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.
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:
- 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?
- 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?