Home-based care providers and Program of All-Inclusive Care for the Elderly (PACE) organizations are in a unique position to strengthen the work one another is doing to care for seniors.

No one understands this better than Alivia Care, a home-based care provider that also has PACE programs under its umbrella. In 2021, Alivia Care opened up Jacksonville, Florida-based The PACE Place.

“We thought No. 1, it related to the type of care that we gave, in terms of chronic elderness, geriatric frailty, many of the things that we see in our hospice patients, so we felt that we had some core competencies there,” Alivia Care CEO Susan Ponder-Stansel told Home Health Care News. “One of the things that we also wanted to do is just practice being responsible for the total cost of care, over a longer period of time.”

Jacksonville, Florida-based Alivia Care provides home health care, hospice care, personal care, palliative care, advanced care planning and PACE services across Northern Florida and Southern Georgia. Currently, The PACE Place serves roughly 150 seniors.

Ponder-Stansel has seen opportunities to bring in its home health resources to benefit the seniors who are receiving care through the company’s PACE program.

“We found that it was actually better to work with our home health agency, especially for things like wound care,” she said. “Home health [clinicians] have certain skill sets that most are very good at, things like wound care or cardiac rehab or diabetic education, some of those things that we would see in our PACE population. Some PACE providers just do it all themselves, so it depends on what works for them, but we felt this was a better way.”

In addition to this, Alivia Care utilizes its personal care staff to offer transportation escorts for medical appointments to seniors receiving PACE services through The PACE Place. These caregivers are also providing support in the home, delivering housekeeping services and help with chores.

On the other end, the company has been able to bring PACE services into the home.

“Not every PACE participant will come into your day center every day,” Ponder-Stansel said. “There are times when people just don’t feel well. We’ve been able to do occupational therapy, physical therapy, and bring that to the home for them. Because PACE is the payer for this, you don’t have to necessarily go through all the hoops of the OASIS. You can just contract with your home health to provide it.”

Referral-based partnerships

One Senior Care is a PACE organization that has formed referral-based partnerships with home-based care providers.

“Oftentimes it’s those home health companies that really know and see the conditions that the patients are living in, and really have a good understanding of the complexity of these patients,” Craig Worland, chief operating officer at One Senior Care, told HHCN. “They’re the ones who realize that the patient may need more, and they actually can be a referral source for us.” 

Erie, Pennsylvania-based One Senior Care is the top PACE provider for rural and Appalachian communities.

Similar to Alivia Care’s The Place Place, One Senior Care also brings its home-based care partners into the home of PACE participants that need additional support.

“There are definitely times where there’s a skilled need that we don’t have at a center within our staff, or there is something that a patient needs just due to how complex they are that we are not equipped to provide,” Worland said. “We work with the home-based care company to provide that.”

The biggest value-add of these partnerships is being able to offer an additional level of care through working with home-based primary care and home health providers, according to Worland.

“That to me is really the sweet spot for these partnerships, it’s allowing us to meet our goal, which is keeping the participant at home, that could be anything from wound care to infusion [services],” he said.

Despite PACE and home-based care providers being natural allies, Worland believes that the latter are sometimes reluctant to collaborate with the former.

“Sometimes home-based care companies view PACE as a competitor, and they almost have an aversion to working together, or an aversion to using PACE as a resource for their really sick patients,” he said. “I think what I’d love to see is just more of that collaboration.”

For Alivia Care, the internal partnership between its home-based care arm and its PACE program has meant leaning into each segment’s strengths, as opposed to taking everything on.

This doesn’t mean the collaboration is completely free from challenges.

“Coordination and communication is something that is sometimes challenging, and you have to build in mechanisms for hearing from those who are providing the care in the home, and then having them coordinate with your interdisciplinary care team to manage that care and make sure you’re responding to anything that’s going on, and planning adequately,” Ponder-Stansel said. “There’s a higher degree of communication than you would normally see with a Medicare patient.”

Worland also stressed the importance of strong communication within these partnerships.

Ultimately, he wants home-based care providers to understand the mutual benefits that come from teaming up.

“The onus is on the PACE plan to explain that and spell that out, but as patients continue to get sicker, get more complex and their care needs become more challenging, I really want these home care companies to be thinking about PACE as a partner,” Worland said.

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“We’re in the Medicare-certified home health business, and we’re in the private-duty business, and we’ve had palliative care for a very long time,” she told Home Health Care News. “But what we’ve been working on at Alivia is a more comprehensive solution.”

Jacksonville, Florida-based Alivia Care provides home health care, hospice care, personal care, palliative care, advanced care planning and Program of All-Inclusive Care for the Elderly (PACE) services across Northern Florida and Southern Georgia.

At Alivia Care @ Home, a more comprehensive solution means patients having the opportunity to take part in a goals of care discussion, while simultaneously receiving care.

“We really wanted to develop something where we could begin to assess, while delivering excellent home health care, if it’s time to perhaps do a goals of care discussion, and bring in our palliative team,” Ponder-Stansel said. “Whether or not the person ever wants hospice, or needs anything more from palliative care, it’s an opportunity to hear more about the stage of their illness, ask some questions and get some good information.”

The main impetus behind the program was the company’s discovery that roughly 55% of patients who are receiving Medicare-certified home health are also going to be hospice appropriate within a year, according to Ponder-Stansel.

The idea behind Alivia Care @ Home is that there is no wrong door for patients to enter.

