In home care, turnover tends to beget more turnover. If providers don’t nip the issue in the bud, they will open themselves up to a larger problem.

Home care agencies report average turnover rates of 76%, which challenges their ability to deliver high-quality services. High employee turnover also means high financial costs. On average, caregiver turnover costs agencies $171,600 annually, a report from Activated Insights showed.

Turnover results in extra hours for the remaining staff caring for clients, often leading to burnout. This also negatively impacts clients, as they don’t always receive the necessary attention due to the limited number of staff.

“These agencies are competing in a broad economy, and there are numerous job opportunities available for workers across various sectors,” Joanne Spetz, director of the University of California San Francisco Health Workforce Research Center, told Home Health Care News. “Licensed nurses are in high demand in hospitals and ambulatory care settings, while direct care aides and assistants with valuable interpersonal and organizational skills can find opportunities in many different sectors of the economy. As a result, there is significant competition for workers.”

Spetz stated that while health care organizations have revenue limitations, particularly in Medicaid or private pay, the significance of work culture in tackling burnout and retention should not be underestimated.

“Often, direct care workers, aides, and assistants are treated as disposable and unskilled, despite having valuable skills that should be appreciated,” Spetz stated. “Home care organizations need to find ways to show respect and appreciation for these workers, and create avenues for them to take on leadership roles, even if they may not be able to offer competitive wages.”

Spetz used the example of Washington State’s Medicaid program, which set up basic training standards and options for caregivers to follow. In this program, pay raises are linked to specific stages in the training options, allowing caregivers to receive formal recognition for their increasing skills and expertise.

Similarly, Austin State Hospital in Texas employs peer providers who are not licensed therapists, but peers who have experienced the same illnesses as some patients. The hospital recognized their contributions and began a career ladder process to move them into other opportunities in the organization. Spetz suggested the same idea could be implemented in home care organizations.

“It’s not all about compensation,” National Association for Home Care & Hospice (NAHC) President William A. Dombi told HHCN. “It’s about worker respect. It’s about people understanding that meaningful work is being done. It almost seems we’ve got a culture change that is developing within home care employment practices, recognizing that once you have someone employed, you must take steps to ensure you can keep them as an employee. Turnover rates are high, mainly because it seems everyone was spending time on recruitment and not enough time to focus on the retention side of the equation.”

Caregivers frequently face high levels of stress due to demanding job responsibilities, unpredictable work conditions and feelings of isolation. These stressors can lead to low job satisfaction and emotional burnout, ultimately causing caregivers to resign from their positions.

“We are aware that factors such as burnout and low compensation contribute to turnover,” Molly Candon, assistant professor in the Center for Mental Health and the Department of Health Care Management at the University of Pennsylvania, Philadelphia, told HHCN. “We also know that characteristics of home health care organizations, such as the quality of supervisory feedback and long work hours, can drive turnover.”

Caregivers value work-life balance and seek assurance that their jobs are not a dead end. They want the chance to develop and grow within the organization. Thus, continuous and thorough education and training can improve staff retention. Training prospects and internal advancement opportunities are crucial for attracting new employees. Candidates are more inclined toward employers who provide them with opportunities for improvement and progression.

For some caregivers, the idea of shift or client assignments helps with burnout and gives them a sense that they are making a difference and offering the best care to their clients by providing continuity.

“Clients and staff generally seem to want continuity of relationships,” Spetz said. “Caregivers want to know, whenever possible, they are going to get a certain client on Monday, Wednesday and Friday and a different client on Tuesday and Thursday, for example. That creates predictability and a sense of routine that can help with burnout and work-life balance.”

For agencies experiencing high turnover, checking in with caregivers can be a great way to understand what they need to feel valued.

“Exit interviews are important, but I would suggest retention interviews,” Spetz said. “When someone has been with your team for a while, interview them to find out why they are staying and what they like about the job or your organization.”

Condon echoed the necessity of interviews, but also acknowledged they can sometimes be challenging to facilitate.

“Surveys and exit interviews are great resources for understanding why and how employees leave their position and could contribute to a root cause analysis,” Condon said. “However, employees need to feel comfortable disclosing their true intentions.”

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From 2013 to 2019, the number of home care workers per 100 HCBS participants declined by 11.6%. Preliminary estimates suggest that a decline in that ratio continued post-2020.

