Blogging in Place

An Interview with Teresa Lee, Alliance for Home Health Quality and Innovation

Aug 09 2016

The Affordable Care Act is helping revolutionize America’s healthcare delivery system by embracing personalized care at home – akin to the old country doctor visits from a bygone era. Home-based care may eliminate or at least delay the need for placement in nursing homes and gives aging Americans the opportunity to retain their independence and dignity.

Home healthcare providers have developed cutting- edge models in care coordination, prescription management, disease management, and behavioral education, which has helped reduce hospital admissions and readmissions and kept people healthy and independent in their homes. Home-based care runs the gamut from skilled medical care – physical therapy, occupational therapy and speech therapy – to non-medical assistance with activities of daily living ADLs), such as bathing, dressing and cooking.

Teresa Lee is a thought leader on home health and home-based care. The daughter of a physician and a lawyer by trade, Lee serves as Executive Director of the Alliance for Home Health Quality and Innovation, based in Arlington, Virginia. Founded in 2008, the Alliance is a 501(c)(3) charitable research organization.

Lee is not a lobbyist but a researcher and educator whose job is to develop research and data analysis that provides federal regulators, policymakers and consumers with information about the value proposition that home healthcare has to offer patients and the entire U.S. healthcare system.

Access to affordable home healthcare is a topic that owners of senior living communities are grappling with, NAIPC’s partner organization National Housing & Rehabilitation Association (NH&RA) and their publication Tax Credit Advisor interviewed Lee to get her thoughts on how the current delivery system is working, what improvements can be made, and what opportunities exist for greater collaboration between her industry and affordable housing professionals.

Tax Credit Advisor: Why was your organization created? What sets your organization apart from other organizations focused on healthcare?

Teresa Lee: My organization’s mission is to lead and support research and education about the value of home healthcare to patients and the healthcare system. We believe in working in close collaboration with patients, caregivers, policy-makers, payers and providers across the spectrum of care to improve healthcare in America. The founding members, which are some of the largest home healthcare companies in the nation, saw a need for more research and data analysis, particularly on Medicare home healthcare, and a need to better educate policymakers and the general public on its value. There are other organizations that represent home healthcare providers, but my organization is unique from the standpoint that we focus on research and education.

TCA: What major trends are you seeing in the home healthcare marketplace?

Lee: Home healthcare companies are tightly regulated by the Centers for Medicare and Medicaid Services (part of the U.S. Department of Health and Human Services). Medicare has a home health benefit and the government wants to ensure its resources are being used effectively. The government wants to pay for value and not just volume. That means transitioning to “alternative payment models” that help improve accountability by various means. For example, CMS is testing a home health value-based purchasing model in nine states that ties payment to performance measures. In addition, CMS is testing bundled payment arrangements and accountable care organizations that provide an incentive to achieve cost and quality targets. These changes are occurring at the same time as significant Medicare payment cuts for home health services. These changes have put additional strains on the home healthcare marketplace and have led to consolidation. Some changes are positive, like the move toward paying for value. On the other hand, the government expects home healthcare companies to deliver high-quality services, which requires significant investments in health information technology and care coordination, even though Medicare’s fees are decreasing.

TCA: What types of health services are provided in the home that used to be delivered only in medical facilities?

Lee: The important thing to note is that yes, there is Medicare skilled home healthcare, but there are other services provided in the home, including care management and coordination. We tend to think of family caregivers not just as clients but as members of the team in terms of caring for the patient. There are formal personal care services, paid personal care services, that you might think of as home health aides or home care aides who help people with ADLs. It’s not medical care, but it is an important type of care. There is also skilled home healthcare, which is mostly focused on nursing and therapy. When skilled home healthcare is paid for by Medicare, it is intermittent in nature, subject to a physician-established plan of care, and only for beneficiaries that are homebound. For individuals with acute conditions, physicians, nurse practitioners and physician assistants can make house calls or home visits. And to go even a step further, there are models that provide hospital-level care at home, called Hospital At Home.

It’s possible to set up the infrastructure that is needed to care for some patients who otherwise might need hospital care, but it’s provided in the home. The last thing I would mention is hospice. Most hospice care is now provided in the home. If you think about the direction of the healthcare system, we are trying to achieve what is called the Triple Aim: 1) improving the patient experience of care (including quality and satisfaction); 2) improving the health of populations; and 3) reducing the per capita cost of healthcare. By providing care in the home, we can have a stronger impact on patient behavior and communicate with the patient in an environment that they are comfortable in every day.

