A working relationship between home health and the ACO

Cale Bradford gave the following speech to the Managed Care Association:

Good Morning. My name is Cale Bradford and I’m the Chief Operating Officer of Pyramid Home Health Services. We’re a state-wide provider of home and community based services including in-home long term care, home health, hospice and pharmacy. I appreciate the opportunity to visit with you today on the topic of a working relationship between home health and an ACO.

My goal is to demonstrate how home and community based services like home health can assist physicians practicing in an ACO structure to build on and make more robust their patient /physician relationships and drive Medicare shared savings and patient satisfaction in the process.

So much of what positively or negatively affects the outcomes associated with any physician’s management and treatment of patent conditions happens outside of their medical office. Where many patients are concerned, particularly those who are elderly or disabled and affected by chronic disease, it happens at home. To follow their doctor’s prescription for diet, exercise, medication compliance, stress management, avoidance of high risk behaviors, or not, is a daily decision for many of the 54 million Americans who receive their health insurance coverage through Medicare. If all of these beneficiaries decisions played out as articulated and agreed to in their physician’s office, surely we’d have a fundamentally healthier society while carving off a hefty apportionment of the $583 billion spent last year by Medicare on these folk’s healthcare- an expenditure that represents approximately 14% of the total national budget.

As a healthcare delivery model, carving off that apportionment is what an ACO has to prove it can do financially. Its physician members have to take currently sicker and more expensive patients and move them toward better health at lower cost. If we take for granted that many patients’ decisions may be bad ones, and that it’s impossible for a physician to physically manifest themself at every intersection of what I should and what I’m going to do, then the question is, what’s the best way to assist physicians to more positively impact these decisions in the aggregate?

Numerous current demonstrations coming out of the CMS Center for Innovation as well as private practice initiatives from around the country, some dating back as far as the 1997 Balanced Budget Act, strongly suggest that home and community based services are the ideal vehicle to deliver physicians a more contemporaneous understanding of the changing factors that influence their patient’s decision making and for delivering physician influence to the point of patient decision making more frequently. Whether we’re talking about the decisions I listed earlier, or choices relating to things like, do these symptoms mean I need an ambulance, or should I take these two medications together, or fill this one, as opposed to that one, because I can’t afford both, the consequences, both health and economic , flowing from these decisions are immense; and the data from these initiatives and demonstrations is showing that easier, more timely access to a physician improves them; and here lays the cornerstone of a working relationship between home health and the physician members of a ACO.

Traditionally home health has been considered a post rehabilitative service, after care relating to an illness, procedure or hospitalization that aides in a patient’s recovery and return to function. However, in the post ACA world, and specifically when working in partnership to an ACO, a home health company’s infrastructure is a powerful tool to aide physicians wishing to extend their positive influence further into their patient’s decision making processes- which is occurring, not in their office, but in their home and community.

When you look at the $583 billion dollars Medicare spent last year, the break down is basically $145 billion, 25%, to Medicare Advantage, hospital inpatient services, 24%, $140 billion, 14% on the combination of part b drugs and services, DME, ambulance, Hospice, outpatient dialysis and lab services, 12% for physician services, or $70 billion, 11% part d drugs, 6% outpatient hospital services, 5% skilled nursing facilities, $29 billion and 3% for home health, $17 billion annually. The key financial question for an ACO has to be; how much of the cost associated with these individual expense categories was avoidable and how do I avoid it in my population of attributed lives going forward? What is the best vehicle for recognizing the opportunity to substitute patient education, less costly technology and timelier, less intensive, interventions for more costly, often avoidable, services?

How about having access to NP, RN, CWCON, LPN, PT, OT, ST, Dieticians, Social Workers, and CNA, 24/7/365; who will deliver, per your order or customized standing protocol, your preferred teaching, technology and intervention to your patient’s home with real time reporting back? That is exactly what a professional relationship between you’re ACO and its home health partner should look like. Further, it should be available at a fraction of the cost associated with an avoidable event stemming from a lack of patient connectivity to your physician’s offices when it’s needed. As a happy aside, it also increases patient convenience and satisfaction.

Consider the average inpatient cost paid by Medicare for the following admission types in Missouri, these do not include any co-pays, deductibles, or other third party payments- COPD $6,300, Pneumonia $8,133, Chest Pain $2,424, Heart Attack $4,344, Hypertension $3,300, Hip fracture $3,912, Diabetes $4,976, UTI $4,540, CVA $4,470. Now consider that the average direct Medicare reimbursement for home health, which includes up to 60-days of aftercare and rehabilitation, inclusive of the cost supplies, and delivered to a patient with an acuity level that prohibits their leaving home without taxing effort is $2,700. In the case of the company I work for, Pyramid Home Health Services, it’s a little over $2,100. How many individuals discharged from an in-patient stay relating to these diagnoses have an elevated risk for re-hospitalization during their first 60-days at home? For those that do, where home health is concerned, for the cost of aftercare and rehab, Medicare is also buying an insurance policy against additional inpatient cost relating to readmission, and for its ACO partner, a better chance of participating in greater shared savings. This assumes of course you’ve working with a home health partner whose outcomes evidence their ability to actually manage that risk.

Medicare Advantage gets it. They’re using the eyes, ears and ability of home health clinicians to accentuate their management efforts as “at risk” entities. Let me give you some examples of how home health is being used by Medicare Advantage and other insurance companies in a way that differs from its traditional rehabilitation and treatment role. These are actual programs that my company, Pyramid Home Health Services, provides under contract to these organizations in a sub-contractual capacity and in support of their own, broader population health management initiatives.

The first of these is Care Transitions Management. Many individuals are discharged to home without a specific need for traditional home health services but, as we’ve discussed, they are still at risk for complications that may lead to unnecessary ER usage or a re-hospitalization. Avoiding this undesirable outcome starts with successfully managing these patient’s transitions from the in-patient setting to the community. So, to do so Pyramid Home Health Services Care Transitions Management program is a 30-day protocol specifically developed to avoid ER usage and hospital readmission post discharge. The program consists of five components.

