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Solving the blindspots in transitional care | Manpreet Singh Dhalla


CMS is moving to a value-based reimbursement program for home health agencies. This change represents a generational opportunity for agencies to implement new models of in-home care.

Manpreet Singh Dhalla

Manpreet Singh Dhalla

For the nation’s home health business, 2023 promises to be a year of tectonic change.

Starting in January, the Centers for Medicare & Medicaid Services (CMS) plans payment cuts so substantial that the National Association for Home Care and Hospice, the leading industry group, says more than half of the country’s home health agencies will operate at a deficit.

Simultaneously, CMS will roll out nationally its value-based reimbursement program, the Home Health Value-Based Purchasing (HHVBP) Model — incentivizing agencies to prioritize the quality and outcomes of care over simply maximizing the quantity of services provided.

The combined impact of the proposed payment cuts and a continued shift away from the traditional fee-for-service (FFS) model is a not-so-subtle nudge for home health agencies to innovate—both clinically and financially— and to do so with urgency. This change represents a generational opportunity for forward-thinking agencies to embrace and effectively implement new models of providing in-home care.

As a former operator of a home care agency, I am acutely aware of the challenges and opportunities posed by this pivotal moment. While home health agencies will inevitably make reactive adjustments going into 2023, this moment marks an opportunity to make more holistic changes to truly improve outcomes for in-home care delivery. Specifically, by focusing on patients' care transition as they move from acute and post-acute care settings to home-based care settings.

Transitional care is extremely complex. There are multiple stakeholders (provider groups, caregivers, families) involved often without visibility, coordination, or proper communication between them. This disjointed process can not only leave patients and their families feeling overwhelmed and underinformed. Far too often, it leads to preventable emergency room visits and hospital readmissions—thereby putting patients at risk and burdening the system with unnecessary costs and poorer health outcomes.

The negative outcomes surrounding transitional care are most prevalent within the elderly community and amongst vulnerable patients with chronic conditions. A recent study shows the negative impacts of healthcare transitions for adults with chronic illnesses: roughly 26% of patients experience emergency room visits, 18% are rehospitalized, 66% experience adverse drug events, and a whopping 81% experience medication discrepancies.

These poor patient outcomes are highly concerning, yet also unsurprising given how siloed care management is today. Just imagine the game of telephone that occurs when an elderly patient— who has multiple diagnoses, complex conditions, and numerous healthcare providers—is transitioning from a hospital to a skilled nursing facility and finally back to his or her home.

At the hospital, this patient will be treated by a physician, numerous specialists, and a nursing team, then a different physician and nursing and therapist team during a stay in a skilled nursing facility, and finally a visiting nursing and therapist team, a team of caregivers, and family members when back in the home.

Without a holistic, real-time perspective of a patient's daily care needs, home dynamics, and personal care goals, it is nearly impossible to provide high quality care.

All too often, a lack of coordination and communication leads to issues with medication reconciliation, DME fulfillment, and misunderstandings about follow-up visits and daily care needs—especially when the patient moves from a care facility into the home.

I’ve personally experienced numerous occasions when my former agency would send caregivers to a recently discharged patient’s home and see that the patient arrived home without his or her updated medications, needed medical equipment (such as a hospital bed or oxygen tank), or a physical therapy provider in place. Providers often operate independently and don’t have the resources or processes to ensure follow-through on seemingly simple tasks, which leads to care aides scrambling and patients suffering.

As it stands, there is often no coordinated communication or unified patient view (with real time updates) amongst caregivers and providers to optimize transitions of care and health outcomes. Therein lies the problem that must be solved–and solved quickly.

Next year's introduction of the HHVBP model offers optimism for providers who focus more on clinically effective patient outcomes. The program will hopefully prompt others to examine how they provide care.

Furthermore, as home health agencies continue to face rising nursing costs and lowered reimbursement, the need to innovate is paramount – both through the adoption of technology and improved processes that focus on value and outcomes.

Specifically, there will need to be an increased focus on transitional care, especially in conjunction with chronic care management. Providers should utilize technologies that increase communication and coordination amongst care stakeholders, while simultaneously investing in tools that enable real-time monitoring of patients and their adherence to the most critical tasks (e.g., medications, follow-up visits).

Focusing on processes that are proven to significantly improve health outcomes and reduce avoidable readmissions will also be important. This includes standardized risk assessments at discharge; automated alert mechanisms to proactively escalate care interventions; and proactive, frequent check-ins with patients or families.

Finally, implementing new technologies and processes to improve transitions of care will place an increased emphasis on care coordinators. Care coordinators are best positioned to utilize emerging technologies that help them “quarterback” and manage a patient’s care, family, and provider team.

Ultimately, providers willing to innovate and adopt change will be best suited to thrive in a reimbursement and inflationary environment that favors more value and risk. Focusing on ways to improve transitions of care will inevitably enable better outcomes and position providers to become more financially sustainable.

Manpreet Singh Dhalla is a founding partner of Reverence Care, a home care technology company.

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