This article is sponsored by WellSky. This article is based on a Home Health Care News discussion with Tim Ashe, Chief Clinical Officer, and Wes Little, Chief Analytics Officer at WellSky. The discussion took place on September 15, 2022, during the Home Health Care News FUTURE Conference in New York City. The article below has been edited for length and clarity.
Home Health Care News: To start with just a brief state of the union for the home health industry, Tim, from a clinical perspective, what do you think are the defining trends for home health care for the rest of this year and for 2023?
Tim Ashe: We actually just came from CareForum, our annual WellSky conference, in Kansas City where we had the opportunity to talk to a tremendous number of providers. The primary themes that emerged from those conversations centered on performance-based and value-based care.
As you overlay these concepts with an emerging, clear opportunity to provide whole-person care, there are some really specific core competencies that become important themes for organizations to double down on when it comes to their clinical workforce. When I say clinical, I’m actually expanding my definition rapidly. I think we all should expand our definition, to not just include professionally trained clinicians, but also personal care providers, informal care providers, and families. We need to engage all of the individuals that are providing care to the people that you are serving across the country.
As I think about it, how are we engaging with the physician community as well? The interdisciplinary care team is not a theme that’s new by any stretch, particularly in hospice, which obviously has a rich tradition in IDT and IDG. Across care settings, we should really borrow some of those core competencies from the hospice philosophy and program. I think we need to translate that into a care team that’s thinking about the core needs of a patient, a group of patients, and a population of patients, focusing on a multidisciplinary, multifaceted approach to delivering whole-person care. Finally, I think we have to simplify how we are caring for patients and individuals in the community. I think that starts with the initial assessment. How are we thinking about gathering data that’s not just clinical in nature, but that’s also social in nature, that’s behavioral in nature, and that has the right demographics?
As we dig into some of the data, connectivity, and data sharing concepts, I think we really need to pay close attention to expanding the skill set of all of our clinical staff and team members across the country related to that initial assessment. It’s critical to start the ball rolling with the right information so that we can provide the right level of care at the right time.
HHCN: What are some key data points, two or three nuggets that really define where the home health industry is right now?
Wes Little: We’re lucky enough to have a unique vantage point here. WellSky started off with a background in being a system-of-record software. We have over 10,000 home-based care providers using our core software solutions to run their businesses and provide care for patients. Increasingly, WellSky has made significant investments upstream of post-acute care into the health systems, really at the front door to post-acute care.
That gives us a unique set of data and insights that is potentially ahead of what others in the industry can see about the transition of care, the move from facility- to home-based care, and the challenges that hospitals are running into working with home health providers. We see from our data that the average referral denial rate has gone from about 49% in 2019 to over 70% in 2022. That means 7 out of 10 referrals that a health system would like to make out into the community are actually being declined by providers, largely due to the staffing challenges that providers are seeing across the country.
What’s even more interesting, and especially in light of reimbursement challenges, is the average length of stay in a hospital pre-home health has gone up from about 6.4 days in 2019 to over 7 days in 2022. The really interesting thing there is that the cost savings that Medicare is looking to get out of the home health space is going to keep driving up that average length of stay in a hospital. We all know that one day in a hospital could probably pay for an entire episode of home-based care.
Seeing that balance of a network from two sides playing out is one of the unique vantage points that WellSky has in looking across our industry as a whole.
HHCN: That last data point was that the length of stay of patients in the hospital increasing prior to perhaps a home health admission, that really suggests that patients are more complex these days. Right?
Little: Absolutely. I think we’ve seen that. One other interesting fact is if you go back to 2019 and look at skilled nursing referrals and home health referrals, there has been a huge shift away from skilled nursing towards home health. We see home health referrals running at about 120% of their pre-pandemic levels. Whereas skilled nursing has actually gotten close to returning to the 2019 levels, but still is not moving at the same rate that home health is.
That suggests patients who otherwise would’ve gone to a SNF are now going to home health. And a significantly more complex patient requires a lot more from providers in managing that episode of care effectively to reduce readmissions and provide a great patient outcome.
Ashe: Providers need to think about really strong educational orientation and uplifting clinical teams because we’re now seeing the rising acuity, complexity, and comorbidities in patients being cared for at home, who would have previously been cared for in facilities. This home-based care is being provided across multiple care settings: certified home health, palliative care, personal care. That complexity defines the economics that we’re seeing play out – the flow of patients, the care transitions, and also the impact to providers out in the community.
HHCN: Something both of you focus on quite a bit is health ecosystem connectivity. It’s more important than ever, especially as those patients are coming home more complex, how should acute and post-acute care providers be thinking about better aligning themselves with one another?
Ashe: I’ve sat in on a few interoperability panels over the last week and a half, and data sharing is something that I would like to highlight at this point. Having the right information requires all of us to participate in this shared pool of clinical demographics and social information.
Aligning the information upstream with our home- and community-based providers is important so that we have that right information as we go out to do the assessments or provide care. And it’s not just interoperability – at the core of this is sharing data for the benefit of the health and wellness of the communities that we serve.
Little: Yes, I think there’s a huge opportunity here. Historically the connection between an acute care provider or a physician and their home health counterparts has been largely one-sided, sharing data out. It’s pretty limited in what data they have been able to share historically. By creating this national network of care providers on both sides of the continuum, we can really deepen the set of insights that are shared back and forth. A home health provider should be able to have access to the Epic patient chart before the patient is admitted.