“When you look over time, we actually found that the number of home care workers was increasing, which we were initially a little bit surprised about,” Rachel Werner, executive director of the Leonard Davis Institute of Health Economics at the University of Pennsylvania, told Home Health Care News. “At the same time, the number of people who were enrolled in Medicaid and receiving home care services through the HCBS benefit was increasing at a much faster rate.”

Using data from the American Community Survey and the Henry J. Kaiser Family Foundation, Werner and her colleagues found that the home care workforce grew from about 840,000 caregivers to 1.22 million between 2008 and 2013.

After 2013, growth slowed, ultimately reaching 1.42 million workers in 2019.

From 2008 to 2020, the number of Medicaid HCBS participants steadily grew, with “accelerated growth between 2013 and 2020,” the study found.

The discrepancy is significant, given the fact that HCBS are the predominant approach to long-term services and supports (LTSS) in the U.S. Medicaid, the primary payer for LTSS, has also expanded HCBS coverage.

“There appears to be an insufficient number of home care workers to keep up with the growth in this program,” Werner said.

Knowing there is no silver-bullet solution, Werner believes the conversation should at least start at compensation. That, in turn, becomes a conversation about Medicaid funding.

“Many home care workers — including home health aides — are often paid at minimum wage, live below the poverty line and actually they themselves are enrolled in some social services,” Werner said. “So wages are clearly, in my view, insufficient and need to be raised for home care workers. I think it’s hard to do when you talk to home health agencies because Medicaid pays, people are reporting, at too low of a rate.”

For now, improving workplace culture, including career ladders and having routine and reliable scheduling are other recommendations proposed by Werner and her colleagues as a way to close the widening gap.

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As a result, there are millions of older Americans — especially those living in rural areas — who are going without the type of life-changing, in-home care they need.

That’s according to a new study published Monday in the journal Health Affairs.

To better understand the use of home-based medical care, a team of researchers from Mount Sinai, Johns Hopkins University, Wake Forest University, Massachusetts General Hospital and the University of Pennsylvania analyzed seven years’ worth of data from the National Health and Aging Trend Study (NHATS). Broadly, the NHATS is an annual comprehensive, population-based survey of late-life disability trends and trajectories.

Researchers looked at 7,552 community-based, fee-for-service Medicare beneficiaries who participated in the NHATS from 2011 to 2017. They then drilled down on that population to see how often home-based medical care was brought into the picture.

“Home-based medical care is serving both clinically and socially complex homebound and non-homebound people, but the number of people who may benefit from this care is much greater than the number who receive it,” the researchers observed.

Generally, the team defined “home-based medical care” as longitudinal services like in-home primary care and palliative care. Any intermittent home-based medical care services — like home health care or physical therapy, for example — were filtered out.

Of the several thousand community-based Medicare beneficiaries surveyed, just 5% received any form of home-based medical care at any point during the study period.

Among the 2,486 homebound individuals in the group, just 11% received home-based medical care. Among the 5,066 non-homebound individuals, less than 2% received home-based medical care at any point during follow-up.

“It is apparent that the current system of community-based primary care does not adequately meet the needs of medically and socially complex homebound people,” researchers noted.

Homebound beneficiaries who received home-based medical care were more likely to live in a metropolitan area or in an assisted living facility compared to those who did not receive such services. They were also more likely to have dementia and to have had a hospitalization in the previous year, researchers found.

Meanwhile, the non-homebound beneficiaries who received home-based medical care typically had more chronic conditions, more functional impairments and a higher overall health care use. Additionally, they also had lower income, a higher use of Medicaid and less education.

“This suggests that home-based medical care may be an important care delivery approach that can address social determinants of health in patients with complex care needs,” the researchers wrote.

Non-homebound individuals that received home-based medical care were also more likely to be nonwhite.

Barriers to home-based medical care

There are 2 million or so older adults who rarely or never leave their homes living in the United States, according to some estimates. There are 5 million more who can only leave with the help of others or after “significant difficulty.”

“The homebound population is understudied and often is invisible to health care delivery systems, payers and quality-reporting programs,” the researchers pointed out.

Moving forward, the homebound population is likely to grow rapidly, particularly with more older adults opting for home- and community-based care instead of moving into a long-term care facilities. The coronavirus has only accelerated that trend.

Several in-home primary care companies and payers have positioned themselves to help meet an increased demand for home-based medical care.

