The U.S. Department of Health and Human Services’ proposed Accountable Care Organizations create incentives for healthcare providers to work together to treat an individual patient across care settings — including physician’s offices, hospitals, long-term care facilities and in the home — with a goal of keeping patients healthy in an affordable manner.
The Medicare Shared Savings Program will reward ACOs that lower healthcare costs and meet performance standards on quality of care in areas including care coordination, patient safety and the health of at-risk populations such as the elderly. Considering the complexity of today’s patients who are being cared for in the home, meeting those standards while keeping costs down may prove to be a challenge.
Local home care experts share how they believe ACOs will influence patients’ transitions from acute care to home care.
Susan Cummins Caputo, RN, BSN, MPA, president, MJHS Home Care, Hospice and Palliative Care, Brooklyn, N.Y.Susan Cummins Caputo, RN
The concept of a patient-centered provider network linked by shared information technology has the potential to fundamentally change how a patient will transition from an acute care to a home care setting.
While the final models for these programs still are being developed, most include risk sharing, bundled payment and interoperable electronic health records between a network of providers, including home care. On the positive side, under the ACO model, more information will be shared electronically between the hospital and the agency streamlining the transition between settings and reducing duplication of effort. The ability for the home care clinician to communicate with the hospital in real time has the potential to improve the flow of information and reduce errors.
At MJHS, we have found the presence of a home care professional as part of the interdisciplinary team in the hospital can have a strong impact on improving care transitions. We believe joint quality councils will help ensure hospitals and home care agencies operate more in concert. Furthermore, the model supports transitional skilled home care visits to support patients who do not need a full episode of care.
However, the role of a hospital or a large physicians practice at the center of an ACO payment model may result in rate reductions to home care agencies and, in turn, less nursing/home health aide hours will be provided. This may negatively impact the transition between settings and reverse some of the positive impacts of tighter partnerships promised by ACOs.
Rachelle Kivanoski, RN, BSN, MA, chief clinical officer, Revival Home Health Care, Brooklyn, N.Y.Rachelle Kivanoski, RN
There is an extremely positive impulse motivating the federal governments attempt to create a new payment entity that focuses on cost-effective collaboration between inpatient facilities, physicians and post-acute providers to encourage greater communication, collaboration and cost-effective patient-centered care. The model reduces the incentive for providers to focus on maximizing reimbursement per visit and provides financial incentives to the organizations that provide cost-effective care. The ACO model promotes more long-range follow-up of older patients with chronic disease that emphasizes avoidance of acute care hospitalization and recognizes the critical role of community-based services.
For an ACO to be successful, all the providers in the organization have to focus on strategies to promote patient self-management and adherence. They have to strive to reduce all the pitfalls inherent in every transition from one care setting to another, such as miscommunication of medications and treatments.
Home care staff bring exceptional expertise to this project, both in getting patients on the right track and clarifying issues while patients are still in the hospital and proactively addressing barriers. Home care staff assist patients in setting up follow-up appointments, arrange for pharmacy delivery and ensure the patient has transportation and support to get to the physicians office or arrange for visiting physicians and medical tests at home as needed.
Once home, clinicians work closely with the patient, caregivers and physicians to educate patients regarding long-term disease management. The home care nurse can serve as gatekeeper between the primary physician and other specialists a patient consults. In the event a patient does require inpatient care, the home care agency can provide critical information regarding patient social and adherence issues that are having an adverse impact on their health status. A unified electronic medical record accessible to all the providers in the ACO also will minimize error and enhance coordination of care.
Telemonitoring also can play an important role in cost-effective patient management. In addition, Revival Home Health Care also has a Rehospitalization Prevention Program that includes daily triage phone calls to recently discharged high-risk patients that supplements clinical visits and provides early information that a patient may be symptomatic and require intervention. The agency also has a dedicated ambulance service that ensures the patient is taken to the appropriate ED if needed with an advance report to the ED case manager so appropriate triage and continuity of care can forestall a re-admission.
Innovative strategies and supplemental services that are possible through an ACO with a strong home health partner could improve patient outcomes and quality of life greatly while reducing taxpayer burden. This is truly a win-win situation for everyone.
