Diversify patient base with niche programs
How one provider reduced Medicare caseload
Hospital home health providers looking to diversify their heavily Medicare patient base may consider some of the Detroit-based Henry Ford Health System agency's actions. Implemented over a number of years, the initiatives reduced Ford's Medicare caseload to its present 50% level, says Greg Solecki, vice president of home health care for Henry Ford.
Ford's diversification efforts involve three broad targets and center on the agency's strategic integration within the Henry Ford Health System, which includes five owned and four managed hospitals, a health maintenance organization, two nursing homes and a 1,000-member physician practice plan.
Develop special-approach programming
Henry Ford Home Care has a lengthy list of special programs, including hip and knee joint replacement, otolaryngologic, diabetic, psychiatric, wound care, opthalmologic, pain management and urologic. Programs usually involve a clinical pathway or "proscribed approach to delivering care in the home; usually chronologically," says Solecki.
Henry Ford Home Care also trains field staff both before and after program implementation, customizes documentation requirements, and pre-establishes outcomes criteria using the Plan Do Check Act (PDCA) performance improvement model, Solecki adds. Henry Ford Home Care develops some programs collaboratively with system hospitals so that clinical pathways begin in the hospital and extend into home care. Others, while developed with physician input, are solely home care-based.
Most disease management programs are designed to decrease the length of stay in Henry Ford Health System hospitals, but others primarily offer improved patient healing and rehospitalization outcomes. For example, Ford's maternity program includes one-to-two postpartum visits timed on peak post-delivery complication days three through five and nine and 10. Nurses look for signs and symptoms of maternal infections and infant jaundice and respiratory distress. The goal is to forestall easily treatable complications from blossoming into rehospitalizations.
Providers implementing disease management programs often gravitate toward the high-volume or high-cost hospital diagnoses. Solecki agrees that most specialty programs arise from hospitals' key patient populations. However, "success may not [necessarily] follow because of cultural or social issues within the health system [and community]," he warns. To overcome such factors, "look towards physician champions," Solecki advises. Success with a low-volume program collaboratively developed with key physicians may pave the road to victory for larger services, he adds.
Niche programming may also result from incidentally collected patient populations. This occurred with patients discharged from Henry Ford Health System emergency departments. Identifying increased emergency department-referred patients, Henry Ford Home Care began tracking outcomes data including same day referral-case opening, returned emergency visits and rehospitalizations. Solecki estimates Henry Ford Home Care will this year serve over 400 patients referred from system hospitals, many with cardiovascular, gastrointestinal, and orthopedic diagnoses.
Quantify agency benefits to hospital
Not all disease management programs benefit home care financially, but "it may make more sense for the home care agency to 'take it on the chin' than [for the patient to remain in] more expensive parts of the continuum," Solecki adds. Using a Microsoft Excel spreadsheet, Henry Ford Home Care tracks un- and under-reimbursed patients by payer, discipline, year-to-date cost per visit, and projected revenue per visit. By quantifying the home care agency's contribution, this analysis bolsters the agency's increasingly important role as a cost - as opposed to revenue - center and facilitates system payments for moving poorly reimbursed patients out of the expensive hospital setting.
Implementing and simultaneously managing many niche programs can be challenging, Solecki admits. Success requires intense field staff education and balancing specialized and generalized field staff clinical focus, he adds. Henry Ford Home Care nursing teams primarily focus on certain diseases to facilitate clinical pathway adherence. While the agency "is growing more specialized, we don't want to be too specialized so that the nurse says 'I only want to do Xs' and the corporate culture supports it. We must balance productivity with our patients' overall care needs," he adds.
Other diversification strategies Henry Ford Home Care has implemented include:
r Private duty services.
In addition to using specialty programs to sell itself to managed care, Henry Ford Home Care also diversified through private duty services. Henry Ford Extended Care provides several private duty services other hospital-based agencies may consider.
While offering a good diversification opportunity, private duty also poses operational challenges, Solecki notes. Operated as a separate home care division, Henry Ford Extended Care does not share staff or other resources with the home health agency. Its very different service orientation requires different management skills and focus, Solecki adds.
r Influenza vaccination program.
Through various managed care and employer contracts, Henry Ford Extended Care provides flu shots to about 4,000 Detroit-area workers at their places of employment.
r Medically fragile pediatric support.
Henry Ford Extended Care professionals accompany handicapped students on their bus rides to and from school, and remain with the children at school. The division's contract with the Detroit public school system accounts for about one-third of its overall revenue, Solecki notes.
r Supplemental staffing.
Henry Ford Extended Care's supplemental staffing has charged forward within the past year and now accounts for almost 45% of its revenue. It provides staffing services to a variety of clinics and hospital units.
r Homemaker services.
The agency ventured into custodial care at a major insurer's request, Solecki reports. Henry Ford Extended Care managers work hard to ensure that the service meets clients' expectations and "makes a meaningful difference in their lives." It requires consistent and thorough oversight, he adds.
Staff recruitment is always a priority, particularly for homemakers. "Their recruitment" is a tough market. A cultural dynamic among the people skilled to provide the care causes them to view the service as beneath their dignity, but it can make or break a person's ability to stay at home. So we make sure we instill a sense of confidence in our caregivers. We also screen very carefully," says Solecki.
r Contract with Medicare and Medicaid managed care organizations.
Henry Ford Home Care has contracts with both Medicare and Medicaid managed care plans.
"These present the greatest opportunities for home care providers to not just survive, but prevail. If we partner well, we can do good things and be integral players along the continuum," says Solecki.
The agency's contracts include case management functions. Eight RNs and a supervisor manage the care of high-risk patients identified through health plan assessments. With a combination of nursing visits and telephone assessments, staff members monitor patients' disease progression. Success is monitored through admissions per thousand.
With so many Medicare-related changes either already occurring or just around the corner, diversifying may seem like one more daunting operational challenge. But Solecki encourages diversification efforts. Initial success will have a "cascading effect," with programs and ideas building on one another, he adds. "You don't have to walk away from Medicare, but it's nice to diversify."
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