At the end of July, for instance, Humana Inc. (NYSE: HUM) announced a strategic partnership with physician house call company Heal. As part of the partnership, Humana plans to invest $100 million into the Los Angeles-based startup.

Walgreens Boots Alliance (Nasdaq: WBA) and VillageMD also announced a five-year, $1 billion plan last month to expand the retailer’s full-service physician services at hundreds of stores.

On the government side, regulators have been exploring a home-based medical care payment model through the Independence at Home Demonstration. More than two dozen practices participate in the shared savings program, delivering home-based primary care services to high-risk, chronically ill patients across the country.

In its first two years, Independence at Home saved an average of $2,700 per beneficiary per year over expected patient costs. Projections suggest an expansion of home-based primary care could create savings of between $2.6 billion and $27.8 billion over a 10-year period.

Leading with value-based care

There isn’t a clear-cut avenue under fee-for-service Medicare to help pay for home-based primary care.

With that in mind, many home-based medical care providers have sought out value-based contracts to support their work.

“An important driver of the underuse of home-based medical care is the challenge of creating a financially sustainable model of such care within a fee-for-service model in which reimbursement for care of patients with complex chronic illness and functional impairments is limited,” the researchers stated.

But even in value-based contracts, challenges remain.

One big barrier to participation in more value-based care arrangements has been a lack of quality metrics specifically linked to the home setting or the needs of homebound older adults.

“Quality metrics relevant to home-based medical care are necessary to ensure that its providers can participate in the growing number of value-based reimbursement options within both Medicare Advantage and traditional Medicare,” researchers wrote.

The post Home-Based Medical Care Can Reduce Hospitalizations and Lower Costs — But It’s Still Underutilized appeared first on Home Health Care News.

As part of the economic analysis study, University of Pennsylvania researchers conducted a randomized, controlled trial that included 302 Individualized Management for Patient-Centered Targets (IMPaCT) patients. The study calculates ROI for the program from the perspective of a Medicaid payer.

IMPaCT is a community health worker intervention program that addresses socioeconomic and behavioral barriers to health in low-income populations by providing support for high-risk patients.

In general, social determinants of health have become a focal point within the U.S. health care system, as the industry has begun to recognize the ways socioeconomic and environmental factors impact differences in health status.

This is partly due to the health care system beginning to embrace more value-based care models over time, according to Shreya Kangovi, an associate professor at the University of Pennsylvania and one of the study’s authors.

“We are gradually moving from a sick care system towards a health care system, where we pay health systems based on whether or not they’re able to keep patients healthy,” Kangovi told Home Health Care News. “When you think about what it takes to keep people healthy and what makes people sick, that’s where social determinants of health come in.”

Overall, researchers found a team of community health workers saved Medicaid $1.4 million — an ROI of $2.47 for every dollar invested in social determinants of health.

“The overall cost savings was pretty significant,” Kangovi said. “The program only costs $500,670 for one team of community health workers — and that same team saved Medicaid $1.4 million.”

Furthermore, when researchers conducted an analysis that varied the number of admissions and outpatient visits attributable to IMPaCT, the return still ranged from $1.84 to $3.09.

“Any time you do an economic analysis, it’s always good to ask, ‘How robust is this?’” Kangovi said. “If we varied a few things, does that change the outcome significantly? It turns out, even when assuming a worse-case scenario, it still had a positive return on investment.”

Researchers note that IMPaCT is a well-structured program and not every social determinant or community-health program will automatically yield the same results, according to Kangovi.

“It’s a positive message, but also a reminder that we have to get this right,” she said.

As far as in-home care’s place in all of this, Kangovi believes that these services have an instrumental role to play.

“Here at Penn Medicine, we have a direct-care program,” she said. “Penn Medicine At Home has been a terrific organization. Community health workers are often in homes and communities, often working alongside home health aides, nurses, PTs and OTs that go into the home. [Home health] complements a people-centered skill-set with a clinical skill-set.”

Senior Helpers is one home-based care organization that has committed itself to social determinants of health. In 2019, the company implemented the Life, Independence, Function, Evaluation (LIFE) Profile — a data-driven assessment tool to enhance its care planning and document “micro-social determinants of health.”

Alliance Homecare is another such organization. Last year, the company began offering food delivery through its partnership with Epicured, a subscription meal-delivery service.

The post Investing in Social Determinants of Health Yields High ROI appeared first on Home Health Care News.