Emma DeVito, MBA, president and CEO, Village Care, New York, N.Y.Emma DeVito
Accountable care organizations should have a tremendous impact on patient transitions because care transitions are the low-hanging fruit in achieving simultaneous cost savings and quality improvement. There is substantial evidence that improved preparation of patients and caregivers for self-care management can reduce re-admissions and achieve net savings.
Acute care facilities and physicians offices must focus on the patients who are in front of them, and ACOs will need home-based professionals who are responsible for care transition for recently discharged patients living at home.
This is an exciting time in the healthcare field, and there is tremendous opportunity ahead for high-quality home care agencies and nurses.
Clearly, networks will favor home care providers that minimize avoidable re-admissions. Successful ACOs will have to be selective in choosing home-based care professionals. ACOs will change the nature of how home care agencies compete for referrals; providers and professionals must now focus on strengthening patient education, improving primary care communications and ensuring adherence to evidence-based protocols.
Its important for there to be a true partnership between ACOs and home care providers. A strong relationship is critical to achieving positive patient outcomes. Incorporating care transition protocols, such as the care transitions intervention or the transitional care model into home care operations will transform care for the better.
Florence Marc-Charles, RN, MPA, CHHE, vice president of home care, Center for Nursing and Rehabilitation, Beth Abraham Family of Health Services, Bronx, N.Y.Florence Marc-Charles, RN
When patients are ready to transition to home care, they will have fewer choices of home care agencies once accountable care organizations have been implemented. They will be referred to specific agencies that have been identified and contracted by their ACO as able to meet their individual needs and improve their level of functioning by providing quality care.
This isnt a bad thing. In fact, patients may be better off because a lot of the research and vetting already will be done for them.
For providers, it will be survival of the fittest, and most certainly there will be some casualties. To become part of an ACO and receive patient referrals, agencies will have to prove they provide cost-effective quality care, have high patient satisfaction rates and can show evidence-based outcomes.
When all the dust settles, there will be fewer home care agencies left in the marketplace, but the accountability will be there and patients should be assured a continuum of care.
Joan Marren, RN, MA, MEd, COO, Visiting Nurse Service of New York, president, VNSNY Home Care, New York, N.Y.Joan Marren, RN
ACOs must meet quality benchmarks and reduce total spending to succeed. Focused attention on improving care transitions from acute care to home care can help ACOs achieve these goals.
One of the most important ACO functions that will affect patients transitions from acute care to home care will be bringing providers and community-based services together to work in new ways to improve outcomes and reduce costs. This ACO function will help bridge the gaps in collaboration, communication and information sharing among hospitals, community-based physicians and home care teams during the post-hospital discharge period when patients can be at highest risk for a re-admission.
ACOs also will need to create incentives for providers to improve performance through payment reforms that ensure shared accountability for transitional care and ultimately enhance the health of a population, improve the patient care experience and reduce cost per capita.
ACOs are expected to be truly patient-centered by ensuring access to healthcare. This includes access when patients and families need it most, within 48 hours post-discharge and 24/7 for a transition period of 30 days. Home care teams are well positioned to partner with hospitals and medical homes to enhance an ACO function that improves access to care during this critical period.
VNSNY has focused on transitional care models for the past six years and is at the forefront of integrating transitional care best practices and nurse practitioner-led teams into home care service delivery. We look forward to working with ACOs to ensure they have the resources and capacity to tackle the changes in practice and to support the cross-setting collaboration that underpins safer transitions from acute care to home care.
Dale Chaikin, RN, MS, director of community health nursing, North Shore-LIJ Health System, Westbury, N.Y.Dale Chaikin, RN
The hallmark of an accountable care organization is providing patient-centered care where the patient and the provider are partners in healthcare decisions, but also shifting the delivery of patient care to ambulatory and home environments. As such, home care will become a more integral component of the provider continuum under the ACO model.
This philosophy is the guiding force of the North Shore-LIJ Home Care Network. As one of the largest home care providers in the New York metropolitan area, North Shore-LIJ Home Care Network contributes to the delivery of seamless, high-quality care as the patient transitions from acute care to home care.