First, we make an in-person/ in- facility visit to a patient prior to their discharge. We develop a rapport with the patient; evaluate their knowledgeable of their condition, medical record, medications and their personal responsibilities relating to a successful recuperation at home. The also receive a “Transitions Packet” that contains information regarding their condition, warning signs and symptoms, discharge medications and instructions, their physician(s) contact information and follow-up visit dates, a list of the addresses, contact numbers and hours of operation of emergent care clinics nearest their home and 24/7 contact information for Pyramid Home Health Services.

Next, we conduct a pre-discharge assessment of the safety and accessibility of the patient’s home and provide a written report to the patient’s following physician(s), the discharging hospital, and their health plan that identifies safety hazards, barriers to self- care or family assisted care, required home modifications or DME that may be necessary for a successful transition. If required we will coordinate orders and referrals for ancillary services, supplies and pharmacy and ensure supplies, services and medications are there when the patient returns.

We complete a home visit within 48- hours of discharge, or sooner to evaluate the return to the home process, the patient’s satisfaction with it, address health questions, concerns and warning signs and symptoms. We check vitals, review medications and the patient’s knowledge regarding regimen/ dosage(s)/ side effects. If needed, Pyramid Pharmacy can provide Tele-health based MTM (Medication Therapy Management) with a certified pharmacist. We draw requested labs and, if needed, assist to schedule necessary follow-up visits to physicians and other providers including arranging transportation to and from were required.

We offer a 24X7 Nurse Line that makes available a Clinician to provide telephone based response to patient health questions and concerns and to triage alternative care options to the ER after hours. Our response is stepwise and ranges from the least invasive- advice and follow-up telephone monitoring to, if required, referral to the nearest open emergent care clinic or dispatch of a nurse to the patient’s home. All documentation of interactions is provided to the patient’s following Physician(s) and health plan within 24- hours or sooner where appropriate.

Finally, we make weekly check-up calls to the patient to review their stability at home and their satisfaction with the home transition process.

Where we are providing Care Transitions Management to a non-home bound individual, who may or may or may not be a Medicare Beneficiary, the total cost to the payer is $550 for the entire 30-day management period. Where we are providing traditional home health services to a homebound Medicare beneficiary, assuming prior evidenced patient choice and appropriate authorizations, these services are included as a part of the standard Medicare reimbursed home health episode.

Another example of Medicare Advantage’s use of home health as a cost avoidance tool is its use by carriers to monitor, longer term the health of patients with multiple chronic conditions. For patients at a high risk for hospitalization, defined in one contract, as any beneficiary for whom the plan has incurred expenses in excess of $60,000 in the previous year, and who has at least one chronic condition, home health is proving very effective. For this particular company we provide no less than three at home visits with an LPN monthly, more and with alternatively credentialed staff if necessary, and weekly phone contact for a flat fee of $400 per month. Best case scenario there is a 12 to 1 positive ratio between the carrier’s additional home health expenditure and their historical cost outlay for these particular qualifying beneficiaries. So, where the past would be prolog with respect to these patient’s outcomes the odds are overwhelming in favor of the carrier’s additional expenditure on home health driving substantially greater cost avoidance.

There was a great article in the Washington Post in April of last year. The title was, “If this was a pill you’d do anything to get it.” It was regarding the impact of Health Quality Partners in Doylestown Pennsylvania on Medicare expenditures. HQP is a demonstration program that was actually implemented as a part of the 1997 Balanced Budget Act. It, and 15 other sites nationally, enroll Medicare patients with at least one chronic illness and one hospitalization in the prior year in a program that sends a nurse to see them every week to month, whether they’re healthy or sick. The HQP demonstration has used the gold standard of experimental design: randomized-controlled trials. Some seniors enrolled are included in the program and some left out. The assignment is random and the group’s similar, allowing researchers to be certain that whatever differences they’ve seen between the groups are attributable to the care each received rather than the company’s success at signing up healthier seniors. Health Quality Partners’ results have been extraordinary; according to independent analysis by consulting firm Mathematica, HQP has reduced hospitalizations 33 percent and cut total Medicare costs for demonstration enrollees by 22 percent. I think it’s fair to say that those same metrics would no doubt be of great benefit to any ACO capable of accomplishing the same on its population of attributed lives.

One interesting point about the demonstration in which HQP participated is that many of its Medicare beneficiaries were dual eligible or qualifying for both Medicare and Medicaid. When we think about home health more broadly, as a home and community based service, and include both those rehabilitative and treatment services commonly associated with it as a Medicare service but also include those lower acuity professional and paraprofessional services designed to maintain beneficiary independence at home under Medicaid, the result is an even more dynamic partner for an ACO.

There are 10.2 million dual eligible Americans, 7.4 million of whom are full dual eligible, those actively receiving services from both Medicare and Medicaid. 61% are over 65, 39% are younger than 65 and disabled. Half have dementia or another mental impairment and 55% have three or more chronic conditions. This is the highest cost group of consumers in the American medical system. There are 168,229 full dual eligible in Missouri and these patients represent a tremendous opportunity for an ACO to have a fundamentally positive impact on the health of the communities it serves and drive major Medicare savings.

Consider this, because Medicare and Medicaid pay for different slices of a dual eligibles’ care this group’s services have been largely uncoordinated. The cost of investments designed to lessen overall spending, if done, is often borne by the state and Medicaid with the benefits accruing to the Federal government and Medicare. For example, reducing avoidable hospitalizations is a direct benefit of better coordinated care. CMS says 45 percent of hospitalizations transferring from skilled nursing facilities last year we’re avoidable. To reduce those hospitalizations requires investments in programs like fall prevention; which when implemented through HCBS reduce the need for and occupancy of SNF and therefore the number of individuals transferring from a SNF to the hospital because of a fall. The cost of expanding these programs is roughly 40% born by the state under Medicaid but the financial savings from reduced hospitalizations and SNF rehab accrue to Medicare and the Federal government. \