“We may interact with them at different stages of their illness, or in different ways,” Ponder-Stansel said. “Each service stands on its own, but then for patients who really need more of a progressive system, more help, they can be put together in a way that meets the patient’s needs differently, than just say, episodic care for home health, which we do too. This is just a novel way to put them together in a manner that follows the patient and really meets a gap in care right now.”

Currently, each service has its own revenue stream, but Ponder-Stansel says that Alivia Care @ Home was designed with future value-based care goals in mind.

“If we’re in that space, where we’re working with an existing ACO to help take over the management of their high needs patients — because that’s something that a lot of the general track, REACH ACOs struggle with — then this is the exact kind of solution that would be able to not only get excellent outcomes for the patient, but also help you with any-value based or risk-based reimbursement,” she said. “Because you’re avoiding events and costs that really don’t improve the patient outcomes through this care navigation.”

Ultimately, Ponder-Stansel believes that there’s an opportunity for home health providers, that also have hospice under their belt, to train their home health staff on what progressive illness looks like.

“I think all of us along the continuum are focused very much on preventing readmissions, and really helping patients not have to go back to the hospital,” she said. “If we’re just doing episodic care, and just thinking transactionally, we may miss the fact that somebody we’re caring for is at the stage where they do need some help understanding they have another choice, and how to find that resource. I just think it’s a great opportunity for some great training.”

The post With Eyes Set On Value-Based Care Success, Alivia Care Introduces Alivia Care @ Home appeared first on Home Health Care News.

As the nation faces a debt ceiling of $34 trillion and climbing, it’s no surprise that the federal government is under pressure to find ways to cut program costs and crack down on overspending.

What is surprising is that the program they continually target in budget cutbacks has an impressive record of saving the government billions: Medicare-certified home health care.

Though home health care helps nearly 36 million 65+ and permanently disabled Americans recover at home and avoid costlier placements in institutions, the Centers for Medicare & Medicaid Services (CMS) has initiated deep cuts to the Medicare home health industry, totaling $25 billion in cuts over the next decade.

Government-funded health care programs like Medicare, Medicaid and Medicare Advantage (MA) home health are closely connected in how they are financed.

This is because Medicaid and Medicare Advantage have such insufficient funding to begin with, forcing providers to rely on Medicare to cover the shortfall to offset the costs incurred in treating patients under Medicaid and Medicare Advantage – a decade-old system that is severely flawed and requires all three programs to ride on the backs of one another for financial stability.

The solution is two-fold: First, CMS must stop cutting Medicare home health care funding. Cutting funding year after year has only created turmoil in the very industry that is essential in providing stable, in-home care for vulnerable Americans.

Second, CMS and the Medicare Payment Advisory Council (MedPAC) must seek to develop new policy approaches that account for Medicare’s cost-savings and support a sustainable funding model for Medicare, Medicaid and MA. This two-fold solution will ensure that purported federal efforts to save money and cut programs are not done so to the detriment of millions of seniors and adults with permanent disabilities.

As funding cuts continue, the costs of business and operations increase, leaving home health providers forced to either cut wages, services and coverage areas or shut their doors altogether. This ultimately costs Medicare more money by pushing patients into costlier institutional settings while simultaneously risking health outcomes.

Medicare home health patients have better health outcomes and are at less risk for rehospitalization. Since COVID, we have seen a substantial shift in America’s future of health care as more evidence has shown home to be the safer and more comfortable setting. Without fixing the flawed system, vulnerable Americans won’t be able to access this option of care and our government will be forced to spend even more money.

To put it into perspective:

It costs $2,010 per month to care for a patient at home for 30 days under home health care.

A skilled nursing facility costs an astronomical $16,500 for that same care.

That’s a cost savings of approximately 88% for every patient diverted from a skilled nursing facility and cared for at home. Put another way, we can care for eight people at home for the cost of caring for one person in an institution.

Why does the federal government continue to put a target on the back of an industry that has shown to be a win-win for both patients and the federal budget?

Year after year, these seemingly baseless funding cuts destabilize the nation’s ability to move health care into the home, and further our growing debt. The federal government should be fixing this broken system by taking the money Medicare home health care saves and reinvesting it into a practical funding model that supports providers’ ability to expand access to these essential services.

In its Strategic Framework plan, CMS claims to have a “commitment to ensuring all American people have access to the highest quality health care.” The home health industry undeniably operates within that commitment, keeping America’s vulnerable populations cared for in the patient-preferred, cost-effective setting. We are finding it increasingly difficult to see how the federal government has lived up to that same promise.

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Now, it’s still on that journey, but much further along. The company’s story is one of promise, one that shows home-based care providers can become risk-bearing entities that have a larger control of their financial futures.

“We really believe that that’s going to be the way that you succeed financially,” Ponder-Stansel told Home Health Care News. “And, also, how you succeed in being able to deliver better outcomes to seriously ill patients.”

The Jacksonville, Florida-based Alivia Care provides home health care, hospice care, personal care, palliative care, advanced care planning and other services across Northern Florida and Southern Georgia. The company has its own Program of All-Inclusive Care for the Elderly (PACE), and plans to open another in due time.

Ponder-Stansel sat down with HHCN and its sister site, Hospice News, to chat about that value-based care journey – and more – last month at Home Care 100 in Scottsdale, Arizona.

The conversation is below, edited for length and clarity.

HHCN: What are your company’s biggest focuses for 2024?

Ponder-Stansel: What we’re really focusing on is standing up value-based care.

We really want to be behind those at-risk physicians in those REACH ACOs, or working with them and figuring out how to be a partner. We’ve been preparing for this for years, that’s what we’ve been doing. And it’s a big opportunity.

