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Transitioning Toward Value-based Home Care

Robert Pritts, President, Home Care & Post Acute Services, SSM Health
Robert Pritts, President, Home Care & Post Acute Services, SSM Health

Robert Pritts, President, Home Care & Post Acute Services, SSM Health

The rising costs on hospital bills, admission fees, and personal medical care have left the patient population apprehensive. Faced with these challenges, patients are seeking an alternative approach to receive better care, but at lower costs. This is where home healthcare has emerged as a silver lining for patients and has proved to be more cost-effective and flexible to clients’ needs.

Moving Toward Value-Based Care

One of the most dramatic developments in the home healthcare industry became effective from January 1st with the conversion of Medicare’s payment methodology for patient services to the patient-driven groupings model (PGDM). The previous methodology—known as prospective payment system (PPS)— paid for 60-day episodes of care and relied on therapy visits as the determinate for medical acuity. PDGM focuses on more than 400 case mix groups, eliminates the use of “therapy thresholds” in determining payment, and changes the unit of payment to 30-day periods of care. This change moves Medicare away from a fee-for-volume methodology to a more value-based payment system in home health and focuses on the unique care needs of the patient based on their diagnostic group.

Due to Medicare’s conversion to PGDM, SSM Health is implementing new strategies that concentrate on the care of the patient in the home. For example, we are focusing on case management teams to identify the best plans for patient discharge upon an acute hospital admission to improve the transition from acute care to home-based services. This pre-certification of the patient, identifying the level of care they need creates the opportunity to place the patient in the correct level of care for their unique needs. These strategies rely on being more proactive on the hospital side by working with families to be better prepared for taking care of chronically ill patients in their homes.

  The movement to a more value-based payment system of care puts the patient first, focuses on medical spend, and meets the need of patients in the correct level of care. This is truly meeting the medical demands of the patient by focusing on treatment in the home and a focus on prevention  

That said, it is not just about cutting costs; it has more to do with keeping the patients healthy, comfortable, and meeting their medical needs affordably, not reducing supply. In light of this, as we transition into a digital world and using technology, we are looking at implementing several AI-based technologies, which can help track patients’ daily tasks and inform family of any changes in routine that may indicate a medical issue. There is also an emphasis on reviewing all types of care in the home such as dialysis, wound care, and infusion, so we’re looking into these areas as well. The first question should be: “Are we able to safely care for the patient in their home?”

Making the Right Choice

SSM Health always chooses partners that have prior industry experience and share a common vision. For instance, we have partnered with Navvis, a firm that has expertise in analytics data collection, value-based purchasing, and working with physicians. Together, we’re looking to design and operate a transformational new value-based care delivery model that helps patients manage their health and well-being throughout every stage of life, including home health. We share a vision for an entirely new and holistic model of care—one that is fueled by data, clinically-driven, and patient-centric—eliminating the barriers that fragment care. Both organizations believe this partnership will serve as an example of the innovation and collaboration needed to improve the health and well-being of Americans while making health care more affordable and sustainable for everyone— patients and their families, employers and their employees, providers and payers.

New Disruptions for New Beginnings

The healthcare industry is currently evolving from a fee-for-service model to a fee-for-value model that focuses on meeting the patient’s medical needs in the proper level of care. At this point, the sector is indulging in partnership with many prominent healthcare companies, including insurance complies like United Health and Humana, which are attempting to vertically and horizontally integrate. These strategies, along with CMS’ focus on Accountable Care Organizations (ACOs), bundled payments and the implementation of PDGM, are indications of the movement toward value-based care models. There is an awareness gaining traction in the industry, where the experts have come to realize that change is required and that legacy systems will not be able to incorporate the newer developments shaping the sector.

The most pressing concern in home health today is ensuring that leaders guide their organization through the cultural transformation that’s taking place in our industry. Home healthcare agencies are expected to provide high standards of value-based care and deliver care regardless of the social determinants, while precisely meeting the needs of patients and their families. In the end, the healthcare business cannot be only about return of investment. Instead, it must be focused on patient engagement, forming great relationships with them, providing low-cost healthcare services and, ultimately, delivering exceptional patient outcomes.

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