As an ACO you’re in a partnership with the Federal government and Medicare. The same Affordable Care Act that ushered in ACO’s also created the Medicare-Medicaid Coordination Office within (CMS). Their goal is to make these two programs work together more effectively. They are charged with testing new approaches to care coordination which permits states to share in the Medicare savings resulting from their management efforts; just like those of you operating in an ACO environment get to participate with Medicare in the shared savings resulting from your management efforts. The biggest of these initiatives is the Financial Alignment Demonstration which is predominantly testing two models, fully capitated managed care and healthcare homes. Due to time constraints we can’t go through all the nuances of each of these models but, what’s important is, just like a state that can drive its participation in shared Medicare savings through more effective use of Medicaid services, so too can you as an ACO. Where your ACO has attributed lives represented by dual eligible individuals, those individuals likely represent the group for whom you can drive the greatest Medicare savings. If your home health partner has the experience and ability to assess qualifying need, eligibility and assist these patients to access these Medicaid programs, these long term supports will dramatically reduce Medicare hospitalization and skilled nursing facility cost, and drive your ACO shared savings. That said, this is task that has to occur in the homes and communities of your patients and it’s not equally available from all home health partners.

Given I’m pretty close to my 20 minute mark I should probably summarize the points I’d like to leave you with today. 1st and most importantly, a good partnership between an ACO and Home Health is good for patients; it helps physician’s gain more granular insight into the influencing factors of patient’s lives and helps them empower patient’s to make better healthcare decisions; 2nd in doing so it drives cost savings for Medicare and improves the profitability of the ACO. 3rd, it’s important to partner with a home health provider that offers a full scope of home and community based services under Medicare and Medicaid with comparatively better and verifiable hospitalization and emergent care outcomes rooted in claims data. Believe me; it’s much easier to stand here and describe what a good partner looks like than it is to actually be one, the time you spend investigating yours is well spent; and we at Pyramid Home Health Services would love the opportunity to prove to you why we’d be a good choice of partner.
Thank you so much for having me here today.

Better Care, Lower Cost Act- A Good Use of Home Health Providers

Earlier this month, new legislation, the Better Care, Lower Cost Act was introduced in Congress. The bill is bi-partisan and sponsored by Senators Ron Wyden (D-OR) and Johnny Isakson (R-GA), and Congressmen Erik Paulsen (R-MN) and Peter Welch (D-VT).  The goal of this legislation is to improve chronic care management within the Medicare benefit. The legislation encourages the formation of multidisciplinary care teams to focus specifically on caring for patients in need of coordinated chronic care management.

The Better Care, Lower Cost Act proposes to create Better Care Programs (BCPs). BCPs would be required to provide all Medicare benefits, including physician visits, in-patient hospital care, diagnostic tests, post-acute care, hospice, and prescription drugs as well as perform health and functional assessments of each beneficiary and create individual care plans for each beneficiary. BCPs would receive risk-adjusted monthly capitated payments for each BCP enrolled Medicare beneficiary. BCP’s would be eligible to share in the Medicare savings generated through their efforts and earn additional bonuses based on their meeting specific quality criteria. They would also be responsible for any losses incurred should the cost of care be in excess of the monthly payment received.

Additionally, the bill envisions the creation of Chronic Care Innovation Centers (CCICs). The mission of CCICs is to research, design and implement strategies to improve the quality of chronic care management across payer types while developing best practices for caring for the chronically ill. It encourages medical education reform by requiring medical schools and residency training programs to develop evidence-based approaches for promoting team-based chronic care with emphasis on the integration of technological advancements into that care. Last, it places greater emphasis on meeting the chronic care management needs of rural and underserved communities.

We at Pyramid Home Health Services believe the infrastructure required to deliver quality Home Health services is exactly the same as will be required to build the foundations of these Better Care Programs (BCP) as contemplated in the Better Care, Lower Cost Act. More than 75% of current Medicare Home Health beneficiaries are living in the community setting with four or more chronic conditions. Accordingly, Home Health providers already have extensive experience assisting in the management of the health of some of America’s most chronically ill citizens. Home Health providers actively partner with physicians daily to bring better coordinated and technologically enabled care into the homes of patients in rural and underserved areas all across the country; and, last but certainly not least, home health is the absolute least costly venue of care in which to manage these patient’s conditions.

Where improving the delivery of chronic care management is concerned, comprehensive discharge planning, deployment of at home interventions, use of evidence-based treatment guidelines, on-going patient education on disease management and self- care and the promotion of collaborative care among health care providers is the key to success; this is also the core function of existing, quality home health providers. Much consideration has gone into the creation of new initiatives like financial alignment demonstrations that establish “Healthcare Homes” as model care management concepts within Medicare and Medicaid. Perhaps as the conversation surrounding the potential establishment of BCPs’ as articulated in the proposed Better Care, Lower Cost Act ensues, the innate benefits of building the same using existing home health infrastructure  as the BCP backbone will cause more thought to be given to the idea that the beneficiaries actual home can also be their healthcare home.

Pyramid Home Health Services is a provider of Home Health, Community Based Long-Term-Care, Hospice and Pharmacy services in Missouri. We have the clinicians, technology and experience required to assist you to improve the health of your patients and beneficiaries living at home with chronic illness. If you would like to discuss working together please call us at 888-880-6565 or visit us at www.pyramidhhs.com.

A Common Assessment Tool for Post- Acute Care

Traditionally Post-Acute Services like Home Care, In-Patient Rehabilitation Hospitals, Skilled Nursing Facilities, and Long Term Care Hospitals have resided in individual silos. Despite the fact that they are utilized, largely, post hospitalization, they have not had any common data sets, no uniform initial assessment tools, no common pricing components, and differing methodologies for assessing quality outcomes. The net effect of this is persons requiring post- acute services at discharge may find themselves discharged to different silos notwithstanding a similar acuity level. For example, two individuals discharged from the hospital for say, a lesser acuity stroke, may find themselves in totally different environments post hospitalization; one individual may be discharged to a skilled nursing facility while another may be discharged into home health with the entirety of the process being driven by individual treatment protocols of the discharging facility or treating physicians usual and customary practices.     

Now it’s certainly to be noted that exceptional care and outcomes can be driven from all of these discharge venues and that there are individual considerations that can make one or the other more appropriate a destination for any one of two individuals of similar acuity. That said there are tremendous benefits for patients and improved cost to the public health system in ensuring that these discharges are driven by patient specific characteristics and not simply historical treatment patterns, preferences and relationships.