So, you’re looking for the best at-risk partners?

That’s right, and we’re also already at risk through our PACE program.

But we’d like to partner with them. We really believe that that’s going to be the way that you succeed financially. And, also how you succeed in being able to deliver better outcomes to seriously ill patients.

And I think that when you’re in any kind of value-based situation, you do need all the components – the private-duty, the Medicare-certified hospice, adult day care, all parts of that care.

Take PACE, for example. It’s a longitudinal service, there’s many mature programs that have had their participants for 10 or 15 years. You’re managing them to keep them in the community and out of long-term care. Now, they may go into long-term care intermittently after a hospitalization, but they’re not custodial. They’re not living there.

You need different tools to do that.

Now, the challenges are that there’s so much consolidation, and so many big companies with a lot of PE investment. We’re a nonprofit regional, so you’re always weighing and balancing how fast you can get your solution to the market without having to merge or take on additional capital. But so far, we haven’t had to go that route.

With some of the cuts coming to home health, and the costs of labor, we’re seeing some margin compression. So we know that the fee-for-service business is probably not going to get us where we want to go.

On the other side of that coin, with value-based reimbursement, there can be lower reimbursement rates there, too. How do you offset that?

It depends on which value-based program, because there’s so many flavors of that.

In PACE, for example. In Florida, Medicaid rates are terrible. That’s why we haven’t had much competition in PACE down there.

But these are dual eligibles. So for almost all of these, you’re looking at their HCC scores. You’re getting your monthly payment – your per member per month – based on their acuity, and then it’s up to you to manage everything, whether it’s a heart transplant or dental care.

That’s the point that I like about it, Special Needs Plans and D-SNPs and the I-SNPS, you get that bucket of money and you get to make decisions based on patient needs without going back for pre-authorization.

It is upside and downside risk, and you really have to have some good AI to help you understand who’s in your population and make sure that you’re meeting that need. It’s about recognizing that risk, and not just giving one visit per week, for example.

We learned the hard way on PACE, and finally have a margin there. It’s year four. If you can manage PACE – because you’re basically a health plan at that point – it really is the best way to manage people with advanced and chronic illnesses.

How specifically are you using AI? Is it table stakes moving forward?

Yes, I think you have to be invested in it. And you have to be intentional about what you need it to do for you.

And part of the challenge is getting the data quick enough.

We want to really be able to stratify risk and create a patient profile. There are certain algorithms that you can develop to say, “Okay, when these particular things happen, you need an extra visit, you probably need to do a med rec.” Because all those things downstream help prevent that rehospitalization, help prevent that adverse outcome. So that’s what we’re looking at.

With the type of risk- and value-based care success you’ve now achieved, does success now beget success, in that you have the proof to show off?

Yes. That was deliberate on our part to do PACE first, because it’s a program that has a structure, a payment system that serves the population we wanted to serve.

We figured if we were going to jump in, we should learn how to do that. And that was a really good decision on our part.

But you have to have a certain scale and the capital to be able to do that in the first place.

This movement toward these at-risk relationships seems kind of necessary to survive in today’s environment. Are you excited about that opportunity? Or are you more worried about it?

Both, obviously. But I really believe that if we have the funds, and do that good, patient-centered care without having to go ask for things from [third parties], we can help people that have these serious illnesses have better outcomes. And that’s the care that gets me going.

You’ll make some margin if you do it well, too. And that’s necessary, but honestly, if you can create that person-centered care based on what you think is best for the patient and build a better system, I think that’s most important.

Because right now, it’s so transactional and so fragmented. You can look at claims data and see what happens to older adults with serious illnesses. And we all lose when there’s low-value care provided. So there’s an altruistic motive too. Plus, I think we’re going to die if we just stay in fee for service.

The post How A Home-Based Care Provider Weans Itself Off Fee-For-Service Reliance appeared first on Home Health Care News.

Artificial intelligence is likely to be a society- and business-altering technological development.

But, just like the advent of the internet before it, AI’s emergence will undoubtedly lead to as many empty promises from business leaders as it does actual use cases.

That’ll particularly be the case in the early innings of AI, which I believe we are currently in.

At any health care conference over the last five years or so, AI chatter was as ubiquitous as COVID-19 chatter was during the early days of the pandemic. But I’d often come away from that chatter with no more information on how providers planned to put AI to use than I had before.

This year is likely to be one of the first where a good chunk of providers are actually putting AI to use, however. That’s why, in Home Health Care News’ trends for 2024, we included the prediction that “providers will find ways to more seamlessly and strategically integrate AI.”

Over the last few months, I have tried to cut through the empty promises and ask providers directly: How are you currently using AI, or how do you foresee your organization using it in the near-term future?

More direct questioning, unsurprisingly, led to more direct answers.

In this week’s exclusive, members-only HHCN+ Update, I hope to take you behind the curtain on providers’ AI strategies across home-based care.

An AI prologue

First things first, every provider I talk to about AI generally starts off with a similar opening statement on AI, which is that they do not believe AI or other technology will be able to replace hands-on, human care.

Particularly in the early innings, that seems like the right mindset.

“We hear so much about tech in the home,” Visiting Nurse Health System CEO Dorothy Davis told me. “Not that I don’t think that’s an important piece, but I think the revolution is going to be on the consumer side and on the caregiver side. Tech is an enablement. If the user and the person impacted doesn’t understand it, the tech means nothing.”

That’s a key caveat. If AI cannot be implemented in a way that can be understood by a select few people – or in some cases a large group of people – then it is useless.