Predictive analytics-driven telehealth outreach programs that risk-stratify patients based on medical vulnerability and other factors can be particularly impactful, findings from a recent study suggest.

“A coordinated approach to analytics may help payers and providers realize efficiencies in care and direct potentially timely interventions to patients in greatest need,” researchers noted in the study, published earlier this month in the Journal of Health Economics.

To help gauge how well telehealth and predictive analytics tools keep patients safely at home, researchers evaluated a care coordination program administered by Independence Blue Cross of Philadelphia to its Medicare Advantage (MA) members with congestive heart failure. As part of their evaluation, researchers used a predictive algorithm to assign the insurer’s MA members a risk score, with the highest-scoring members selected for telephone follow-up initiated via registered nurse health coaches.

In general, the predictive algorithm pulled from medical and pharmacy claims, lab results, demographic data and other information.

Telephone follow-up through the care coordination program revolved around needs assessment, care planning, appointment scheduling, medication assistance and transportation coordination, along with social worker and behavioral health specialist support when necessary.

Overall, researchers analyzed claims data for 29,222 fully-insured Blue Cross of Philadelphia MA members diagnosed with congestive heart failure. Their final sample included 1,974 patients, roughly half of whom were targeted for the predictive analytics-driven care coordination program.

Among high-risk Medicare Advantage members with congestive heart failure, a proactive outreach program paired with a claims-based predictive algorithm reduced the likelihood of an ED or specialist visit over the course of a year by 20% and 21%, respectively.

“These findings suggest that continuity of care, in the form of a communication hub as part of a targeted intervention, may serve as an effective tool in reducing unnecessary utilization among high-risk populations,” researchers concluded. “Additionally, effective telehealth case management, rather than face to face case management, can lead to reductions in ED care.”

Predictive analytics in home health care

The Journal of Health Economics study looked at care management and risk-stratification from an insurer’s perspective, but home health providers have also increasingly turned to predictive analytics solutions to prevent negative health outcomes.

Baton Rouge, Louisiana-based Amedisys (Nasdaq: AMED), for example, has been fine-tuning its use of a risk-stratification tool designed to slash re-hospitalization rates and keep patients away from the ED.

The tool is engineered by Nashville, Tennessee-based predictive analytics firm Medalogix, which Amedisys invested in late last year.

“In order for us to move into where the world’s going to from a risk-based environment, we need to have the data, business intelligence [capabilities] at an individual patient level to drive better outcomes,” Amedisys CEO Paul Kusserow previously told Home Health Care News. “You have to be able to predict on a very regular basis who’s your highest risk and how you are going to alter your care plan so you can stop unnecessary hospitalizations.”

Birmingham, Alabama-based Encompass Health Corporation (NYSE: EHC) has likewise experimented predictive analytics technology.

Additional findings

In addition to reducing the likelihood of an ED or specialist visit, the predictive analytics-fueled care coordination program from Blue Cross of Philadelphia helped cut hospital admissions by 38% at 30 days, 46% at 90 days, 26% at 180 days and 20% after 360 days relative to a control group average, according to the study.

Those findings did not carry full statistical significance, however, meaning they could have been a result of chance.

‘The results imply savings 30 days post-outreach of $500 to $1,000 for ED visits per member per year,” the researchers wrote. “Similarly, while mostly statistically insignificant, the reduction in hospitalization implies annual savings of about $13,000 per member over the 30 days after outreach.”

In general, those savings are triggered by more efficiently targeting the sickest members within a high-spending population, who — based on predictive models — have the most to gain from an intervention.

Guy David, associate professor at the University of Pennsylvania’s Wharton School, was the lead author of the study.

HHCN previously connected with David as part of a story highlighting how longer home health visits are tied to lower hospital readmission rates.

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That’s according to a new article published in JAMA Internal Medicine, which shows readmission rates for patients discharged to home health agencies were 5.6 percentage points higher than those who went to SNFs.

Researchers analyzed more than 17 million hospitalizations of Medicare beneficiaries to reach the findings, which compare home health and SNF patients using readmission rates at 30 days post-discharge, mortality rates at 30 days post-discharge, improvement of functional status and Medicare payments.

Patients studied could have appropriately been discharged to either setting. However, the majority of patients (61.2%) were discharged to SNFs, while 38.8% of patients were discharged to home health care services.