Interestingly, the Medicare Payment Advisory Commission (MedPac), a 17- member Commission established by the Balanced Budget Act of 1997 to advise Congress on issues affecting Medicare payments to private health plans and providers, is beginning to turn their attention to the matter of post- acute services discharge. In its annual March report to congress, among many other recommendation, MedPac will recommended that Congress ask HHS (Health and Human Services) to implement a common assessment protocol for home health agencies, skilled-nursing facilities, inpatient rehabilitation hospitals and long-term care hospitals. The proposal is intended to facilitate comparisons of patient outcomes and costs across post-acute care settings. This is significant as it represents a first step toward moving to a post- acute discharge methodology that will be determined via specific patient assessment for best point of destination post hospitalization. It represents the basis for building a discharge process rooted in risk adjusted data that can serve as a foundation for developing best practices for the post- acute discharge process.

To the extent that patients want and the public health system benefits from the discharge of hospitalized patients into the least restrictive and lowest cost venue of care most able to meet their rehabilitative needs, home health care stands to benefit from this type of policy implementation. For patients with a home environment supportive of their return to it for rehabilitation, with assistance where necessary with ADL’s (Activities of Daily Living), making a singular transfer from the in-patient setting directly to home just makes more sense. The fewer steps or the shorter the step down from the in-patient to the home setting the more likely the care transition process is to be successful and the less likely the patient will find themselves re-hospitalized. From Medicare’s perspective it also creates an environment to lower overall post- acute care expenditures.

Home Health generally, and Pyramid Home Health Services specifically is highly focused on demonstrating its value to the healthcare continuum as the optimum manager of the care transitions process. Medicare policy changes that result in all patients indicating a need for post- acute care services receiving a standardized post-acute assessment will serve to increase the utilization of home health initially post discharge; both due to home health’s capabilities to serve as the patient’s least costly primary location for rehabilitation but also because of the greater level of coordination it brings to the overall transition to home process. In the post ACA (Affordable Care Act) environment where the concepts of global capitation with gain share put intermediaries and hospitals simultaneously at greater financial risk for and eligible to receive greater financial rewards relating to outcomes, these two  attributes, found in well organized and efficacious home health services, bode well for its longer term success.  In the final analysis, home is where the patient wants to be and its where the American Health System has to get them back to as expeditiously as possible when cost considerations come into play.


If we at Pyramid Home Health Services can assist you, your family, practice or beneficiaries with rehabilitation at home, visit us at www.pyramidhhs.com or call us at 888-880-6565.

Care Transitions by Pyramid Home Health Services

Pyramid Home Health Services assists many Missourians recently discharged from an in-patient hospital stay to rehabilitate at home through the services of its home health division. These services provide individuals with the skilled nursing, therapy, social service and dietary assistance required to recover in the comfort of their own home. Beginning in 2014, Pyramid Home Health Services will begin providing comprehensive care transitions management under contract to health plans and hospitals operating in Missouri.
Many individuals are discharged to home without a specific need for traditional home health services but who are still at risk for complications that may lead to unnecessary ER usage or a re-hospitalization within 30-days of discharge. The key to avoiding this undesirable outcome lays in successfully managing those patients transition from the in-patient setting to the community. Pyramid Home Health Services Care Transitions is a 30-day program specifically developed to avoid ER usage and hospital readmission during that period. Specifically the program:
1- Makes in-person/ in-facility contact with patients at high risk for re-hospitalization prior to their discharge from the hospital. Pyramid Home Health Services staff develops a rapport with the patient and ensures they are knowledgeable of their condition, medical record, medications and, generally, their own responsibilities relating to a successful recuperation at home prior to their leaving the hospital. All patients receive a “Transitions Packet” containing vital information regarding their condition, warning signs and symptoms, discharge medications and instructions, the contact number for Pyramid Home Health Services’ 24×7 nurse line, their physician(s) contact information and follow-up visit dates, and list of the addresses and hours of operation of emergent care clinics nearest their home.
2- Conducts pre-discharge assessment of the safety and accessibility of the patient’s home and provides a written report to the patient’s following physician(s), the discharging hospital, and their health plan covering any identified safety hazards, barriers to self- care or family assisted care, and required home modifications or DME that may be necessary for a successful transition to home. Additionally, if necessary, Pyramid Home Health Services will coordinate orders and referrals for ancillary services, supplies and pharmacy and ensure any required services, supplies or medications are in the patient’s home upon their return.
3- Delivers a home visit within 48- hours of discharge, or sooner where required, to evaluate the return to the home process, the patients satisfaction with the same, address health questions and concerns, check vitals, and review medications and the patient’s knowledge thereof regarding regimen/ dosage(s)/ side effects. Where beneficial Pyramid Home Health Services provides tele-health based MTM (Medication Therapy Management) with a MTM certified pharmacist. Additionally, Pyramid Home Health Services staff reviews and updates the transitions packet, schedules necessary follow-up physician visits and/or ancillary care provider visits, arranges necessary transportation thereto and again reviews with the patient relevant condition warning signs/ symptoms. A written report of this visit is provided to the patient’s following physician(s), the discharging hospital and the patient’s health plan.
4- Within 48-hours of the initial home visit and no less than weekly thereafter Pyramid Home Health Services conducts check-up calls with the patient at pre-arranged times to review their stability at home and their satisfaction with the home transition process. Included in these calls is reminder of and verification of the patient’s making their required physician appointments. If necessary, Pyramid Home Health Services will conduct additional home visits should its calls to the patient or in-bound calls from the patient indicate a potentially worsening condition. Written report of these calls/ visits will be made available to the patient’s following physician(s), discharging hospital and health plan.
If you are a Missouri Hospital or Health Plan and would like to discuss contracting with Pyramid Home Health Services to manage the Care Transitions process for your patients and beneficiaries visit us at www.pyramidhhs.com or call us at 888-880-6565.

