The Backbone of Value-Based Care

How to look at wound care from a different perspective, especially if working with ACOs

By Kaitlyn Rios

Homecare is growing faster than almost any other health care segment, yet more than half of agencies can’t find enough caregivers to meet demand. Simultaneously, payment models are shifting from rewarding volume to rewarding outcomes, placing even greater expectations on an already stretched workforce. For the patient recovering from surgery at home, the quality of their care can mean the difference between healing quickly or ending up back in the hospital. For the exhausted homecare nurse juggling a full caseload, it’s about finding a way to give each patient the attention they deserve, despite a system that’s asking them to do more with less.

Value-based care, or home health value-based purchasing (HHVBP) as it’s referred to in many cases, is defined as a shift from traditional fee-for-service payment models to a provider payment system that supports quality improvement and cost-effective care for successful health outcomes and experiences for patients. Essentially, it represents a systemic push to shift care away from incentivized volumes to competitive, outcomes-based care. In doing so, patients should ultimately reap the benefits, while providers are held accountable to helping their patients recover more efficiently and effectively. Prevention and proactive care are becoming the focus while episodic and transactional encounters are slowly but surely becoming a thing of the past.

With the rise of this care model in virtually all health care market segments, we’ve simultaneously seen a significant increase in the presence of accountable care organizations (ACOs). These organizations are “groups of doctors, hospitals and other health care professionals that work together to give patients high-quality, coordinated service and health care, improve health outcomes and manage costs,” according to the Centers for Medicare & Medicaid Services (CMS). The success of these groups is based off improving health outcomes relative to both cost savings and quality metrics. ACOs are incentivized to achieve the same or better patient outcomes while minimizing associated health care costs and optimizing care coordination.

With a shift to value-based care models and accountable care organizations financially incentivized to drive the change, where does this leave the homecare market, specifically those providing disposable products like surgical dressings? For the homecare world, this shift can drastically impact the way providers write product orders, enhances the need for cost-effective and evidence-based formularies that align with ACO’s highly streamlined formularies, increases the need for timely care plan establishment to reduce gaps in care, and there becomes increased pressure to demonstrate positive impacts on outcomes.

Provider Order Impacts

Historically speaking, orders written for surgical dressings may have included daily or even twice daily dressing changes. Now, with a shift to HHVBP in full focus and evidence-based care being pushed, providers are seeking longer wear-time dressings to optimize care. This is great from a care perspective as wound healing potential is optimized when dressing change frequency is reduced due to the body’s ability to maintain an ideal wound healing temperature consistently. It also alleviates a significant care burden for clinicians visiting the home as well as the responsibility placed on caregivers between skilled visits.

While these are all positive shifts, supply coverage can still pose unique challenges. Under the Patient Driven Groupings Model (PDGM), CMS denotes wounds as one of the highest-paying clinical groupings, but only if documentation supports skilled intervention and the frequency aligns with medical necessity. For patients receiving products via home delivery orders, there may be lack of continuity in supply quantities approved by insurance, which may not align with what was ordered as medically necessary; this often stems from varied coverage limitations relative to the vast landscape of insurance provider policies and/or lack of referral source understanding on how supplies are covered in the homecare setting.

In-home clinicians must be willing to actively communicate with referring providers, judiciously utilize medical products during medical visits and thoroughly educate their patients about supply utilization and dressing changes between visits. The good news is that the general shift is reducing the need for dressing changes between visits at all, and that manufacturers are developing longer wear-time dressings to accommodate the value-based care approach.

Streamlining Product Formularies

As homecare organizations begin to join or support large ACOs focused on value-based care, they will recognize quickly that these organizations have adopted tightly streamlined and highly evidence-based product formularies to support their efforts to manage costs and improve outcomes. For homecare entities in this space looking to be a successful partner, adoption of the products on these stringently vetted formularies is essential. Providers in these groups may not accept substitutions relative to the homecare organization’s pre-established product formularies. Because of this, inadvertent spending may be realized in some instances, especially where homecare organizations have favorable pricing negotiations or rebate incentives in place with alternative supply sources.

Even for homecare organizations not affiliated with ACOs, the shift to a streamlined formulary that can be effectively adhered to in the in-home setting is appealing. Formularies not only support clinical consistency, but can also help agencies manage cost per episode in a PDGM environment, where supply and labor costs need to be balanced against fixed reimbursement. Formulary development should be a topic of consideration when evaluating how to better adhere to HHVBP while remaining cognizant of effective business initiatives.

Reducing Gaps in Care

Just as product consistency enables strong continuity of care, minimizing gaps between care settings is critical. Home health providers have a unique opportunity to engage with patients who are potentially receiving adjunctive outpatient care, those who are at end of life, or those patients transitioning between care settings along the health care continuum. At these pivotal gaps, homecare organizations that are most successful will support patients in a timely fashion.