While mortality rates and functional status were very similar when comparing home health and SNF patients, readmission rates and costs varied greatly.

“There’s a significant trade-off in the amount of money we spend on post-acute care and patient outcomes,” Rachel Werner, lead author and associate chief for research in the Division of General Internal Medicine at the University of Pennsylvania in Philadelphia, told Home Health Care News. “Medicare spent significantly less money on [patients discharged to home health agencies] than they did on patients who were discharged to a SNF, but they also had higher rates of readmission.”

Readmission rates

Since 2012, hospitals have been held liable for avoidable readmissions for certain patients. Medicare financially penalizes hospitals for high readmissions in patients with pneumonia, heart failure and hip and knee replacement, along with chronic obstructive pulmonary disease (COPD) and other select conditions.

As such, there’s a growing push to reduce readmissions rates, which researchers found SNFs do a superior job of compared to home health agencies.

However, researchers hypothesized that readmission rates of home health patients were several percentage points higher than their SNF counterparts for multiple potential reasons.

For example, SNFs can monitor patients 24-hours per day and often provide “a higher level of treatment intensity,” the researchers wrote.

Additionally, the study only looks at Medicare beneficiaries who could appropriately be discharged to either a home health agency or a SNF.

Cutting costs

SNF’s reduced readmission rates come at a cost — literally.

Medicare reimbursement for home health care was significantly lower than for SNF care, in turn saving the program more money.

Hospital patients discharged to a home health agency reduced the average Medicare spending on post-acute care by $5,384 and cut the overall 60-day episodic cost by $4,514, according to the study.

“Even after accounting for the lower costs from fewer readmissions from SNFs, the total amount paid by Medicare for hospitalizations and post-acute care during the 60-day post-hospital period is lower for patients discharged to home compared with those discharged to a SNF,” the researchers wrote.

These results warrant further investigation of post-acute care settings to improve costs and care, Werner believes.

“Patients often prefer a home-based setting rather than an institutional setting such as SNFs, so trying to balance the benefits, such as reduced readmissions, with patient preferences is a challenge,” Werner said. “I think the solution to that is to find better ways to balance the financial incentives to reward outcomes and quality of care in addition to reducing cost — [and] also to consider alternative ways to provide more intensive care at home.”

The post Home Health Providers Lag Behind Skilled Nursing Facilities in Preventing Re-Hospitalizations appeared first on Home Health Care News.

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CMS Launches Home Health Prior Authorization Requirement—Despite pushback from the home health industry and lawmakers, CMS announced this week it plans to move forward with a preauthorization requirement. CMS’ plans for prior authorization, now called the Pre-Claim Review Demonstration for Home Health Services, will roll out in five states as announced in February.

New Overtime Rule May Pose Little Threat to Home Care—A new wage rule that increases overtime benefits for millions of American workers is expected to put some wage pressures on employers across many industries, but how much it will impact home health care is still up for debate. “We really don’t think this is going to impact home care at all,” said Caitlin Connolly, home care fair pay campaign coordinator with the National Employment Law Project (NELP). “There are very few home care workers who are salaried workers.”

Husband, Wife Get Prison Time in $80 Million Medicaid Fraud Scheme—The husband-and-wife owners of a Global Healthcare, Inc., a Washington, D.C.-area home care agency, have been sentenced to 17 years combined in prison for participating in an $80 million Medicaid fraud scheme.

More CCRCs Extend Services into Seniors’ Homes—Home care providers across the country may be seeing new opportunities for business due to the growth of a particular type of program: the continuing care retirement community (CCRC) “without walls.” There currently are 29 of these types of programs nationwide, with more under development, according to the latest figures from Ziegler and CliftonLarsonAllen LLP.

Weekend Reads

Tiny Trailer Homes for Families in Need—In a twist on the “tiny home” trend, New Brighton, Minnesota-based NextDoor Housing sells and rents out handicapped-accessible, 240-square-foot trailers designed to sit temporarily in homeowners’ backyards when a family member can’t quite live on their own.

Finding Ways to Keep Patients at Home—”When we talk about advance directives and reducing costly and unnecessary treatment at the end of life, we should also be talking about ways we can provide more support,” David Casarett is a professor at the University of Pennsylvania Perelman School of Medicine, writes in The New York Times. “We need to make sure that people like my patient have access to the kinds of care that can help them remain safely and comfortably at home.”

Written by Mary Kate Nelson

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