Practice Extender

Practice Extender:
Pyramid Home Health Services assists many Missourians to manage the challenges of living with multiple chronic conditions at home. Beginning in 2014, through its new Practice Extender Program, Pyramid Home Health Services will offer these Patient’s Physicians a powerful tool to better coordinate their care and live healthier.
Practice Extender Services Includes:
1- 24X7 Nurse Line: The availability of a Pyramid Home Health Services Clinician 24/7 to provide telephone based response to patient health questions and concerns and to triage alternative care options to the ER after hours. Response is stepwise and ranges from the least invasive, advice, follow-up telephone monitoring and scheduling of a physician office visit to referral and arranging of transportation, if required, to the nearest open emergent care clinic to dispatch of an RN or NP to the patient’s home to evaluate symptoms and take appropriate action. All documentation of interactions will be provided to the patient’s Physician within 24- hours or sooner where appropriate.

2- Tele-Health: Pyramid Home Health Services Tele-health platform allows Physicians to “cast” HIPPA compliant and billable Patient office visits from the Physician’s practice location into their Patient’s homes when Patients are unable or unwilling to travel to the practice location. Pyramid Home Health Services will assist the practice to preschedule these visits and deploy the appropriate staff and equipment to the patient’s home to ensure a thorough examination, including review of vitals and, where necessary, collection of lab specimens.

3- Intermittent NP staffing: Staffing can be for “In-Office” needs, including managing Tele-Health Services, or for conducting home visits. This service includes provision of all requisite contracting between the NP and the Physician, scheduling, and electronic documentation of patient services.

4- Medication Management: Includes Tele-Health based MTM with a certified Pharmacist, in-home nurse review of and teaching on medications and medication compliance, electronic medication reminder calls with tracking and follow-up, free home delivery of multi-dose packaged medications, specialty drug compounding and administration.
Pyramid Home Health Services provides Physicians a range of partnering options. Where services are individually billable to a patient’s insurance, the Practice or Pyramid Home Health Services may bill for the same with Pyramid Home Health Services receiving payment on a fee for service basis directly from the insurance company or under contract to the physician. Where practices are managing the care of Patients under capitated agreements or are participating in “Gain Share” or other “Shared Savings” programs, Pyramid Home Health Services will contract on a per member, per month basis (PMPM) with the practice or the intermediary.
Practice Extender from Pyramid Home Health Services will permit Primary Care Physicians to qualify for the Chronic Disease Management Fees established in the final 2014 Physician Fee Schedule.
If you are a Missouri Physician and would like to add Practice Extender as a benefit for your patents, please contact Pyramid Home Health Services on line at www.pyramidhhs.com or call us at 888-880-6565.

Delivering the Right Care at the Right Time

The Institute of Medicine defines appropriate and affordable care as “Delivering the right care at the right time with the right provider in the right setting.” Technology enabled home health providers like Pyramid Home Health Services in partnership with Patient’s Physicians represent a uniquely well suited team to ensure delivery of the type of maximally coordinated and effective care contemplated in this definition. Within the operational perimeters of Affordable Care Act (ACA), these partnerships provide a distinct advantage for both Physician and Home Health company and, more importantly, for patients.

Nearly a quarter of Medicare beneficiaries have five or more chronic conditions. These individuals account for approximately two thirds of total Medicare Spending. As we’ve discussed in earlier blog posts, the care provided for these individuals, especially where they are dual eligible, is largely uncoordinated and disjointed. This is one reason why this population of patients is fully 100-times more likely to experience a preventable hospitalization than non- chronically ill Medicare beneficiaries. Under the ACA, failure to better coordinate and manage these patients’ care has a huge price tag for providers; particularly hospitals, in the form of readmission penalties and forgone revenue from “Shared Savings” opportunities. Additionally, failure to deliver quality outcomes can imperil long standing referral relationships as “At Risk” providers can ill afford to be further imperiled by low performing partners. Through the application of these economic consequences, the ACA is very definitely driving a strong shift up and down the continuum of care toward delivering desired outcomes at lower cost.

Embedded in the ACA are multiple opportunities for Physicians and Home Health Companies to work together to deliver better outcomes for chronically ill patients. One of the first areas evidencing this opportunity can be found in numerous Independence at Home Demonstration (IAH) programs. Basically IAH are Physician, Nurse Practitioner or Physician Assistant led house call programs. Under IAH guidelines providers are paid for their services but they have the opportunity to share in 80% of Medicare’s savings after meeting a minimum 5% total savings of the fee for service average for beneficiaries in their practice region. While the IAH demonstration specifically is only permitted to enroll up to 10,000 Medicare beneficiaries nationwide; its pay for performance metrics are embodied in numerous other ACA initiatives.

Where Medicaid is concerned, the ACA establishes the opportunity for State Medicaid plans to create Health Homes. Eligible beneficiaries are those who qualify for medical assistance under a state plan or waiver and who have two or more chronic conditions or who have a chronic illness and a concomitant mental health condition. We in Missouri were the first in the nation to establish health home programs and today they are operating within FQHC and CMHC state-wide. These initiatives couple per member per month payment for care coordination with the opportunity for states and providers to share in the Medicare savings resulting from better coordinated care.

The ACA additionally funds a vastly expanded national preventive health initiative. Annual physical examinations, health risk assessments, and personalized disease prevention services are all mandated to be fully covered for all Medicare beneficiaries.

In the healthcare landscape molded by the ACA, Pyramid Home Health Services represents a perfect practice extender for Missouri Primary Care Physicians. With new patients resulting from expanded insurance coverage generally as well as the aging of the baby boomer population, it’s going to be tough for Primary Care Physicians to meet the increased demands on their time. Through the use of Pyramid Home Health Services’ Nurse Practitioners, RN, and HIPPA compliant Tele-Health portals, these practitioners are enabled to see patients at home without incurring the expense and inefficiency of personally travelling from house to house. When cast from their offices these interactions are billable per the standard 2014 Physician Fee Schedule; so with Pyramid Home Health Services, Physicians can focus on those patients who are most critically in need of their personal, physical presence while also meeting the demands of their growing patient base by treating many of those patients in the comfort of their own home.