It’s also generally useless, particularly for generative AI, if there is not good data to feed into it.

Providers can’t go from an archaic operation with no data tracking capabilities to a future-facing, AI-embedded operation in one jump.

“I often describe data as the clay,” Guillaume Vergnolle, a senior data scientist at AlayaCare, told me on stage at Aging Media Network’s Continuum conference. “It’s your best material to come up with an [AI] solution. You need the right kind to come up with the solutions. So, when it comes to the retention problem, make sure that you’re actually collecting the right data to mirror what you’re trying to solve.”

AlayaCare is one of the home-based care vendors aiming to help providers out with AI. Its commitment to AI solutions – along with WellSky’s, for instance – is a heavy indication that providers will soon be further along with practical implementation.

Where AI will be useful

Compassus COO Laura Templeton told me that she sees AI becoming useful in two areas in the near-term future: documentation and scheduling.

“We currently have a couple of work streams right now — one being for clinicians — around how AI can make their job and role easier or better,” Templeton said. “We’ve been looking closely at how to consolidate and optimize processes by utilizing AI tools.”

Compassus leaders were the first to divulge AI use cases to me in December at the Continuum conference.

“We’ve piloted several scheduling programs where we’re using our clinicians at the top of their license, and where we are sending the right clinician, at the right time, to the right place,” Templeton continued. “Scheduling is one area that comes to mind where I’m excited to see what AI can do.”

Indeed, scheduling is one area where providers could use advanced help.

After all, staffing is a top concern for nearly all home-based care providers. Within that, most leaders will say the key issue they’re trying to solve is retention. Within that, scheduling is the No. 1 reason that home health workers turnover.

“We’re having humans doing things that humans don’t have to do, scheduling being one of those,” VitalCaring President Luke James told me. “Medical records. Systems work. Where can we apply some generative AI and some kind of workflow technology that can take most of it out of the hands of humans? Reacting to the exceptions only, for instance.”

Axle Health, a home health scheduling platform, announced a $4.2 million funding round Thursday.

James also mentioned documentation, which Jordan Holland – the VP of value-based contracting at Compassus – also dove into in December.

“Clinical documentation has always been a big one — which has a lot of different layered potential use cases,” he said at Continuum. “There’s the idea of talk-to-text, but then there’s also talk-to-text to other discrete fields. Talk-to-text is great, but is that actually going to help you facilitate filling out an OASIS form? There’s an added layer to that because that talk-to-text then gets submitted to another party.”

James added that VitalCaring “has to get more efficient in the back office with rates continuing to fall.”

That is the core driver of a lot of home health providers’ AI strategies: finding ways to become more efficient to avoid fallout from any rate cuts from the Centers for Medicare & Medicaid Services (CMS).

Alivia Care CEO Susan Ponder-Stansel is taking the same approach, but through a different lens.

A provider that has gone deep into value-based care over the last few years, Alivia Care wants to find ways to up reimbursement through better outcomes.

“We want to really be able to stratify risk and create a patient profile,” Ponder-Stansel told me. “There are certain algorithms that you can develop to say, ‘Okay, when these particular things happen, you need an extra visit, you probably need to do a med rec.’ Because all those things downstream help prevent that rehospitalization, help prevent that adverse outcome. So that’s what we’re looking at.”

Elara Caring CEO Scott Powers, meanwhile, told me that stripping caregivers and home health aides of non-value work is the “No. 1 use case” that he sees coming to fruition.

The home care side

Personal home care providers are generally approaching AI a bit differently, which is interesting to note.

For instance, Home Helpers sees it helping most on the marketing side, particularly for franchises.

“We use AI in our franchise-development process around identifying potential new franchisees, and doing some specific psychographic targeting,” Home Helpers President and CEO Emma Dickison said during a HHCN webinar last year. “Internally, for the team, where we see the biggest lift with AI … is in the marketing department. But there are just so many applications.”

Similarly, BrightStar Care isn’t writing big AI checks yet, but is, for now, using AI-enabled chats on its website to help out with back-office functions and to get feedback from clients.

But there also are rate concerns for these home care providers, some of which are similar to home health providers’ concerns.

For those that are diving further into Medicare Advantage (MA), for instance, there’s a need for more efficient processes to make MA beneficiaries worthwhile clients from a business sense.

“I think you just have to prioritize where you can make the biggest difference on the margins,” Kristen Duell, the EVP of experience and innovation at FirstLight Home Care, told me. “We need to create automation in certain areas, leveraging technology and leveraging machine learning so that we can reduce overhead costs – and sometimes field costs – so that we can take on those health plan [clients]. We need it to make economic sense.”

The post No Empty Promises: How Home-Based Care Providers Actually Plan To Use AI appeared first on Home Health Care News.

Home-based care providers have faced many headwinds over the past few years. They’ll continue to do so in 2024.

But uncertainty has also plagued providers, and there may be less of that this year.

Providers know the threat of fee-for-service Medicare cuts. They know Medicare Advantage (MA) penetration is an unstoppable force. They know staffing woes will be a mainstay, even if the labor market nominally improves.

Last week, at Home Care 100 in Scottsdale, Arizona, I had the chance to catch up with over a dozen home-based care executives. I listened to panels. I had on- and off-the-record conversations.

What follows won’t be a complete emptying of my notebook from the conference, but it will be a good summation of most of the reporting I’ll publish on Home Health Care News over the next month or so.

These thoughts pertain to value-based care, M&A, a big-name turnaround and more. They’re the topic of this week’s exclusive, members-only HHCN+ Update.

