Finding home health providers’ place in the home-based care boom

In order to maintain hospital capacity during Covid-19 surges and to reduce potential exposure to facility-based care, many hospitals took a home-first approach to discharge planning during the pandemic. Because of this strategy, hospitals successfully sent patients to home health that they might not have previously. This both interrupted discharge planners’ traditional preference of defaulting to SNF for most patients needing post-acute care and gave home health agencies a chance to prove their ability to care for a wide variety of patient types and acuity levels. These factors combined may make hospitals more willing to divert post-acute patients from facilities to home health now than ever before– making them a better audience for home health providers.

To pitch facility diversion and increased use of home health to hospitals, home health providers should explain how they can help hospitals achieve their goals, like lowering costs and readmissions. In addition, home health organizations should showcase the new ways they provided care during the pandemic, including demonstrating how they have been able to successfully treat different or more complex patients than usual. For a ready-to-use pitch deck communicating these points, view Conveying the Value of Home Health. 

Strengthening referral streams from current hospital partners capitalizes on the efforts that have already been made to create these partnerships. Additionally, because this approach is not inherently novel and does not require new investments or skills sets, it can be easier to implement then the other strategies in this document. For these reasons, all home health agencies should consider this to be a key part of their business development strategies.

However, home health agencies should not rely on SNF diversion as their only way to take advantage of the home-based care boom. This approach has a smaller growth potential than the other strategies in this document due to the limited patient population that Medicare-certified home health providers can care for, for both regulatory and cost reasons. Depending on a hospital’s patient population and utilization, there simply may not be many more of these patients to divert from facilities to the home. As such, it is advisable to combine an attempt to increase facility-based care diversion with other efforts to grow.

Partnering with an organization that provides a different type of home-based care, like hospital-at-home or home-based primary care, can be a good way for home health agencies to utilize their expertise in delivering care in the home in a new way without having to stand up a new model on their own.

For example, the Visiting Nurse Service of New York (VNSNY) partners with Mt. Sinai to provide hospital-at-home, expanding VNSNY’s business and helping Mt. Sinai grow their program. VNSNY uses their expertise in scheduling and delivering care in the home to send nurses to check up on acute patients daily. For additional information on their collaboration, see our case study, How Three Providers Expanded Hospital-at-Home Amid Covid-19.

Home health organizations can help home-based care providers expand in a few ways. Many new entrants in the home-based care market are startups. Home health agencies have nurses and therapists who are good at providing skilled nursing and rehabilitation in the home. Additionally, home health agencies are already set up with the scheduling and training infrastructure to deliver care outside of a facility setting.

Furthermore, if the home health provider already has an established good reputation in a market, the partnership could help a newcomer become accepted by local providers and patients.
The benefit of this approach is that home health providers can become involved in a growing model of home care without having to build their own from scratch.

However, there are potential downsides to this approach. Collaboration across organizations involves significant time and effort to set up and sustain. Additionally, it can be challenging to find sufficient staffing to maintain regular home health activities on top of new partnership activities, whether the new partnership activities involve using nurses in a new way or simply an increased census for typical home health services.

For example, Unity Point Health System partnered with their owned home health agency, UnityPoint at Home to create a hospital-at-home program. At first, UnityPoint at Home struggled to do both hospital-at-home and home health activities with the same staff. To solve this problem, they carved out their hospital-at-home staffing separately from their home health agency staff and built an additional layer of staff for it. This solution ensured sufficient staffing for both home health and hospital-at-home, which in turn made it possible to scale their hospital-at-home model.

Providers considering this strategy should ask themselves the following questions:

• Which type(s) of care could my organization feasibly assist with? View the chart below for guidance.

• Which organization(s) provide that type of care, and may need a partner to expand into my market(s)? How will partnership be mutually beneficial?
• Who will be dedicated to setting up and maintaining the partnership?
• How will partnership affect my staffing? Will I be able to maintain my regular home health activities as well as partnership commitments?

Beyond partnerships with hospitals and home-based care providers, organizations can capitalize on the growing interest in home-based care by creating their own model of care to meet market needs and serve additional patient populations.