Where Physicians are participating in population health management strategies like IAH, Health Homes and under risk based contracts with managed care entities, utilizing Pyramid Home Health Services staff and its various monitoring technologies provides a powerful tool to identify issues prior to their becoming ER visits and hospitalizations. Where these relationships are concerned, Pyramid Home Health Services can work with these providers on a shared risk or per member, per month basis. Including in these arrangements are various levels of home monitoring, laboratory, referral to ancillary services and our MTM certified Pharmacists.

An effective partnership with Pyramid Home Health Services offers Missouri Physicians the opportunity to further their patient relationships by making themselves and their practices more available to all patients all the time; which is exactly in-line with the policy push implicit in the ACA, “To deliver the right care at the right time with the right provider in the right setting.”

If you are a Physician in Missouri and would like to talk further about how we can help you extend your practice into your patient’s home, visit Pyramid Home Health Services online at www.pyramidhhs.com or call us at 888-880-6565.

Chronic Care Management

Let’s presume the starting point for a particular individual’s engagement with a Chronic Care Management program begins after transition from an inpatient stay back to home. As a part of the care transition process, the individual, optimally, is in possession of their healthcare record and understands their health status upon discharge. Using this baseline, the Chronic Care Management team can begin the long term job of keeping that individual in the community and avoiding acute events.

The core job of the Chronic Care Management team is to provide the extensive and ongoing supports required to help the patient and their caregivers handle obstacles that arise and have the potential to result in an exacerbation of their chronic condition. Success is measured in improved health and quality of life, reduced hospitalizations and ER visit, reduced duplication of diagnostic tests and decreased overall medical expenses.

The caseload management approach utilized by Pyramid Home Health services’ regional care teams, MSW/ LCSW, RN and MTM certified pharmacist coupled with para- professional care givers is a model that lends itself perfectly to the cause of Chronic Care Management. These teams are skilled in disease specific patient education. They actively manage the inflow of information from medication screens, tele-monitoring devices in patient’s homes and family caregivers and react as necessary. Where acute incident seem to be developing they communicate effectively with the patient’s broader medical team, intervene as necessary and stop the advancement of symptoms that can lead to the ER or a hospitalization.

Notwithstanding the capability of our credentialed team members, Chronic Care Management is not solely the responsibility of credentialed clinicians. For example, many chronically ill individuals know what they should be doing to control their disease(s). Many just don’t do it or they need help doing things like checking their insulin, remembering to weigh daily, take medication and make physician appointments. Sending a trained clinician to the home of these individuals daily to help with these sorts of issues is simply not cost effective over the long term. Sending one of Pyramid Home Health Services’ Para-professional care givers, utilizing our automated medication reminder call program, multi-dose medication packaging, pre-scheduling services for physician visits and assistance arranging transportation is. Matching the appropriate support and assistance to the most cost effective deployment thereof is an important part of an effective Chronic Care Management program.

Pyramid Home Health Services provides HCBS, Home Health and Pharmacy services for a large population of Missourians residing in both rural and urban areas. Our Care Management teams effectively serve patients in 110 Missouri counties daily. Should you require assistance implementing a Chronic Care Management Program or require the same for a family member, patient or patient population contact Pyramid Home Health Services at 888-880-6565 or visit us at www.pyramidhhs.com.

Care Transitions and Chronic Care Management

Merging Transitional Care Programs with Chronic Care Management Models at the community level is the key to long term cost control and patient satisfaction where the dual eligible, frail elderly are concerned. These initiatives should be given great consideration where transformation and reform of the healthcare system that meets the needs of these beneficiaries is concerned.

First let’s define these two terms:

A Transitional Care Program is using LCSW, RN and Advanced Practice Nurse, and clinical pharmacist in a team to provide, pre and post hospital discharge, patient education and assistance in the following areas: medication self-management, use of a personal health record, follow-up with Primary Care and Specialty Physicians, warning signs of potential health problems, and advanced care planning.

A Chronic Care Management Model is the ongoing application of population/ condition unique healthcare protocols to improve aggregate health and avoid acute exacerbations of chronic conditions avoiding additional medical cost and generalized worsening of individual(s) health.

In this week’s blog we are going to focus on what an effective Transitional Care program looks like. Next week we will discuss how an effectively deployed Chronic Care Management model keeps the successfully transitioned patient out of the hospital over the long- term and then; in our November 29th post, we will explain how a fully integrated Home and Community Based healthcare provider like Pyramid Home Health Services can be a hospital, managed care plan or state government’s best partner where meeting the need for consistent and broad geographic deployment these services is concerned.

So why do we need Transitional Care programs? The difficulties of moving from one health care setting to another are challenging for anyone and particularly so for a frail elderly individual. It is at this point of transition that the likelihood of emergency department visits and hospital readmission really spikes. Just think about it; you’ve just been discharged from a hospital after having had a multi- day stay and following a procedure; you have new and discontinued medications to deal with, a modified ability to meet your routine and/or new self- care needs and now something just doesn’t feel right. It’s not hard to understand how this scenario so frequently leads to an ambulance ride to the nearest ER and then readmission to the hospital.

So what do the Transitional Care Team members do? How can an LCSW, RN and clinical pharmacist avoid the undesirable outcome described above?

1- They Identify the High-Risk Senior before they are discharged. Team members can make daily telephone rounds discussing with the hospital’s in-patient case managers the health status of patients pending discharge and determine who on the hospital’s census needs to be added to the list of persons the Care Transition Team needs to meet in person and begin to engage.

2- Before discharge the Care Transition Team can meet with the patient, develop a basic rapport and elicit consent for a home visit to occur no later than 72 hours post discharge and preferably within 48 hours. At this time the Care Transition Team coordinates with the physician that will follow the patient upon discharge and ensures all appropriate orders and conveyance of referrals to required ancillary care providers occurs.

3- Provide the patient a “Transition Packet” that contains their medical record, advanced directives or election documents therefore if the patient does not have an advanced directive, list of clinical warning signs and relating to their condition, symptoms to be aware of and actions to take to avoid condition worsening, and a list of the urgent care locations in the vicinity of the patient’s discharge address with contact information and hours of operation should they need seek medical care unexpectedly.