TCA: How are people paying for these services?

Lee: For skilled home healthcare, the biggest payer by far is Medicare. Medicaid is also a payer of skilled home healthcare, but not nearly as significant as Medicare. There are private payers who include home healthcare benefits, but in general those benefits are much more limited compared to Medicare. There are an estimated 3.4 million Medicare beneficiaries who receive some form of home-based healthcare, at a total annual expenditure of $18 billion. It’s worth noting that there are people who receive benefits under both Medicare and Medicaid.

TCA: How does your industry measure success? Fewer hospital visits? Reduced costs?

Lee: There are performance measures that Medicare home health agencies are subject to, one of them being a reduction in hospital readmissions. There is a web site, at https://www.medicare.gov/homehealthcompare/search.html, which consumers can use to look up any home healthcare agency to see how it has performed against these performance measures.  

TCA: It has been two years since the implementation of the ACA. How has it changed the method of delivering healthcare? Do current home healthcare delivery methods work? What improvements would you like to see implemented?

Lee: Because of the Affordable Care Act, there has been an increased emphasis on trying to achieve the Triple Aim, which I mentioned earlier. Hospitals are more concerned with what happens to patients after they leave, because if certain types of patients are readmitted, the government may penalize the hospital. This has resulted in cultivation of better lines of communication between hospitals and home healthcare agencies. At the same time, the increasing emphasis on what happens after hospitalization requires financial investments to achieve the Triple Aim. Home health agencies seek to provide patient-centered, seamlessly coordinated, high-quality and technology-enabled care, so that they can be strong partners with hospitals, physicians and caregivers and serve patients optimally. One key factor for the future will be shoring up home health agencies as key infrastructure and this will require policies that enable such financial investments.

TCA: Last year, I interviewed a developer in Minnesota who formed a home healthcare company so that he could deliver services directly to his residents. This model has attracted a lot of attention, but has been a challenge to replicate in other states because they all manage Medicaid differently. What efforts are underway to help improve reimbursement delivery methods at the state level, so that similar models can be adopted throughout the country?

Lee: States are shifting long-term care services covered under Medicaid from nursing homes back into the communities. It’s called “rebalancing.” Some states have invested more resources and are more thoughtful than others. New York and Oregon, for example, have invested heavily in home-based long-term care. But some states are still upside down. North Carolina still has laws on the books that make it easier to put someone in a nursing home, rather than have them live independently in their own home. So, there is a lot of variation state-to-state and there is a lot to be learned and coordinated in order to have more consistent models that point in the direction of independence in the community and trying to enable that.

TCA: The Bipartisan Policy Center’s Senior Health and Housing Task Force, co-chaired by former HUD Secretaries, Henry Cisneros and Mel Martinez, recently published a report called “Healthy Aging Begins at Home,” which concluded that “greater integration of America’s healthcare and housing systems will be essential to improve health outcomes for older adults and enable millions of Americans to age in place in their own homes and communities.” Is this a realistic outcome? How are your organization and members working toward this goal?

Lee: I have not read this paper, but we absolutely need to be working more closely. We have this gulf between the healthcare system and so many critical long-term services, supports and infrastructure that really are needed to help people stay healthy and age in place. A big issue is just how fragmented our systems are that each affect healthy aging. Housing is critical.

TCA: What is still missing from successful, accessible healthcare delivery?

Lee: There is so much missing. The biggest thing that is missing is that we are not thinking about care for patients as persons. Because of the way we pay for all of these different aspects of care in different silos it’s very difficult to have a coordinated, seamless experience. That, I believe, is the biggest thing that is missing from our healthcare delivery system. If we can drill down to what is really important to the person, sometimes what it takes is not something medical. Sometimes it’s outside of the four corners of what the Medicare benefit will pay for and because of the constraints of what is covered by insurance and Medicare, we are not able to get at it. I think you put your finger on a gulf between what is paid for under typical healthcare insurance and Medicare versus what is really needed in the community. Helping is one thing but there are personal care services, meals, transportation, housing and many other services and supports that may be needed to age in place, but there is no comprehensive system or even a thoughtful model that recognizes the different streams of funding.

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