Ordinary issues

Home health providers have faced extraordinary issues for so long that they’ve rendered those challenges ordinary.

My “What are your biggest challenges?” questions were frequently met with, “Well, you know” responses.

“A lot of headwinds,” Visiting Nurse Health System CEO Dorothy Davis told me at the event. “It would be nice to talk about the wins rather than the headwinds, but that’s become pretty common.”

Based in Georgia, Visiting Nurse Health System provides home health and hospice to more than 7,000 patients across the greater Atlanta area.

Because those headwinds have been so constant and prolonged, providers are beginning to make strides against them. Like the process of grieving, they’re not getting over the issues necessarily, but they are learning to survive despite them.

“We’re really focused on standing up value-based care,” Alivia Care CEO Susan Ponder-Stansel told me. “We really believe that that’s going to be the way that you succeed financially, and also succeed in being able to deliver better outcomes to seriously ill patients.”

Jacksonville, Florida-based Alivia Care provides home health, hospice and palliative care services across North Florida and Southeast Georgia. The company also operates its own Program of All-Inclusive Care for the Elderly (PACE), which is one of the more proven value-based care models in senior care.

In 2022, Ponder-Stansel told HHCN that her organization was embracing the “learning curve” of getting into value-based care. This was right around the time the Centers for Medicare & Medicaid Services (CMS) first proposed a significant rate cut for home health providers.

But, eventually, that learning curve bears fruit. And it has done so for Alivia Care in PACE, but also in all of its service lines.

While certain providers have offloaded certain service lines to hone in on core competencies, Ponder-Stansel believes that all of those different types of care are necessary to truly go at risk, including primary care – through partnerships or otherwise.

“I think that when you’re in any kind of value-based situation, you need all the components: private duty, Medicare-certified home health, hospice, adult day care, etc. We have all of these parts of care,” she said.

Outside of the services lines, both Ponder-Stansel and Andrew Molosky, the CEO of Chapters Health System, believe that a top-down understanding of value-based care is non-negotiable.

In other words, it’s not just about “moving to value-based care”; it’s about ingraining a culture and understanding around value-based care – and determining what exactly that means for each organization.

“I think the first relationship that you must establish – and this sounds a little hokey – is a pretty good internal harmony with your employee base, your stakeholders, your board, your governance, structure, whatever that might be,” Molosky told me. “Because nothing will waylay an organization faster than when you have people viewing the priorities differently.”

The Tampa, Florida-based Chapters Health System is a community-based nonprofit organization. It provides types of home-based care services to nearly 120,000 patients.

Buyers and sellers

As providers come to grips with their operating realities, their leaders seem to believe that the M&A market will open up, too.

While some offered caveats, nearly every leader I talked to believed that transactions would increase in 2024. To be fair, 2023 had quarters with historically low activity. But, at some point in the near-term future, consolidation is likely to become even more of a feature of the home health landscape.

“I do think you’re going to see some more activity with the bigger companies this year than we saw last year,” Elara Caring CEO Scott Powers told me. “I think interest rates are going to help with that. And I think private equity is going to get a little more involved in some of these deals.”

One of the largest home health providers in the country, Elara Caring provides care to more than 60,000 patients across about 200 locations. It offers home health care, hospice, personal care, palliative care and behavioral health care.

Outside of interest rates, one of the micro trends that has been holding home health M&A back over the last two years is the disconnect between peak multiples in 2020 and 2021, and what buyers are willing to offer now.

“The big question mark right now is what multiples are going to look like,” VitalCaring President Luke James told me. “I think we’re going to see a couple of deals that reset the market, especially for sizable transactions.”

VitalCaring, also based in Dallas, will likely be a part of that resetting. The company, led by April Anthony, is growing steadily. It has dozens of home health and hospice locations in six Southeastern states.

James believes that hospice valuations will remain at bay, but that home health multiples will continue to come down until buyers gain a greater appetite for seller targets.

At the same time, those 2020 and 2021 multiples are already baked in. Financial backers looking to offload an asset in 2024 or 2025 could have a hard time making a desired return on investment.

“Even if those businesses doubled in size, if they’re only able to sell for 11 or 12 times, you’ve got to make up a lot of ground versus where they enter those businesses,” James said. “It’ll create pressure. Where are those sellers? How low are the sellers willing to go to get a deal? Or how high are those buyers willing to go to satisfy their return metrics?”

An Aveanna turnaround

Aveanna Healthcare Holdings (Nasdaq: AVAH) went public right before the markets came tumbling down, in April of 2021.

It has undergone extreme staffing headwinds and also leadership changes. And yet, almost three years later, it’s still standing.

That led to a seemingly chipper Jeff Shaner – the CEO of Aveanna – in Scottsdale last week.

Based in Atlanta, Aveanna provides Medicare-certified home health care, personal care and pediatric care across 33 states. Through acquisition, the company went from being a primarily pediatric care provider to a senior care provider in just a matter of years.

Though it is not near its initial stock price of close to $12 per share – it sits at about $2.50 per share right now – it has climbed significantly over the last year. In January 2023, the company’s stock price was sitting around $1. That led to speculation that it would not even make it on the public market for another year.

Shaner is now around to tell the turnaround story.

“We took a very detailed, strong, honest look at ourselves about 15 months ago,” Shaner said. “We didn’t necessarily like everything we saw. I had to make some very honest assessments of where we were as a company, and where we wanted to be. But, 15 months later, we can exhale now as an organization. Because we know where we’re going.”

That’s significant. Aveanna boasts one of the strongest home-based care footprints in the country. Historically acquisitive, it has been quiet during recent years. Perhaps that could change in 2024.