4- Conduct the 1st post-discharge home visit. At that visit the team must, (A) Make sure the patient has a current list of all their prescription and over the counter medications, screen that list for adverse reaction, ensure the patient understands why they are taking each medication, how to take the medications and if there are any barriers to the patient’s medication compliance. When identified, address those barriers. (B) Review and explain the contents of the patient’s medical record. Make sure they understand the importance of sharing the same with their primary care physician, specialists, and post- acute ancillary care providers. (C) Schedule the necessary follow-up visits then and there and confirm or transmit to the following physicians all discharge orders. (D) Review with the patient their condition specific warning signs. (E) Complete a full patient health evaluation and affect a baseline health status post discharge with a copy retained by the patient in their Transition Packet and to be shared with following physicians and other post- acute providers.

5- At least 1 follow-up call with 48- hours of initial home visit and continued contact as necessary.

As documented by the National Transitions in Care Coalition, effective Transitional Care Programs have a huge and positive impact where reducing ER and hospital re-admission risk for the frail elderly is concerned. In some initiatives observed rates of re-hospitalization have decreased by as much as 60% with ER visits decreasing by more than 30%.

Pyramid Home Health Services has 16- Regional Care Management Teams; each of whom is staffed by LCSW/ MSW, RN and Advanced Practice Nurses, and MTM certified Pharmacists. Additionally, our HIPPA compliant Tele-Health Portal can provide the patient’s physicians the ability to participate with, real time, the patient and their Pyramid Team while all are in the patient’s home.

Traditionally, HCBS and Home Health Services more specifically, have been thought of as “Post -Acute” and “Post Discharge” services. Notwithstanding, the same professionals that make up a Pyramid Home Health Care Team can also deliver a very effective Transitional Care Program for Hospitals and Managed Care companies working to improve the success and satisfaction rates of their patients and beneficiaries transitioning from the in-patient to home setting.  Where these organizations are concerned Pyramid Home Health Services represents a more cost effective solution than implementation of their own teams to accomplish the same or their contracting with call center based third parties who have to further contract with additional providers to actually and meaningfully “touch” a patient. Simply stated, Pyramid Home Health Services permits Hospitals and Managed Care entities to avoid the added cost and managerial responsibilities associated with doing it themselves and the unnecessary cost of adding a middle-man to the equation. When coupled with the financial capacity and willingness to contract on an “At Risk” basis, Pyramid Home Health Services represents a great partner for Hospitals, Managed Care Entities and State Government wishing to improve Care Transitions for Missouri’s dual eligible.

If you would like to discuss implementing a Transitional Care Program for your patients or beneficiaries please contact us at www.pyramidhhs.com or via phone at 888-880-6565.

Case Management of Chronically Ill Elderly Dual Eligibles

With chronic illnesses like diabetes and heart disease being cured isn’t the goal; feeling better on average, not going to the hospital as much, living a longer and higher quality life is the goal. The existence of chronic illness is a somewhat ironic demonstration of modern medicine’s success. Three decades ago, many chronic conditions killed you at much younger ages. Today, many like heart failure can be fought off for years or indefinitely.

Kenneth Thorpe, chairman of the health policy and management school at Emory University, estimates that 95 percent of spending in Medicare goes to patients with one or more chronic conditions — with enrollees suffering five or more chronic conditions accounting for 78 percent of its spending. According to Mr. Thorpe, “This is the Willie Sutton rule; If 80 percent of the spending is going to patients with five or more conditions, that’s where our health-care system needs to go.”

This is the basic health profile of full Dual Eligible, a population in the United States of more than 7 million people and in Missouri more than 168,000 of our citizens.  As we’ve discussed in earlier blog posts, dual eligible individuals are using the full benefits available to them under both Medicare and Medicaid. 61% are over 65, 39% are younger than 65 and disabled. Half have dementia or another mental impairment and 55% have three or more chronic conditions. This is the highest cost group of consumers in the American medical system. They are 15% of the Medicaid population and account for 40% of total Medicaid spending. In Missouri we spend in excess of $2 billion annually on this group’s healthcare.

Individuals with chronic conditions, many dual eligible, represent perhaps the best group for home health and community based services (HCBS) generally to demonstrate their biggest benefit to the healthcare system overall.

Many traditional care-management systems rely on nurses sitting in call centers, checking up on patients over the phone. These centers are often housed within insurance companies or subcontracted providers to insurance companies who have capitated contracts with state governments to manage chronically ill Medicaid beneficiaries and, increasingly, the dual eligible population at large.  That model has mostly proven to be a failure where maximizing long term savings to state governments is concerned and, more importantly, where improving the long term quality of life for beneficiaries is concerned. Most savings driven by this model are attained via provider reimbursement cuts and minimization of services which produce early savings that then tend to marginally abate with time.

While many are familiar with the use of home health nurse visits in the days and weeks after a serious hospitalization or nursing home discharge; a much greater benefit to the system can be achieved by sending a nurse to regularly visit chronically ill patients at home. Using home health in this fashion basically redefines the health-care system’s role where the elderly and chronically ill are concerned. It acknowledges that being older and chronically ill is a condition that requires ongoing, professional medical management. In this acknowledgement there is tremendous improvement in quality of life at much lower public expense, especially where the dual eligible beneficiary is concerned.

Many chronically ill patients think of the hospital as a place people go to get better. What providers of Home and Community Based services (HCBS) realize is that, in reality, a hospital is a place where chronically ill seniors get worse. Being in the hospital for multiple days is often the point at which a chronically ill but basically stable senior’s health condition really begins to deteriorate. It’s when the individual ends up in a nursing home and in some cases never makes it back to their own home. It’s also the point at which public health cost absolutely skyrocket. Keeping seniors out of the hospital and out of the nursing home is the core focus of HCBS; they cut cost and save and preserve quality of life; and it saves money, lots of it.

At home is where chronically ill elderly patients spend the time they don’t lose to hospitalizations. It’s where they take their medicine or fail to properly, eat healthy meals or eat poorly, are engaged or become depressed, get around or fall down. This is the key to the power of home health and HCBS; in the home a trained medical professional can see trouble before it becomes too late. As well intended as they may be, clinicians in call centers in O’Fallon and Omaha can’t get the same level of understanding of a situation as can a clinician on-site. It’s just very difficult to build an effective relationship over the phone that makes a lasting difference.