Conversely, a hospital discharge planner and care management team really want to know more about whether this patient is progressing towards a good outcome or likely to end up back in an emergency room in the next few days if care protocols aren’t put in place to intervene. Never before have we really had a system where the discharge planners and the care managers in a hospital are using a common technology with people who are providing direct patient care in the home. Also, through the addition of the patient engagement solution TapCloud, we really hope to create that triangle of data sharing that allows all of the constituencies in this care process to collaborate towards a common desired outcome.
HHCN: Wes, when we talk about hospital length of stay increasing, do you have any insights into hospital volumes? Has hospital volume increased as well?
Little: Well, what we see is that referral volumes have increased dramatically, especially to the home health marketplace. Our team released a really interesting report on the transformation of post-acute care. We found that home health referrals have essentially doubled from 2019 to 2022. Those aren’t unique referrals. It’s interesting to see the effect of more and more patient declines from providers. We are seeing a greater demand for home-based care, and the lack of supply of home-based care is resulting in people staying in the hospital longer.
HHCN: How is technology today being used with face-to-face requirements? It’s a connection between acute care providers and home health agencies that home health agencies have to establish outside using phone and fax. What are you seeing in regards to that area?
Ashe: Yes. I think the direct secure messaging capabilities and connectivity that Wes talked about are huge advantages over the manual process that we’ve seen to meet those requirements in the past. The document management of those workflows is critical. I also think as we start to see the real capabilities of automation of NLP and OCR become real, we can start to query our clinical records and our databases for consistent adherence to face-to-face and Conditions of Participation requirements. We’re starting to use technology in different ways, not just for face-to-face, but for other regulatory compliance areas. Because as we know, this rate pressure isn’t going to change. I do believe that in the long-term, value-based, performance-based payment will be aligned with the overall policy interest to move more patients into the community. But in the near term, we really need to think about total cost of care.
One of the ways to reduce that is to think about pointing clinicians toward patient care and using automation and technology for the transactional review audit areas that we know can be done safely and appropriately.
HHCN: To shift gears a little bit and talk more about something that falls broadly under the value-based care category, let’s talk about providers being able to identify their most vulnerable patients so they can deploy resources appropriately. Wes, what are some ways that you’re seeing home health providers use risk stratification tools and predictive analytics to better identify their most at-risk patients?
Little: I think this is one of the biggest opportunities in our marketplace and it’s going to become even more important once some of the rate changes in 2023 go into place. Providers need to be able to care for patients and get better outcomes at a lower cost and with fewer visits over time. What we think is integral to that challenge is using insights and data to better inform your care management processes and your prioritization. That’s what we’re providing at WellSky with our WellSky CareInsights solution.
This is data that’s informing a patient’s risk, not just at day 1 of admission, but at day 10. If they’re progressing well, then you may not have to worry about them as much, but if they are headed towards readmission, the caregiver is able to not only predict and stratify risk but actually determine the specific type of visit that is needed – because as all of us know, the different visit types have different costs and value in actually improving patient outcomes.
Helping providers think about what the best plan of action is for this individual is a huge opportunity for everyone. Our clients who use predictive analytics to better manage care have been able to reduce their overall hospitalization rate by about 21%, while reducing their number of visits per episode by about 19%. Interestingly, they’re not taking those cost savings to the bottom line or not hiring nurses; they’re using that extra capacity from those savings to go out and grow their census. If you can do all three things at once, it makes it very worthwhile to prioritize leveraging technology to better inform your care processes.
Ashe: Overall, we see an opportunity to reduce total visits. As we do that, we really need to think about the allocation of those visits. Is it a nurse that needs to make it? Is it a therapist? Do we need to make that visit at all? The ability to use science to drive predictive algorithms that suggest the intensity and type of service is awesome. At the end of the day, we have to come back to the concept of patient-centeredness and make sure that we’re meeting that.
As an absolute core mission for our industries, science is a huge part of that. You start to combine the data, the science, and the art of providing care into what I think is truly intelligent care management, but it’s the intensity, the allocation, and the timing of those interventions that becomes really important and understandable as we start to get better using the data.
Little: We want to put these insights into the hands of an experienced clinician who can use them to guide care. We don’t ever want to overanalyze and just focus on the analysis. It needs to be a combination of the clinical and the analytical to drive the best outcomes possible for the patients and the populations being served.
HHCN: I just want to open up the stage and let you guys add any final remarks to tie a bow on this discussion. One thing in particular that I was interested in learning a little bit more about is how risk stratification and predictive analytics could help with a negative rate environment next year. What are some other mitigation strategies that you’re looking at WellSky if 2023 rate cuts do come into play?
Ashe: I think doubling down on simplicity, on lean workflow engineering, and on making sure that we’re investing in that care team concept so that folks know exactly where they fit into the construct of whole person care, patient centeredness, and delivering good outcomes.
Little: One thing I’ll add is regarding the Medicare rate cuts. As all of us know, Medicare has been subsidizing Medicare Advantage payers historically. As you think about a significantly decreased Medicare reimbursement, we have to enable you as providers with the data to be able to go to your payer partners and advocate for better rates for yourself, advocate for more episodic forms of payment, and then give you the data and insights to help you execute on that episodic, risk-oriented type of care.
How do we take that Medicare Advantage population that’s going to be more than 50% of all Medicare recipients, and how do we make that a great business for you all by giving you the data to go and advocate for yourself successfully with Medicare Advantage plans. We see that as a big opportunity as providers think about their portfolio of payers more selectively here in the next few years.
WellSky is passionate about helping home-based care providers successfully increase their efficiency, grow profit, improve communication, and optimize care for patients. To find out how, visit wellsky.com/.
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