The obstacles remain. But providers, such as Aveanna, could be starting to find their way.

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Instead, leaders at in-home care organizations are working strategically to enhance services, creating a more integrated care delivery model – a continuum of care.

At Intrepid USA, this means pairing the company’s home health and hospice services more closely together.

“Let’s pair up our hospice program everywhere we have home health. We include the palliative programs,” John Kunysz, president and CEO of Intrepid USA, said during a panel discussion at the Aging Media Network Continuum conference. “Not from the standpoint of a separate service line that’s profitable, but primarily for identification of patients that were hospice eligible.”

Intrepid USA is a Dallas-based home health and hospice provider with more than 60 locations across 17 states.

Strategically, creating a continuum of services allows providers to maintain relationships with clients and patients longer – before their needs become acute, all the way through to end of life. In turn, from a business perspective, this creates revenue stability and increases appeal to payer partners.

“All of those different pieces that we’ve added are upstream of hospice, but they’re all really designed to help people have a better experience when they’re experiencing either a decline, an acute illness, a serious illness,a chronic illnesses, or an end-stage of illness,” Susan Ponder-Stansel, CEO of Alivia Care, said during the event.

Alivia Care is primarily a provider of home health, hospice and palliative care services. The company operates across 32 counties in North Florida and Southeast Georgia. The organization’s roots are in hospice, but under Ponder-Stansel’s leadership, Alivia has pursued diversification to best serve patients.

That task has been a gradual process, Ponder-Stansel explained. And for in-home providers that are trying to build out a continuum of care, the road isn’t always easy, she noted.

“It’s the risk involved: the capital that you need, the tolerance for failing, but also I see regulatory barriers,” Ponder-Stansel said.

One of Alivia’s most recent continuum efforts – and an example of the challenges associated with such a build – is its expansion into the Programs for All-Inclusive Care for the Elderly (PACE) model. Standing up a PACE arm has taken “three years of losses and hard lessons,” but now, Year 4 of the initiative, Alivia is seeing a positive margin with it.

Another barrier to building out a continuum of care at a home-based care organization is having a “silo mentality,” according to Kunysz.

“There’s almost the nostalgia to go back, and there’s a resistance to innovation,” he said. “It’s hard to deal with.”

Salmon Health, an organization that has seen success when it comes to building out a full continuum of care, has also encountered challenges along the way.

Namely, the idea that the organization’s focus should be providing value to health systems.

“We’ve really turned our focus away from what we can do, in terms of adding value into that part of the health care system, to looking at the value that we can provide for the residents that reside under our roofs,” Matt Salmon, CEO of Salmon Health, at Continuum. “With the advent of adding home health, hospice and private-duty, the company has grown to adding our skill and expertise to people living under their own roofs.”

Salmon Health has a full continuum of senior care that spans independent living, assisted living and skilled nursing to home health, private-duty hospice and even childcare. The Milford, Massachusetts-based operator reaches about 1,000 older adults in its communities and another 1,000 in the surrounding area.

“People are starting to realize that it is worth it to pay for those services to stay at home,” he said.

With this in mind, Salmon Health is looking to aggressively grow its home health business. The main hurdle to clear on that front is consistent staffing constraints, however.

The company is also looking at innovative models, such as continuing care at home.

“[We’re] looking at how we can leverage our reputation and our skill set, and start to manage families in the community, and then layer in the ability for people to sign up for a subscription and pay for services that would be in the bank,” Salmon said. “For example, we might guarantee that you would have 21 days of home health aides in the next year anytime you need it.”

On its end, Alivia Care is looking at primary care acquisition targets, too.

“CMS believes that primary care is going to be the answer to this fragmented care problem, and it can be depending on how you structure it,” Ponder-Stansel said.

Ultimately, for providers hoping to build out continuums of their own, Ponder-Stansel, Salmon and Kunysz all emphasized the importance of staying the course.

“It’s water grinding away the stone rather than trying to figure out where to get the capital and the staff for a significant expansion,” Salmon said.

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Home-based care organizations continue to evolve. As they do, they’re becoming more pre-acute and embracing preventative care.

Traditionally, providers step in after an acute event has already occurred. This has slowly begun to shift, as providers realize that if they are already in the home, they can prevent some of these events or outcomes.

Signify Health, a part of CVS Health (NYSE: CVS), exemplifies this shift.

“What we do is pre-acute, we do not specifically target members after acute scenarios,” Denise Graeber, senior vice president of product management at Signify Health, told Home Health Care News. “That doesn’t mean it doesn’t happen, that we actually have a visit after an acute event, but the purpose of our visit is not to address any specific condition. The purpose is to really be holistic and complete in the evaluation, and to help prevent acute incidents.”

Dallas-based Signify is a value-based platform that leverages analytics, technology, health care provider networks and over 10,000 clinicians to power value-based payment programs. The company’s home and community services division conducts millions of in-home evaluations per year.

The company spends anywhere from 45 minutes to an hour in a member’s home doing a full assessment of their health — a medication review, prior history check, a physical examination, coverage of social determinants of health and in-home diagnostics and labs, Graeber noted.

“Last year, a provider came to [a member’s] home and identified something when listening to her heart that sounded like a potential concern,” she said. “We suggested the member follow up with her PCP. She went in and found that she actually did have an issue with her bowels that was extremely concerning, both important and acute. [In-home evaluations] are just another check to help get ahead of acute situations and prevent other health conditions.”

Signify is able to collect data in the home that becomes a bridge to eliminate information gaps for their member’s PCP.

