Health Policy$ense

Carrots and Sticks to Reduce Readmissions and Improve Home Health Care

The Potential of Accountable Care Organizations, Bundled Payments and Innovative Home Care Programs

The Affordable Care Act has generated carrots and sticks for hospitals to reduce readmissions. With the goal of achieving the Triple Aim (improving quality of patient care, improving population health, and reducing overall cost of care), innovative care delivery models are being tested locally and nationally, including the roll-out of Accountable Care Organizations and bundled payment programs. These programs create incentives in terms of shared savings for health care systems that provide high quality, coordinated care.

Olga Jarrín is a National Hartford Center of Gerontological Nursing Excellence, Claire M. Fagin Fellow at the Center for Health Outcomes and Policy Research.

Meanwhile, a readmission penalty has taken effect, and hit safety net and teaching hospitals hard. While increased referrals to home health care from hospitals might lower readmission, there is wide variation in home health agencies’ ability to keep patients safely in their homes, and out of the hospital.

Institute of Medicine Workshop on the Future of Home Health Care
Health services researchers, home health agency executives, other industry representatives, and stakeholders including patients and patient advocates met at the Institute of Medicine for a 2 day workshop on the Future of Home Health Care #FutureofHH September 30-October 1, 2014. Major challenges for home health include reduced/insufficient payment for home health care, misaligned regulatory requirements and statutes, and the image of the home health care industry, that has been tainted with fraud, abuse, and sub-optimal patient care. Core issues discussed at the meeting included the use of technology to enhance care, the need for interoperable health records, the need for statutory changes at the federal level to allow advanced practice nurses to sign orders for home health care, and new models of care.

In contrast, the existing way that home health care is provided to Medicare beneficiaries was criticized as fragmented, uncoordinated, siloed, slow, and unable to meet the functional or clinical needs of today’s population. The desire to scrap the entire system and start over was balanced by a call for action “Let's work to improve, not diminish our existing home health care system” from keynote Steve Landers, MD, President and CEO of VNA Health Group. Reminding the audience of the Jimmo v. Sebelius Settlement Agreement, Judith Stein, JD, founder and Executive Director of the Center for Medicare Advocacy, pointed out the discrepancy between how home health care has been provided to Medicare beneficiaries, and how it should be provided.

Home Health Agency Work Environment Study
Using publicly reported CMS Home Health Compare data linked with nurse-reported ratings of the home health agency work environment, researchers from the Center for Health Outcomes and Policy Research have established a mechanism for why some home health agencies have better outcomes. Hospitalizations, including both acute and long-term stays, were lowest for patients receiving services from home health agencies where nurses reported excellent working conditions. Nurses working in home health agencies with poor working conditions were much more likely to report being unable to complete necessary care coordination and patient teaching due to time constraints. These findings are published open access in the October issue of the journal Medical Care.

These findings have implications for hospital and home health administrators, as well as policymakers. Hospitals should consider partnering with home health agencies that have better nurse work environments as a strategy to improve their patient outcomes, and bottom line. Home health agencies should work towards creating optimal conditions for nurses to care for patients. Policymakers should remove barriers to full scope of practice for Advanced Practice Nurses (APNs) and Registered Nurses (RNs) working in home health care, especially the requirement for physician co-signatures of APN orders for changes to the home health plan of care, including medication changes. The federal statute restricting APN authority supersedes state laws, and provides a disincentive for home health agencies to hire and collaborate with expert nurse clinicians.

Some of the “new” care models highlighted at the IOM Workshop: The Future of Home Health Care were strikingly similar to old models of home health care provided by public health district nurses and community-based family practice doctors who made both house-calls and hospital-rounds. Removing barriers to practice in home health care for APNs to direct care and directly order services is a small but important step towards raising the quality, responsiveness, and cost-effectiveness of home health care.