Home care providers play important role in value-based care, consultant says

After much wrangling, RiverSpring Health is bringing New York City its first, and possibly last, continuing care retirement community. The man set to lead it, RiverSpring President and CEO Daniel Reingold, sees a great future for the baby boomer-focused addition to the vast array of other RiverSpring offerings. Meanwhile, he wants nothing but subtraction and destruction for the way the typical nursing home does business. “Blow it up,” he says in this McKnight’s Newsmaker podcast moderated by McKnight’s Executive Editor James M. Berklan.

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Right at Home, which has 700 locations across the United States and five other countries, recognizes that the need for personal care services is only growing and it needs more caregivers — specifically 26,000 nonmedical ones this year domestically — to meet that demand. To help find enough and capable caregivers amid a workforce shortage and to compete with other agencies also seeking to grow, the company needs to win at the local level, according to Margaret Haynes, CEO of Right at Home. Renee Pfister, a Right at Home franchisee in the South Carolina Upstate who employs about 130 caregivers, has set a goal of hiring eight to 10 new caregivers every week. To find these new employees, her franchise is reaching out to new potential applicants: those who did not finish the application process, caregivers who may have left due to childcare and other issues, people interested in going to nursing or medical school, and also family caregivers who have hearts for caring for older adults. A robust training program and also ties to a local college for CNA certification help to entice interested applicants. Since Haynes became CEO in 2022, she has been most surprised about the resilience of the network and the brand and her franchise owners.

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The government’s thinking toward value-based care has evolved in recent years thanks to innovative partnerships between healthcare stakeholders and payers, Katy Lanz said. Thanks to healthcare entities successfully assuming risk for seriously ill populations, the Center for Medicare and Medicaid Innovation (CMMI) has taken the stance that it wants to continue to drive value-based partnerships, said Lanz, former chief clinical officer of Aspire Health. CMMI models such as the Value-Based Insurance Design (VBID) Model and Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) Model are examples of this. The models, which involve providers assuming risk, have proven to save money and avoid unwanted, unnecessary hospitalizations and care. Traditional home care firms would be wise to initiate “strategic refreshes” and find opportunities to partner with at-risk providers. Lanz, who advises healthcare organizations on growth and innovation, talked about one of her large-scale clients, Dollar General. The retailer is interested in value-based care because it is concerned about its female shoppers not being able to afford or access healthcare. Also, during the podcast, Lanz clarified that when she talked recently about providers having to “show me the money,” she was talking about sharing in upside and downside risk, not receiving money for referrals.

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The rule issued last month from the Centers for Medicare & Medicaid Services reduces wait times to within one week for many standard Medicare Advantage prior authorization decisions. It does not go far enough, said Nicole Fallon, VP of managed care public policy or LeadingAge, noting that prior authorization decisions should only take a couple of hours. She and her colleague, Mollie Gurian, VP of home-based public policy for LeadingAge, pointed out that they also are pushing for MA prior authorizations to cover patients across their post-acute care journeys, including 30-day home health episodes. They also are striving for payment adequacy, as many MA plans pay only 60% or 80% of Medicare fee-for-service rates. Among other changes, they are hoping for the shedding of the statutory noninterference clause that prohibits CMS from telling plans how to pay. Despite the challenges ahead in reforming MA, Fallon and Gurian believe MA has introduced positive healthcare reforms, such as supplemental benefits, and CMS and lawmakers are asking the right questions to continue to improve the private Medicare benefit.

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Rural Peril 

The nursing shortage is preventing home care from meeting client demand, Sun acknowledged. But advances in immigration, outreach in nursing schools and CNA career pathing are three ways to solve the nursing shortage, she said. Besides home care, the company, which has more than 365 franchised and company-owned locations nationwide, has branched into senior living and care homes. The latter is a residential community initiative that involves homes of 10 to 12 residents in the Boise, ID, area. Franchises have signed up in other states, and Sun is hoping there will be 30 to 35 communities across the country in the next couple of years. Besides diversifying her business, Sun is looking for new payer sources and continues to be an advocate of Medicare Advantage. She is eyeing hospital-at-home as one of the company’s next big growth opportunities. Ensuring clinical quality comes before offering consumer experience tools, she said.

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The Medicare payment reduction in the home health final rule is making it difficult for providers to operate, David Grams, CEO of Compassus, told McKnight’s Home Care in a podcast. To make up for some of the financial pressures, providers have to exercise “a better stewardship of resources,” he said. This entails being mindful of staffing numbers as well as the allocation of capacity to help patients access home care from the hospital, said Grams who was in Washington, DC, as recently as this week advocating on behalf of providers.

Notes: While reimbursement poses a problem in home health, it also is challenging in hospice, particularly in rural areas. Grams supports efforts to make sure it is a “level playing field.” He also is in favor of increased hospice oversight to root out bad actors. Compassus, which offers home health, hospice, palliative care and infusion services across 29 states with 250 points of care, should see double-digit growth in all of its lines of business for the foreseeable future, Grams said. It is working to innovate across its service lines to bring technology into the home. Among its solutions are a tool that is “over 90% accurate” in trying to identify when people are reaching the end of life. It also recently introduced a patient engagement and family engagement application in a limited number of markets and is looking to expand it nationwide. Grams expects rapid growth in its SNF-at-home service line, which it introduced in 2023.  

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