At-home interventions

As a company, MedArrive’s core focus is emergency department (ED) diversion and hospital admission reduction. This means pushing back against the ER as the first primary source of care.

The Dallas-based company works with health plans to enable home-based care and virtual care, utilizing non-traditional workers on the way, such as emergency medical services (EMS) professionals. The company focuses almost exclusively on Medicaid and dual-eligible populations.

More recently, MedArrive moved into the cardiology at-home space, through a partnership with Heartbeat Health, a tech-enabled virtual cardiology company. The collaboration will allow the company to deliver medication titration, symptom assessments and other at-home services.

Even with a focus on preventative care, MedArrive CEO Dan Trigub is quick to clarify that the company isn’t operating in the on-demand care space, and that health care is a lot more than just one acute episode.

“For us to really lower the total cost of care and have a material impact on health outcomes, we want to see these people over an extended window of time,” he told HHCN. “Our case management social work team is really helping to address health literacy, getting better durable medical equipment and helping with transportation.”

Trigub thinks that vulnerable populations will be the ones to benefit most from at-home care companies adapting more features of pre-acute care.

“For more vulnerable populations who don’t have anybody coming to see them and who, unfortunately, use the ER as their primary care source of care, there’s a huge impact from doing pre-acute visits, building relationships and extending care into the home of these populations,” he said.

Whether more at-home care organizations will become more pre-acute in nature will depend on if the company has the size and capacity to potentially pull it off, Alivia Care CEO Susan Ponder-Stansel told HHCN.

“In our case, we have hospice, we have PACE, we have some other lines of service that very much complement one another and are part of a continuum, but if you’re a standalone home health … it might not be something that you really have the resources or interest to do,” she said. “A lot of it depends, too, on the payment source.”

In other words, providers working strictly under the Medicare umbrella may have a tougher time pulling this off.

Alivia Care is primarily a provider of home health, hospice and palliative care services. The company operates across 32 counties in North Florida and Southeast Georgia.

“If you’re working in a value-based environment where you’re either working with a Medicare Advantage plan, or you’re part of a system or medical provider group that has at-risk lives, that’s where I think the opportunity is going to come for preventative, proactive care of the patient rather than, letting things progress to the point where you’re basically cleaning up after an incident that perhaps could have been either avoided or moved fairly far into the future,” Ponder-Stansel said.

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However, providers that have gained a foothold in the palliative care space have seen strong clinical value in it.

Broadly, palliative care is both an approach to care, as well as an actual medical subspecialty, according to Rory Farrand, vice president of palliative and advanced care at the National Hospice and Palliative Care Organization (NHPCO).

“The goal of palliative care is to improve the quality of life for people living with serious illness, whether that illness is going to be life limiting, terminal, or just something that’s really serious,” she told Home Health Care News. “Our objective is to manage pain, symptoms and provide other types of support, depending on a person’s individual situation or their specific needs.”

The Washington, D.C.-based NHPCO is the largest membership organization for providers and health care professionals who care for people affected by serious and life-limiting illness.

Oftentimes, palliative care is conflated with hospice care services.

“The biggest difference between palliative care and hospice is that [the former] can be provided at the same time someone is receiving curative care or disease modifying therapies like treatments for cancer or dialysis,” Farrand said.

Palliative care is sometimes operated by home health or hospice companies — 41% of home-based palliative care programs are operated by hospice agencies and 7% are operated by home health agencies, according to Center to Advance Palliative Care and Palliative Care Quality Collaborative data.

Still, the reimbursement landscape for palliative care isn’t always as straightforward as it is for home health or hospice.

“Medicare does not cover palliative care as a benefit, so a lot of organizations really struggle with how palliative care is paid for,” Farrand said.

Most commonly, palliative care is covered under fee-for-service arrangements, for example, under Medicare Part B.

This largely limits services to clinicians and organizations that can bill for these services, such as physicians, nurse practitioners, physician assistants, and some social workers or psychologists, if they’re providing therapy. This creates a barrier to entry for home health providers.

Along these lines, nTakt CEO Mark Hendrix pointed out that palliative care isn’t exactly a high-margin business model.

“They are not what I would consider highly profitable, but you can build a palliative care program that is financially sustainable,” he told HHCN.

nTakt helps organizations launch palliative care programs. The company assists organizations in building financially viable programs with the right technology in place.

Though palliative care is financially reliant on fee-for-service reimbursement, there are other opportunities in the space, especially for providers that have an established track record of positive health outcomes.

“Once you’ve proven yourself in the marketplace, and you’ve proven that you can reduce cost of care of patients with your palliative program, you can then go out and prove your value to insurance companies and other payers,” Hendrix said. “Then you could step away from the fee-for-service model and go more with a negotiated alternative rate. At that point in time, it can be much more financially viable.”

Palliative care is a differentiator for Alivia Care

One company that has made palliative care work is Alivia Care Inc.

Alivia Care is a provider of home health, hospice and palliative care services. The company operates across 32 counties in North Florida and Southeast Georgia.

Alivia Care provides palliative care for patients through hospital partnerships. It also provides these services to patients through oncology partnerships.

In general, Alivia Care CEO Susan Ponder-Stansel has seen an increase in the demand for palliative care, even if patients aren’t able to identify these services by name.

“Sometimes patients and families don’t know the term, but we will see someone in our home health side, for instance, who has end-stage renal disease or advanced cancer, and their caregiver will say, ‘She’s tired of going to the hospital, I wish there was something different we could do,’” Ponder-Stansel told HHCN. “People are sometimes looking for an alternative to very aggressive care that doesn’t always improve their situation.”

