign Team: Team includes nurses, therapists, social workers, disease management specialists and a sales liaison. The team evaluates care protocols to determine what do they need to do before episode, during episode, and after discharge. The team considers questions such as: How will they reconcile medications? When does social work intervene? How do they identify patient engagement issues and assess what patients’ capabilities are?
– Strong relationships with hospitals in order to identify patients and work collaboratively on transitions of care
– Placing HHA employees in the hospital to assist with assessing the patient for purposes of determining discharge site of care (e.g., home health, skilled nursing)
– Development of patient assessment tool that both clinicians and non-clinicians can use to determine appropriate discharge site of care
|Tips & Lessons Learned||– Select models for participation by identifying the intersection between your organization’s strengths and hospital and other conveners needs|
– Once the 60 day home health episode is over, the HHA no longer needs to follow the home health Conditions of Participation and has more flexibility in managing those patients
– Build data collection and analytics systems that will provide as close to real-time access to data. Quarterly data feeds from CMS are insufficient