Coordination of care across all disciplines is essential to return patients to the maximum level of health and function. Today, more than half of Medicare beneficiaries have five or more chronic conditions. With census bureau projections indicating the number of people 65 and older will more than double by the middle of the next century, the need for management of patients living in the community is sure to increase. Uncompromising and well coordinated healthcare to the patient residing in the community is a priority of an accountable care organization and of the North Shore-LIJ Health System.
As the North Shore-LIJ Home Care Network has experienced, home care providers that are innovative in care management and utilizers of technology, such as telemedicine, will add value to every medical episode it participates in by targeting high-risk patients with individualized evidence-based interventions. Successful coordination of care across all disciplines is key to returning patients to maximum levels of health and function.
Hospital systems, such as North Shore-LIJ, have benefited greatly by having their own home care network, and will benefit even more under a new ACO model. Home care provides value to its system hospitals by enabling its patients to be cared for in the community a less costly environment than the hospital. Home care also seeks to reduce unnecessary hospital re-admissions by collaborating with hospitals on new chronic care and transitional care models.
The system created the ability to share electronic medical records across the continuum, enabling real-time intervention in the home. Sharing of information and access to data is essential in the coordination of care across the provider spectrum. This is not an easy task, but certainly one that is attainable when providers have a common culture and similar values.
Home cares changed role will be in context of the entire array of medical services. The ultimate goal of home care providers is to improve coordination, communication and care to the patient as he or she transitions from the acute care setting to the community. Home care is an essential tool in this process, improving healthcare the beneficiary receives, as well as helping to lower the cost of that care.
Theresa Cafiero, RN, BSN, MA, MBA, GNP-CS, director of patient services, Americare CSS, Brooklyn, N.Y.Theresa Cafiero, RN
As a component of the Patient Protection Affordable Care Act of 2010, the creation of ACOs is one of the first initiatives proposed as a potential solution to the fragmentation and multiple methods of payment delivery for healthcare. The goals of such an entity are keeping people healthy in the community, preventing disease and disability and coordinating comprehensive chronic care management.
Hospitals will be seeking to align themselves with home care agencies that have proven to be efficient, effective organizations with demonstrated positive outcomes. Home care agencies will want to position themselves as a value added, that is, providing services focused on high quality and cost effectiveness.
Within this newly envisioned home care model, home care will become a plug in to a greater network of healthcare delivery systems. Home care will be part of a larger care plan across the continuum and join a larger care team with greater accountability to produce cost-effective, successful outcomes. The implications for home care are far-reaching. For many types of patients with medical conditions, such as heart failure, diabetes, hypertension and COPD, home care almost always will be a key player within this bundled team.
Home care agencies must evaluate their individual structure, systems, processes and technology to ensure a competitive edge and viability within this rapidly changing healthcare arena. Measurable outcomes should be at the heart of every home care agencys strategy moving forward, in both financial and quality decisions, as they will take on even greater importance shaping the future of home care.
Catherine Pignatello, RN, MPH, MBA, administrator, Home Health and Community Services, Nyack (N.Y.) Hospital Home CareCatherine Pignatello, RN
Medicare-certified home health agencies are in a unique position to promote the achievement of ACO goals of lower cost and higher quality. Healthcare provided in the home is cost-effective and patient- and family-centered. CMSs proposed rule for ACOs links the amount of shared savings the organization earns to its performance on quality standards including those related to patient safety, care coordination and health care management of the at-risk, frail elderly population.
The goals of home healthcare are not only aligned with these quality standards, but they also can be clearly demonstrated through the Medicare home health outcome-based performance measurement system in which HHAs are required to report quality measures to CMS. Outcomes reported include patient improvement in functional status, such as ambulation, transfers, toileting, self-management of oral medications, surgical wound healing and incidence of unplanned hospitalizations.
Many HHAs have the technology in place point of care systems, electronic medical records and telehealth that will facilitate effective communication and coordination of care with other healthcare facilities in the ACO network, such as hospitals, primary care practices, rehabilitation and skilled nursing facilities.
Therefore, ACOs need HHAs to help provide care for those Medicare patients who can achieve safe management of their illnesses and chronic diseases in the home setting. HHAs also will strengthen ACOs coordination of care capability; the healthcare at home becomes a part of the organizations overall plan of care and fragmentation and gaps in care are avoided.