Pyramid Home Health Services has been building these relationships with Missourians suffering from chronic illness since 1972.  We fundamentally believe that where chronically ill dual eligible are concerned, you can’t treat them when they’re sick and ignore them when they’re well. You need to know them well enough and see them frequently enough to catch if they are depressed, if their color is good or bad, if they understand their medications and are managing them appropriately. When you consider that a relatively high acuity dual eligible with multiple chronic illness can be effectively kept out of the hospital and nursing home for approximately $4,000 annually and a very high acuity individual for less than $8000 annually and compare the same to one, three day hospital stay at $5,800, and $125 per day for rehab in a skilled nursing facility afterward, which can often run up to 100 days, the economic benefits of using HCBS to case manage the health of chronically ill elderly become abundantly clear. Further add to that fact that home is where everyone would rather be unconditionally.

If Pyramid Home Health Services can assist you or your organization with case management and/or additional HCBS for a chronically ill loved one or a population for whom you’ve contracted to manage, please contact us at 888-880-6565 or visit us at www.pyramidhhs.com.

The Medical Home Model and Dual Eligible

Last week we discussed the two main types of Financial Alignment Demonstrations sponsored by CMS and for full dual Eligible. These are:

  • The Capitated Model. This is a model that pays private health plans that contract with the state a PMPM rate to provide all Medicare and Medicaid benefits to full dual eligible on behalf of the state.
  • Patient Centered Medical Home Model. This model allows states to design systems to coordinate care for full dual eligible while Medicare and Medicaid continue to pay providers directly for delivered services.

This week let’s take a deeper look at the Patient Centered Medical Home Model in Missouri. Like we discussed last week, Missouri submitted in its proposal on May 31st, 2012 for a Patient Centered Medical Home Financial Alignment Demonstration.

Missouri proposed to build their Patient Centered Medical Home demonstration around their existing Medicaid Health Home initiatives. You may know, the state of Missouri applied for and received approval from CMS for two Health Home programs under Section 2703 of the Affordable Care Act (ACA) in January 2012. We were actually the 1st in the United States to be approved. These health homes currently provide care coordination services state-wide to 11,996 dual eligible Missourians. The first of the two programs, the Community Mental Health Center (CMHC) Health Home program, targets individuals who have serious mental illness in combination with another chronic condition. The second approved program, the Primary Care (PC) Health Home, targets individuals who have multiple and chronic conditions. There are currently 29 Community Mental Health Center based health homes and 24 Primary Care Health Homes mostly located in Missouri’s FQHC.

Missouri’s Financial Alignment Demonstration requests to extend Missouri’s existing Health Home initiative for select, full- dual eligible within the state. So what are the hallmarks of the Patient Centered Medical Home Model?

1. Strategies to target high-need, high cost beneficiaries. Missouri identifies eligible not already enrolled in a health home and who have 2 or more chronic conditions and/ or serious mental health issues through analysis of healthcare claims data and via referral from providers.

2. Care team led by a Care Coordinator who is the patient’s Physician or Advanced Practice Nurse.

3. Coordination of Multidisciplinary care teams that integrate behavioral and physical health. The care coordinator unites the disparate pieces of the health care delivery system and makes them work collaboratively for each beneficiary. Additional physicians (specialist), Nurse Practitioners, Psychiatrists, Behavioral Health Consultants, Nurse Care Managers, Dietitians, Diabetes Educators, Pharmacist, labs and other ancillary care providers work as governed by the beneficiaries personal plan of care as coordinated by their health home care coordinator. The Patient Centered Health Home locates, conducts outreach to and manages the ongoing treatments of all the extended team members. In Missouri these health homes receive a per member, per month payment of approximately $60 for the Primary Care Health Home Program and $80 PMPM for the Community Mental Health Center Health Home.

4. Enhanced access. This is early identification of need for and connection to community services that can avoid higher cost and usually facility based services after an acute event.

5. Provider and Payer Alignment. This is accomplished through PMPM case management fees and in some cases additional provider participation in shared savings.

6. The ability to drive Medicare and Medicaid Savings. In Fiscal year 2012 alone the Missouri State Budget was benefited by $44 million in avoided healthcare expenditures from existing Patient Centered Health Home initiatives.

Home Health and HCBS services can greatly extend the inherent benefits of the Patient Centered Health Home model. By effecting an ongoing relationship with the patient and the their health home based practitioners, a home health partner can ensure the dual eligible patient’s physician has a more granular understanding of the daily challenges a patient faces where adherence to recommended behavior and compliance with physician orders is concerned. HCBS services can assist as well to educate and train the patient’s friends and family in providing the supports necessary to better their adherence to the plan of care.

Additionally, where more complex co-morbidities exist, for example, a diabetic with open wounds, a home care provider with an expertise in advanced wound healing can add exponentially to the effectiveness of the health home team by bringing specific expertise in the form of knowing how to deploy, at home, support surfaces, wound vacuums, advanced debridement techniques and alternative dressings. This reduces the need for inconvenient and more expensive out of home trips for follow-up care and minimizes the potential for infection which often results in avoidable hospitalization and SNF rehabilitation.

Pyramid Home Health Services Wound Healing Program consists of the following:

  • WOCN, a credentialed specialist RN, who reviews each patient’s H&P, initial assessment/ wound etiology, electronic wound photos, and consults on a holistic POC recommendation with the treating physician. They are also available for patient, physician and family in-home and in-office consultations and case conferences.
  • Case Manager that tracks compliance with POC, monitors healing progress, coordinates the communications of treating clinicians, the patient’s physician(s) and Pyramid’s WOCN using electronic medical record updates and digital transmission of wound care photos and treatment notes.
  • Treating Clinicians that are trained in and receive continuing education on advanced wound treatments, dietary and behavioural management techniques and patient education.

If Pyramid Home Health Services can assist you Medical Home Model please contact us at 888-880-6565 or visit us at www.pyramidhhs.com