LeadingAge Magazine · May-June 2019 • Volume 09 • Number 03

Scaling Up Home Health and Hospice

May 22, 2019 | by Debra Wood, R.N.

Home and community-based services providers are coping with increased demand, finding skilled workers, using technology, and adapting to a changing business environment. Here is how some see their futures.

Home health and hospice providers are experiencing rapid growth in the demand for services as the country ages and most people want to stay in their homes.

“A lot of it has to do with the increase in chronic, complex patients who are finding their way home, where previously they were in the hospital or a long-term care [community],” says Andrea Lazarek-LaQuay, RN, MS, chief clinical officer of Nascentia Health in Syracuse, NY. “Now, advances in home care and health care allow us to provide more complex, high-tech care at home. And that is where people want to be.”

People want to remain independent and at home for as long as possible. An AARP study found 77% of people age 50 or older wanted to remain in their community for as long as possible and 76% want to stay in their current residence, yet only 59% think they will be able to stay in their community, and of those, only 46% expect to remain in their current home.

“The demand for home-based services is ever-growing and ever-present,” adds Erin Denholm, RN, MSN, RWJENF, president & CEO of Trinity Health at Home, based in Livonia, MI, but serving people across the country. “The culture of the people who are retiring is to stay in their homes.”

Trinity Health at Home serves people in rural and urban areas and finds demand is the same all over. Denholm says that never before in the history of America have more people retired. And all people are going to die, increasing the need for hospice.

Nascentia photo
Nurse recruitment for home and community-based services
is just as much of a challenge as it is in other service lines.
Photo courtesy of Nascentia Health.

“The graying of the baby boom generation coupled with longer life expectancies has created a steady increase in the senior population and rising demand for home care since 2011,” adds Faith F. Scott, MPH, MBA, president and CEO of Visiting Nurse Association of Northern New Jersey in Morristown. “That trend will continue until 2030 and beyond when every baby boomer in the United States will be [older than] age 65, and 1 in 5 residents will be retirement age.”

Scott adds that different levels of care each have their strengths. Small amounts of home health care services over years while living at home contribute to well-being and independence and can delay or eliminate the need for institutional care.

Visiting Nurse Association of Northern New Jersey, a full-service provider, has experienced increases in patient volumes, particularly acutely ill patients and those older than 80 years, needing ventilator care, wound care, and management of comorbidities. Friends and relatives may live together, and both need professional care.

“Scaling up to serve this influx of patients in today’s highly competitive employment market is one of our current challenges,” Scott says.

Overcoming a Nursing Shortage

A shortage of nurses exists across the country, which strains home health agencies’ ability to recruit. Adding to the challenge, hospitals typically can pay more. The Bureau of Labor Statistics reports that an average of more than 200,000 registered nurses will be needed each year until 2026.

“I do not think there [are] ever enough people,” Lazarek-LaQuay says. “As soon as I have a nurse able to take on a caseload, I could take on another nurse with another caseload. I think that is consistent across the state.”

Nascentia officials work closely with home health agencies across New York state to share best practices and recruitment ideas. As a recruitment incentive, clinicians are given access to all-wheel-drive vehicles, a lifesaver in a snowy region.

“We try to be as efficient as possible with the resources that are available,” Lazarek-LaQuay says. “We do a lot of leadership development, so the managers are the best they can be.”

Nascentia continues to hire nurses with some recent acute-care experience, so they can rely on their own instincts. The agency is considering a residency program, which would enable it to bring on newly licensed nurses.

“It will give us an opportunity to try something different,” Lazarek-LaQuay says.

“Scaling up to serve this influx of patients in today’s highly competitive employment market is one of our current challenges.”

Attracting Millennials

Visiting Nurse Association of Northern New Jersey works to attract millennials and new nursing graduates. Once on staff, the agency coaches and trains the new hires. The agency offers a new graduate program, which provides recent BSN graduates with extensive one-on-one mentoring with an experienced nurse. Each newly hired nurse will take on a full caseload at his or her own pace.

To make the positions attractive, the organization allows flexibility in work days as long as productivity goals are met.

“We’ve crafted a culture that’s desirable and comfortable for millennials, with incentives and tools that foster their success,” says Scott.

Retaining Staff

Nascentia Health provides nurses with additional education and support to keep their skills strong. Physical and occupational therapists help teach people how to function independently, which is vital to keeping people in their homes.

VNA of Northern NJ retention strategies include a clinical career ladder with pathways to advancement and a salaried model to help with retention. Software helps configure nursing care plans based on algorithms.

