Thought Leaders On Home-Based CareIt was quite a day!

I have great clients. I don’t usually brag but today I want to send a big shout-out to Caleb Roseme of Assured Quality Homecare (ASQ).  Caleb started working with me on caregiver recruitment and retention in 2016. I continue to provide HR support to his growing agency through HR on retainer.

Caleb was brave enough to accept my invitation to present at a national conference. So last week, we had a joint presentation at the National Leadership Conference of ElevatingHOME. We spoke on the 7 HR systems to be an employer of choice in home health and how ASQ has implemented them.

The presentation went well. We had a number of good questions. In the audience was Mark Baiada, home health pioneer (and legend!). Mr. Baiada was visibly engaged and stayed around to speak with Caleb and me after the presentation. I was thrilled to meet him in person, honored he had chosen to attend our breakout session. He remarked that the “Bayada Way” is very similar to what our presentation was advocating. I couldn’t resist taking a picture to memorialize the occasion!

A note about ElevatingHOME: It is a new professional association created by home health leaders and Visiting Nurse Association of America (VNAA). It aims to unite different players in the field to advocate for high-quality home-based care at the heart of a patient-centered health care system. I have followed the organization since its foundation in 2016. I am hoping they have the vision to advocate and address the workforce development challenges faced by home health and home care across the country.

The session opening the conference demonstrated the positive impact that home health has on population health in the continuum of care. ElevatingHOME is supporting research to study the ROI of home-based care.

In recent years, the policy debate on home-based care is focused on cost and fraud reduction. But is it the right approach for patient outcomes? Ian Juliano, CEO of Excel Health and research partner on this study, shared some of the topline findings. The data strongly suggest that home health is not only good for the patients who experienced better health outcomes, it’s also a good deal to the taxpayer.

Home health provides better health outcomes

Considering a population of nearly 500,000 Medicare patients discharged after a hospital stay, the study found that a staggering number of patients do not utilize home health although it was recommended to them. In fact, 46% of patients who had the recommendation to use home health didn’t get home health services.

In addition, the study found that there is a distinct impact of home health utilization in the 30-day readmission rate. Of those who had home health recommendation, those who received home health services were less likely to be readmitted within 30 days of discharge from the hospital (13% with home health vs. 23% without home health were re-admitted within 30 days). They also have better health outcomes with 5% less mortality rate after 12 months.

Home health is a good deal for the taxpayer

The cost of home health (average of $4,000 per episode for Medicare) demonstrates that using home health after a hospital stay lowers the total cost of medical expenses compared to those going without home health services. Looking at Medicare payments over 6 months, patients who adhere to home health cost about $12.8K in total medical expenses (including the cost of home health) versus $16.5K for patients who do not adhere to home health.

The next research phase will seek to identify the causes of non-adherence to home health. The fact that the groups with the highest medical needs are also the most likely to not adhere to home health points to possible barriers to access. Although barriers to access need to be studied further, the value of home health in terms of patient outcomes and cost is now established with reliable data. Driving down the cost of home health is counterproductive when considering the continuum of care costs.

Atrius Health’s Experience with Home Health Partners to improve population health

Dr. Steven Strongwater, CEO of Atrius Health, shared his organizations’ experience in Massachusetts of partnering with home health to improve population health.

Interesting data gleaned from his presentation:

  • Five medical diagnostics drive most of the healthcare expenses: heart disease, cancer, trauma, mental health/behavioral problems and pulmonary conditions. These top 5 have not changed over the last 20 years. Addressing population health and focus prevention and risk reduction on these 5 areas will have a major impact on healthcare costs.
  • Telehealth has a major role to play. The introduction of telehealth for 30 days after a hospital stay reduced hospital readmission by 50% for Atrius patients. The readmission rate is almost zero if telehealth is provided for 60 days. The main reason for this success is the significant improvement in biometric patches monitored through telehealth. The data collected allows providers to see changes in conditions early and address then better.
  • Providing house calls to at-risk patients (80+ years old with 2 chronic conditions) reduce the hospital readmission rate by 30%.

Population health can reduce the cost of healthcare through concerted actions and partnerships along the continuum of care.

I also attended the presentation by Tina Hilmas from the Center for Patient Safety. Her presentation focused on a Just Culture in healthcare.

Historically health care has been a “punitive” environment where errors are investigated and blamed on the provider. However, punishing without change can perpetuate the problem. Most health providers do not make willful errors. On the other hand, healthcare cannot afford a blame-free culture. The solution? Introduce the ‘just culture,’ one that finds a balance between the extremes of punishment and blamelessness and puts in place processes to handle patient care.

What is ‘Just Culture’? The concept of Just Culture was put forth by James Reason in 1997. It recognizes that individuals should not be held accountable for system failings over which they have not control. However, it also does not tolerate a conscious disregard of risks to patients or gross misconduct such as falsifying documentation or working under the influence.

Interestingly, the concept of Just Culture has been adopted by many high-risk occupations outside of healthcare (e.g. train systems, aviation, nuclear power plants

Just Culture – Why do it? Organizations with bad culture experience high employee turnover and more errors. A poor culture wastes money. It affects the lives of patients and employees. It will affect a home health CMS Star Ratings. People are more likely to write negative reviews about a provider or an employer. In an era where everything is searchable online, a poor culture impacts the public image of the organization.

Just Culture – How to do it? At its core, a Just Culture designs systems and processes to taking into account human capabilities and limitations. Good design accounts for fatigue and stress not only under ideal circumstances. The idea is to focus on the prevention of errors with systems that anticipate problems and catch glitch before they lead to a major error. One of the practical application is the use of checklists for each medical procedure rather than relying on individual memory.

Accountability in the Just Culture. There are three types of accountabilities:

  • Human error which is the result of current systems and behavioral choices. The Just Culture handles it through changes in procedures and training. The response to human error might be to console the healthcare professional if the error had grave consequences such as death of a patient.
  • At-risk behavior is often a choice made because the risk is believed to be insignificant (e.g. practice drift) or justified (e.g. make visits notes at the end of the day so there is more time to see patients). The Just Culture addresses those behaviors by removing any incentive for the at-risk behaviors and hopefully creating incentives for healthy behaviors. The organization needs to raise the issue through communication and training. The response to at-risk behaviors is coaching.
  • Reckless behavior is the conscious disregard of substantial and unjustifiable risk. It is managed in the Just Culture with sanction and remediation.

In order to promote a better culture in home health, leaders need to assess the culture of their agency. Culture manifests itself through response to mistakes, communication, recruitment and training. Although culture is a concept, it has very tangible manifestations and impacts how well your agency performs. Culture matters and a just culture might be what your agency needs!

This was an action-packed conference. Well worth attending. Shouldn’t you consider attending next year? I certainly will.