How to Launch a Value-Based Care Model

Payers determine the level and frequency of homecare needed to keep patients healthy and safe at home. Home health agencies bring these care plans to life through the day-to-day care of patients in their homes, with little or no feedback returning to the patient’s clinical team or payer. But as the industry moves to a patient-centered focus, home health agencies need to be part of the clinical decision-making process.

Home health aides are uniquely positioned to capture rich and timely data while caring for patients in the home. But data alone is not enough to impact outcomes. The real value comes from coupling point-of-care data with actionable insights for care.

Currently, most home health agencies don’t have the technological tools needed to quantify observations and outcome measures in the home. But these types of tools can provide a better approach to value-based care and population health initiatives. By embracing technology-based solutions, an agency can:

• Equip home health aides with a simple mobile platform to capture insights;
   
• Automate the surveillance of daily patient check-ins with cloud-based artificial intelligence (AI); and
   
• Provide real-time escalation and intervention to payers, hospitals or other risk-bearing providers.

Coaching Homecare Workers with Technology

Home health aides know their patients well and recognize when they are not acting like themselves. They may notice subtle changes; perhaps a patient is a little unsteady on their feet or is more thirsty or drowsy than usual. These slight shifts in behavior might be warning signs of something more complex.

To capitalize on these insights, home health agencies can coach homecare workers so they can perform higher level tasks. With the right mobile tools, aides can conduct simple assessments, monitor important changes in behavior and unlock real-time information with critical clinical potential. Using standardized measures, aides can easily monitor items such as pressure ulcer risk, pain, readiness for discharge, nutrition risk, activities of daily living, fall risk and caregiver strain.

The goal is to uncover even the smallest change in condition before it develops into a risk incident or crisis.

Real-Time Escalation Management in the Cloud

AI can help identify and prioritize clinical action items by combining a patient’s longitudinal record with real-time insights and assessments in the home and transforming them into concrete recommendations that might not be obvious to a caregiver.

Clinical supervisors can then use this information to escalate change requests and improvements to care plans. With cloud-based tools, payers, hospitals and other licensed professionals are connected and can work efficiently to find the best care solutions for patients in the home.

Technology-enabled tools are the critical facilitator that transform information from the home into meaningful and relevant data. When mobile technology is coupled with an AI-backed clinical recommendation engine, home health agencies are newly empowered in the decision-making process. They have a way to quantify the patient experience and can initiate a new level of information exchange between the agency, clinicians and payers. This gives payers the opportunity to offer feedback and adjust prescribed actions for a solution that’s a better fit for the patient.

6 Steps to A Value-Based Care Model

Under the Patient-Driven Groupings Model (PDGM) proposed by the Centers for Medicare & Medicaid Services (CMS), home health providers will no longer determine payment rates by therapy volume. Instead, payment will be tied to patients’ needs and clinical characteristics. The goal, according to CMS, is to remove incentives for agencies to over-provide therapy.

The value-versus-volume discussion is here and moving quickly. The challenge is to figure out how to bring that value to life in clinical practice. It involves more than just reporting on service measures; an agency has to demonstrate the value it brings to patient care.

Here are six steps to get started:

1. Commit to patient-centered and outcome-based care as a key organizational strategy.

Communicate this shared vision with staff.

2. Train your workforce on new technology.

Home health aides need mobile technology to capture and deliver clinical insights and assessments from the home. Clinicians require evidence-based recommendations for interventions and escalations.

3. Identify an innovation partner.

Work with an accountable care organization (ACO), payer or another risk-bearing provider to launch your program. Select a champion and key stakeholders to help launch the initiative and validate the initial workflows.

4. Start small.

Prioritize clinical escalations that are actionable, achievable and meaningful for the clinical team. A good technology solution will filter out the noise and provide proper context so clinicians can make the best decisions possible.

5. Build on success.

Once you and your partners have proven clinical impact and demonstrated outcomes, increase the scope of the program by expanding clinical recommendations and escalation paths.

6. Market your agency as an innovation leader.

Make sure ACOs and other payers are aware of your foresight in this area. ACOs take on a significant amount of risk-sharing when they partner with home health agencies. They want to partner with agencies that demonstrate they can minimize risk to patients and keep the costs of care and service delivery in line.

The Time is Right

Hospitals, health systems, ACOs and payers are beginning to recognize the value of monitoring patient progress in the home. They want to partner with home health agencies who are investing in patient outcome measures, assessment tools and advanced clinical decision-making support. Consider these industry realities:

• Health care is moving to a patient-centered, outcome-based model that prioritizes optimizing care over predetermined lengths of stay.
   
• There’s growing pressure to reduce total medical costs, unnecessary hospitalizations, unnecessary emergency department use and unplanned long-term care placements.
   
• The United States has a large and rapidly aging population that will require care.
   
• Significant human resource shortages across the industry result in aides handling more complex tasks, including administering medications, tube feedings and catheterizations. This creates more opportunities to observe patients and monitor changes.