Embracing Technology

Trinity Health at Home has embraced technology in a big way. Registered nurses admit a patient into care and set up a digital platform, with a blood pressure cuff, a scale, and a tablet. Trinity Health at Home’s 24-hour call center nurses field queries from patients, who can push a button on the tablet and immediately connect with a nurse. The nurse can see the patient and the patient the nurse.

“We can intervene in the moment to help get their problem addressed, so they do not have to go to the emergency room for something [for which] ER services are not necessary,” Denholm says.

More than 21,000 patients have used the Trinity Health at Home electronic monitoring program during the past 2 years. Fewer live visits are needed.

“We have been able to decrease the 30-day readmission rate from 15% to less than 8%,” Denholm says. “The way we provide the care is giving patients and their families more of a sense of safety than sending a nurse 1, 2, or 3 times a week. We are able to craft the model of care to make the reimbursement work.”

VNA of Northern NJ also uses telehealth. Nurses can remotely monitor patients with serious chronic conditions, such as heart failure.

“I anticipate continued movement toward remote monitoring,” Scott says. “In fact, independent self-monitoring via cell phones and other mobile devices with web connectivity will become the norm.”

Lazarek-LaQuay agrees that the use of technology to keep an eye on patients will continue.

Challenging Reimbursement

Medicare is a growing system with more beneficiaries, as about 10,000 baby boomers turn 65 each day, according to a Pew Research Center study. Many are shifting from original Medicare to Medicare Advantage plans. A 2018 Henry J. Kaiser Family Foundation study found that Medicare Advantage enrollment nearly doubled from 1999 to 2018. In 2018, 20.4 million people were in Medicare Advantage plans, 34% of Medicare beneficiaries. The highest concentration of Medicare Advantage enrollees is in 4 states: Oregon, Hawaii, Minnesota, and Florida. Medicare Advantage plans aim to keep costs down and keep their quality ratings high, which has earned them $6.3 billion in bonuses from the Centers for Medicare & Medicaid Services (CMS).

VNA of Northern NJ operates on a 1-2% margin. “Reimbursement is not keeping up,” Scott says.

Lazarek-LaQuay agrees, adding that “Reimbursement is always a challenge, and as home care has gotten bigger and bigger, reimbursement has not kept up.”

Trinity Health at Home is part of a health system that includes hospitals. Home health contributes to reductions in total cost of care and cost containment in the health system.

“We are all working as a seamless unit,” Denholm says.

Dealing with PDGM

Come January 2020, CMS will introduce the Patient-Driven Groupings Model (PDGM), with 30-day periods of care rather than 60-day episodes of care and the elimination of therapy thresholds for determining payment. (See LeadingAge coverage of PDGM issues with this search link.)

“Moving to 30-day episodes will be a big shift,” Scott says. “In some instances, home care support at 45 days could prevent a hospital stay, but that will be gone. Our [field] is in a wait-and-see mode, yet we’ll remain committed to providing quality care and helping our patients stay compliant with their self-care.”

Sixty-day episodes gave home health care agencies more time to wean patients off services and maintain health and progress, Lazarek-LaQuay says. Nascentia is looking at ways to continue to monitor patients to prevent hospital readmissions or emergency department visits, perhaps through interactive voice response or follow-up telephone calls to pick up problems.

“[CMS changes] force innovation and change,” Lazarek-LaQuay adds. “You have to think how to be more creative.”

Nascentia photo #2
Photo courtesy of Nascentia Health.

Starting Afresh

“From a business perspective, the landscape is about to change in home care along with the rest of the health care continuum,” Scott says. “Private investors will drive innovation and improve productivity. However, their interest in our [field] is short-term, and their goal is to achieve a substantial return on investment in 5 years or so by participating in mergers or acquisitions.”

In this volatile environment, Scott urges home health agencies and their leaders to remain focused on serving older adults; deliver high-caliber care; optimize use of data, technology and metrics; get to know other home health and hospice players in the region; break down silos; and forge mutually beneficial alliances and partnerships.

Lazarek-LaQuay also reports extensive cooperation and coordination with other providers. Anyone wanting to start a home health care or hospice agency in New York may face more obstacles than in most places due to the state’s certificate of need process, which currently has a moratorium on new providers.

Trinity Health at Home partners with a private duty agency for hourly home health care, including aides. For those who can afford such services, Denholm says, the agency needs to offer it or partner with another agency.

CMS has changed home health reimbursement policies related to “request for advance payment.” Those Medicare-certified agencies operating on Jan. 1, 2019, can still request such payments but new agencies cannot.

“That has made a difference for people wanting to be entrepreneurs,” Denholm explains. “People will need credit lines and financing to get through the process of dropping a final bill and then getting paid.”

Debra Wood, R.N., is a writer who lives in Orlando, FL.