The challenge of homecare often lies with insurance restrictions and limitations on qualifying for in-home care in the first place. Aditionally, effectively closing the care gaps means not only offering timely provision of skilled care, but also timely turnaround for supply delivery. In most home health settings, an initial patient evaluation must occur before to ordering, let alone delivering, necessary medical supplies. Delays in starting care after referral can shorten the 30-day PDGM payment window, affecting revenue and patient outcomes.

Some mitigate these challenges by adjusting workflows to accelerate processes while either risking reimbursement approval, retroactively billing for supplies provided during initial visits or absorbing the costs. Others have demonstrated the ability to effectively do things by the book and still achieve excellent provider and patient satisfaction. The difference in how homecare agencies address these gaps in care often comes down to how risk averse organizational leadership tends to be, along with how much administrative support exists behind the scenes. With turnover trends on the rise, organizations face continued pressure to take risks to remain competitive and to uphold high patient and provider satisfaction scores.

Impact on Outcomes

The shift to value-based care brings an inherent need for health care entities to provide more data to support effective achievement of positive outcomes. Currently, homecare organizations serving Medicare and Medicaid beneficiaries use CMS guidelines to report outcomes assessments. The CMS OASIS guide assists homecare organizations with adherence to requirements, while also offering explanations for how OASIS data ties into quality reporting and HHVBP. The standardized wound metrics established within section M of the OASIS-E Guidance Manual are a perfect example but are just one of many metrics that serve as required reporting for these patients. Improved wound healing and reduced rehospitalizations directly support higher PDGM performance by reducing costly unplanned care within the 30-day payment period.

For home-based care providers, “significant infrastructure investments are often needed to participate in models, including electronic health record (EHR) enhancements, new staff and data analytic support, especially for safety net providers and those serving Medicaid beneficiaries,” according to the CMS Innovation Center. From an innovative standpoint, increased stringency around outcomes reporting may mean adopting new systems in the future, such as remote patient monitoring (RPM) services, while skilled care providers are not physically in the home with their patients. RPM could require costly equipment or effective interfacing with referring providers’ EMR systems to provide feedback on product utilization, adherence to care plans and wound healing progress, just to name a few. While this type of service is not yet required or covered by CMS under the home health benefit, CMS’s Chronic Care Management and Remote Monitoring codes demonstrate preparation and potential for future coverage. The challenge with mass adoption of this type of outcome tracking today lies in the fact that some home care organizations are simply not built to support such data feedback loops and advanced reporting systems.

In the meantime, organizations are working fervently to increase tracking and accountability measures to uphold current documentation requirements. To do so requires a strong organizational culture, stringent adherence to roles and responsibilities within set organizational structures and systems to monitor individual performance. The challenge with this is that the documentation time for clinicians has become increasingly burdensome, and the manual review process cumbersome—both of which can contribute to high turnover and burnout. Additionally, many health care organizations have been slow to adopt highly advanced tools that could use artificial intelligence (AI) to support the effort to scrub charts for errors or missing components.

In any case, data increases our awareness of the effectiveness of our efforts, and it is critical to demonstrate the success of any value-based care model. Homecare organizations need to be creative and forward-thinking in their approaches to meeting this need to remain relevant and favored in this highly competitive market.

A Collective Call to Action

With a massive shift to home-based care over the last decade, it is no surprise that Home Health Value-Based Purchasing is one of the most robust and comprehensively established forms of value-based care models in existence to date. As homecare agencies adapt to the changing health care landscape, absorb the evolving documentation requirements, while demonstrating effective outcomes management and navigating their ongoing staffing challenges—it is imperative that they remain nimble and open-minded to innovation.

Available technology is quickly outpacing cumbersome reporting mechanisms and analytics platforms, especially those that exist within large organizations that have excessive data points to manage. Compared to referring providers, homecare agencies are falling behind when it comes to technological advancements. It would behoove homecare companies, large ACOs and insurance organizations like CMS to begin strategic, collaborative and intentional adoptions of supportive and innovative technologies—together.

Value-based care requires a massive team effort to be truly successful. As it exists today, the onus to drive value-based care forward seems to rely heavily on homecare—a market segment with a compounded annual growth rate of 7.4% through 2032, well above most other health care markets—while 59% of homecare agencies continue to report ongoing caregiver shortages. The question remains: Will we continue to let homecare shoulder the primary weight of this transformation, or will we finally rally as a unified health care continuum, leveraging every sector’s strengths to create a value-based care model where every sector shares both the responsibility and the reward?

Kaitlyn Rios holds a doctor of physical therapy degree from the University of North Texas Health Science Center and is a Certified Wound Specialist through the American Board of Wound Management. She leads new product development and collaborates closely with marketing and clinical teams while serving as the vice president of clinical business development at DermaRite Industries. Rios enjoys spending time with her family, crafting ceramic pottery, developing her nonprofit organization and writing both recreationally and professionally in her free time. Visit dermarite.com.