Palliative care has brought value to Alivia Care’s home health service line by allowing the company to stand out among peers.

“If you’re in a crowded market, having a palliative care specialty program or focused care program can be a differentiator for you and it can give you an opportunity to look for referrals and patients who might come from oncologists, or those treating advanced heart disease or breathing disorders,” Ponder-Stansel said.

At Alivia Care, palliative care is also a big component of its value-based care engagement.

“Palliative care has been shown to be a way to help patients receive the appropriate type of care that will really improve their outcomes, but will not get them into places where they will receive what we call low value care,” Ponder-Stansel said. “Some of that low value care is often very aggressive, can be very painful, can be very wearying and it won’t really change the course of their illness or improve their quality of life or outcomes.”

Ponder-Stansel noted that many Medicare Advantage organizations are eyeing palliative care as a way to manage people with very serious and advanced illnesses.

Ultimately, Ponder-Stansel believes that palliative care is a valuable tool for post-acute care providers to have.

“I don’t think people are making big margins on that particular line of service, but it can be a way to help the other types of services you provide,” she said. “If you have provider bandwidth, you have resources in your home health segment, or among your medical group, it is a way to utilize that capacity very effectively.”

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The pursuit of growth is a never-ending journey for home health providers, and there are plenty of ways to err on that pursuit.

Many leaders, through observation and first-hand experience, are able to recognize what should be avoided for companies that are aiming to accelerate.

To get a better understanding of what home health operators need to know when it comes to the right and wrong way to grow, Home Health Care News asked several home health leaders to weigh in.

According to them, the lack of proper training, failure to embrace payer diversification and not taking patient experience into account are all examples of errors that can be detrimental to a company’s growth plans.

***

Now that health systems and payers unanimously recognize the high value of home health care services, providers like us are in a period of unprecedented demand and rapid growth. Growth brings change, and in organizational psychology, doing new things or more things at a faster rate is going to initially produce anxiety and fear. This is natural and to be expected.

The biggest mistake that home health providers are making in the pursuit of growth is not focusing enough on the activities and behaviors that build trust. Leaders must slow down enough to listen to their teams, address their concerns, and inspire them, and that includes new teams when your growth is acquisitive. We are only as good as our people. They’re our greatest advantage. It’s crucial to take the time to build understanding, trust and buy-in. When you’re doing that right, you can feel the sense of excitement and shared vision, and that’s what it takes to grow and innovate effectively. Speed and success are heavily dependent on going slow, at just the right times.

— Michael Johnson, president of the home health and hospice divisions at Bayada Home Health Care

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The constant pursuit of traditional Medicare is by far the biggest mistake being made today. These patients are becoming scarce and are already scarce in many MSAs, yet even the best and most well-run providers are continuing to spend resources competing for a shrinking subset of endangered Medicare patients. This may make sense financially in the short-term, yet long-term, it more than exacerbates the cost-structure problem. The powers that drive the U.S. health care market: MedPAC, CMS, legislators from both parties, and the American health care consumer, are demanding lower cost of care. Providers who are busy fundamentally restructuring their back-office support and veraciously streamlining workflow will not only survive, but flourish in the new reality of Medicare Advantage home health.

— Brent Korte, CEO of Frontpoint Health

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In my opinion the biggest mistake that home health care providers are making in their pursuit of growth is – based on our own experience and growth pains – a come one, come all approach to both patients and clinicians. We want to help all patients to the best of our ability as caregivers and agencies, but what if the patient’s in-home support system is not sufficient, or a patient is better suited for a long-term care facility? Unfortunately, physical decline or dissatisfaction could be a result of a patient simply not being placed in the health care venue that best meets their specific care needs.

When it comes to new clinicians, it is best to really spend time in the onboarding process to determine mutually-beneficial assessments of focus, fit and future. Is home health care the best career fit, is the focus on continuous learning and growth, and how about the future? Are we meeting each other’s expectations as an employer and employee? Disappointment is often the realized gap between expectations and reality.

— Cleamon Moorer Jr., president and CEO at American Advantage Home Care

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A mistake companies make when seeking growth is not investing the time and effort to ensure that staff providing care have a high-level of training and skill that will assure high-quality care. This includes training around the structure of each visit to ensure that all the areas they should touch on with the patient are addressed consistently and at each visit. Due to OASIS-E, skill in assessment and in high-quality documentation is more important than ever.

Oftentimes when we are growing there is such pressure to keep up with volume that we put people out in the field without the depth of preparation needed to help them succeed, and to support our care quality. It is a tough place to be because there are consequences to turning down referrals, but I think we have to be careful not to lose sight of what will sustain our agency over the long-term – and that is quality and patient satisfaction.

— Susan Ponder-Stansel, president and CEO of Alivia Care Inc.

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As an industry, we love to talk about “quality” and focus on what we get paid for — or get dinged for. However, what we are missing is a view of the overall patient journey. What all of us in home care really need to do is to understand the patient’s experience so we can add value to that journey. While a patient is in our care, we have such a terrific opportunity to help them in so many ways. These are things that could keep them living safely at home, out of the hospital, and experiencing their best possible lives.

If our industry pays attention to the entire patient experience, and delivers it well, we will see word-of-mouth drive our business toward sustainable growth. Patients and family members will demand our services. People will inform their providers. It’s the same for payers. When home care providers deliver that excellent experience for plan members, they become more valuable to the payers as well.

— Dan Savitt, president and CEO of VNS Health

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