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The New Health Care Partnership: How America's Hospitals, Home Care Agencies And Community Physicians Are Working Together To Improve Outcomes And Reduce Costs

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Picture this scenario: An elderly woman suffering from chronic heart failure arrives at her local emergency department with shortness of breath -- but instead of admitting her into the hospital for a one- or two-day stay, the ED clinicians confer with the home care agency liaison who is onsite, and arrange for the woman to be sent back home in the care of a home care nurse trained to manage heart failure symptoms. At the same time, the home care agency works with the hospital's social work staff to set up an appointment within the week for the woman to see her primary care physician for follow-up care.

In fact, this type of ED-to-home diversion is already happening in the emergency departments of major medical centers in New York City. For years, home care agencies have partnered with hospitals to provide home care for patients after they've been discharged from the hospital. Recently, however, my own agency, the Visiting Nurse Service of New York (VNSNY), has begun stationing intake staff in the EDs of our acute care partners -- not to coordinate patients' care after hospitalization, but to help them avoid being admitted to the hospital in the first place.

VNSNY has also started working with local hospitals to manage their patients with chronic illnesses like diabetes or asthma, by embedding our own health coaches in the offices of these patients' primary care physicians. And we're working with hospitals to develop innovative approaches to post-discharge home care for patients who have psychiatric comorbidities.

These are just a few examples of the burgeoning partnership among acute-care hospitals, community physicians, and home health care organizations. This collaboration has been accelerated by today's increasing focus on the quality of patient outcomes, as well as by new regulations implemented by the Affordable Care Act (ACA) and other health care legislation.

Bundled Payments: Sharing Responsibility for Medical and Surgical Care
One of the most sweeping new areas of collaboration involves patients who have gone through significant medical or surgical episodes. Several years ago, the ACA established a new program called the Bundled Payment for Care Improvement Initiative (BPCI), in which each complete course of treatment is viewed as an "episode of care." Four BPCI program models cover different payment scenarios that range from in-patient hospital stays to episodes triggered by an acute stay that initiate with post-acute care services at a skilled nursing facility, inpatient rehabilitation facility, long-term care hospital or home health agency. Episodes can extend for a 30-, 60- or 90-day recovery period following discharge from the hospital.

In most BPCI models, Medicare pays the providers as they would in a fee for service model, but there is a retrospective reconciliation that compares the total cost of those Medicare payments to the Medicare target price. These costs may include services provided by the hospital, any rehabilitation facility the patient may transition to, and any home care services the patient receives after discharge.

Because the total cost of the episode of care is what's being compared, the idea is that hospitals, home care agencies and other care providers will make every effort to make sure the patient's recovery stays on track, and that expensive complications -- especially ones requiring readmission to the hospital -- are avoided.

In practice, this new payment model has led to much closer collaboration in the ongoing care of patients. Hospitals and home care agencies have worked together to draft clinical pathways--a series of benchmarks that a patient will ideally hit during acute and post-acute care. Hospitals have also hired care coordinators who communicate with skilled nursing facilities and home care agencies to carefully track each patient's recovery post-discharge, and have set up hotlines that allow home care workers or discharged patients themselves to connect immediately with hospital clinicians if a problem arises.

At the same time, VNSNY and other home care providers have developed clinician-led protocols for feeding patient records back to the hospitals and patients' physicians on a regular basis. We also just added an entirely new position -- a clinical liaison for patients in bundled payment programs. The job of these liaisons is to make sure communications between the hospital and our case management teams are open and functioning well, and to intervene and troubleshoot if they aren't.

While the long-term benefits of the bundled payment approach are still being evaluated, acute care providers have indicated they are already seeing significant reductions in per-patient medical costs along with sustained quality in patient outcomes. The Medicare initiative has been extended through 2018 for a wide range of procedures. Meanwhile, as of April 1 of this year, in select metropolitan statistical areas, Medicare has mandated a new type of bundled payment program, called CJR (Comprehensive Care for Joint Replacement) that is modeled after BPCI.


Proliferating Ties Between Hospital, Home and Community

Bundled payments are the best-known example of the new, close partnerships between acute-care providers, home care agencies, and other providers. But other types of collaborations are proliferating as well. Here are just some of innovative partnerships that my agency, VNSNY, is involved in:

• As noted above, we are in the process of placing onsite intake staff in the emergency departments of major New York medical centers, to help evaluate and develop plans of care for emergency room patients whose medical conditions can be managed at home with the right mix of skilled care.

• We are adding physical therapists to our mix of intake staff at orthopedic hospitals, to provide an additional perspective in developing a home care plan for patients following orthopedic surgery. We're also collaboratively doing a research project with a major hospital in Manhattan, that would explore the value of pre-surgical education and home care planning visits from a physical therapist for patients undergoing knee replacement operations -- an approach that will hopefully better prepare the patient and improve outcomes and decrease costs.

• For patients undergoing spine surgery, we've worked with our partner hospitals to develop a unique home therapy protocol that is allowing these patients to return home from the hospital sooner and reach full recovery faster.

• We also have a number of new programs underway, in which our home care staff is working with both hospitals and physicians in the community, to help at-risk patients successfully manage chronic physical and mental illnesses in a home and community setting. The goal of these programs is to catch and treat troublesome symptoms early, so as to avoid expensive, repeat hospitalizations.

A number of these programs are being supported by New York State's recently launched Delivery System Reform Incentive Payment (DSRIP) initiative -- a 5-year Medicaid transformation initiative designed to reduce avoidable hospitalizations by encouraging local coalitions of hospitals, health homes, home care providers, physicians and community-based organizations to develop care coordination models and other projects for vulnerable individuals. While these new models are certain to undergo plenty of tweaking along the way, this collaborative approach represents the future of health and wellness -- and at VNSNY, we're excited to be active participants in this new wave of health care partnerships.