Creating a new model of care

One of the major limiting factors of Medicare certified home health is the limited patient population it can serve for regulatory and cost reasons. However, the competencies of a home health agency—skilled nursing, physical therapy, care management, etc.—can be useful beyond Medicare-certified home health. 
To use these competencies outside of this patient population, home health agencies can create a new model of care to meet market needs. This could be a pre-existing model, like SNF-at-home, or a brand new one.

Meeting market needs

Meeting market needs refers to serving the three key stakeholders: referrers (typically hospitals), patients, and payers. A new model is successful when it helps each of these stakeholders achieve their respective goals. Finding the intersection of these three stakeholder’s needs and your organization’s capabilities is the key to creating a successful new model of care. This ensures there will be demand for the program and will help secure reimbursement.

Securing reimbursement

When creating a program, securing reimbursement is one of the biggest challenges to overcome.  Pilot programs typically begin with grant funding, with the goal of collecting enough cost savings data to graduate to reimbursement from a payer. Appealing to payers can be challenging, and programs will need to have solid cost-savings data to show. For resources to aid with appealing to payers, view the payer section of Resources to Promote Post-Acute Growth.

Case study: Bluegrass Care Navigators

Bluegrass Care Navigators created a successful new model of care, their health coach program, by applying their competencies to meet the needs of their hospital partners, patients, and payers.

Bluegrass Care Navigators is a home-based care provider based in Lexington, KY. One of their hospital partners, UK HealthCare®, was experiencing challenges with high readmission rates, and needed a partner to help them lower it. Payers in the area were also affected by the high cost of care of these patients, due to frequent readmissions.

Bluegrass Care Navigators already had expertise in providing a variety of services in the home, from transitional care to hospice. To meet the needs of this patient population using their current competencies, Bluegrass Care Navigators developed a health coach program. Bluegrass health coaches visit patients in their home after discharge from the hospital on at least a weekly basis and provide services for either 90 days or six weeks, depending on the patient type. During these visits, they provide medication reconciliation and education, clarify and explain the importance of the care plan, offer clear follow-up instructions, connect patients with home care services or neighbors or relatives who can provide assistance, ensure patients receive follow-up appointments, inform community physicians about what happened during the hospitalization and coordinate transportation.

This program was initially grant funded, but by meeting the needs of the patients, Bluegrass Care Navigators was able to lower readmissions and reduce overall costs for UK HealthCare® and local payers, allowing them to secure reimbursement after the grant ended. For more information, view our case study, How Bluegrass Care Navigators Fills Care Gaps for Complex Patients.

Case study: Starwell Health

Starwell Health is a hospital system with an owned home health agency. Starwell devised their ED diversion program at the start of the pandemic to increase hospital capacity, but they see the benefits of this program lasting past the end of the pandemic.

Using Starwell Home Health’s expertise in care coordination and delivering skilled nursing and therapy in the home, this program provides in-home care to low-acuity patients presenting in the ED. It benefits Starwell’s hospital by leaving beds open for the most acute patients, and appeals to payers by lowering overall costs. Patients like it because they prefer to be treated in their own homes, rather that the hospital.

Instead of being admitted for observation or initiation of therapy, patients are discharged directly home after stabilization. The home health nurse initiates therapy on the same day of ED discharge under physician oversight. A liaison—typically an RN or LPN with care management experience—coordinates all the necessary care and orders any DME needed directly to the ED so patients can go home fully equipped. As of May 2020, this program was funded by Starwell Hospital, but Starwell was in talks with multiple payers to secure reimbursement.  To learn more about this program, read our case study, How an Enhanced Home Health Program Creates Hospital Capacity.

Questions to consider

Overall, this approach involves the most effort and risk, but can also reap the highest reward. As such, organizations should carefully vet the market potential, their ability to provide this new type of care, and reimbursement options. View questions to consider below:

Market potential

• Which patient populations in my market are growing?
• Who are the existing home-based care providers in the market?
• What services are referrers interested in sending patients to?
• How strong is the patient preference to receive this type of care in the home vs. in a facility?
• How will this appeal to consumers, referrers, and payers?

Ability to provide care

• How will I staff this new venture, at both the administrative and front-line levels?
• Will my staff need to build up new skill sets?
• Will I need to use new technology?

Reimbursement

• Do Medicare or Medicaid cover these services?
• Are grants available for pilot programs?
• Can we help a local hospital or health plan achieve their goals with this program, in order to secure reimbursement?