How Home-Focused Conveners Bridge the Gap Between Payers, Providers

May 11, 2021
Home Health Care News

The home is increasingly becoming the No. 1 site of care for seniors, partly thanks to the services of both home health and home care providers. But as the post-acute care world transitions away from fee for services toward value-based care, in-home care operators often find themselves in need of support. And that’s where the […]

The home is increasingly becoming the No. 1 site of care for seniors, partly thanks to the services of both home health and home care providers.

But as the post-acute care world transitions away from fee for services toward value-based care, in-home care operators often find themselves in need of support. And that’s where the convener comes into play.

Broadly, the convener’s role in post-acute care is to organize services for payers, acting as the middleman between them and the providers they’ve contracted with. Strategically, conveners give payers one go-tosource instead of a slew of providers offering different services to their members, Andy Friedell, the CEO and founder of healthAlign, told Home Health Care News.

“It can be hard to organize lots of different services into the home and to ensure that fulfillment happens,” Friedell said. “And when fulfillment does happen, it’s often siloed across lots of different providers. So the plan is not getting a good picture on member risk and member needs.”

Founded in 2018, Annapolis, Maryland-based healthAlign offers a data-driven platform to its health plans and provider partners, who collectively operate 2,500 locations. Those providers include national, regional and local post-acute care agencies. 

As a convener, it believes that payers are hindered by administrative burdens, fulfillment gaps and poor visibility into the needs of members — and therefore struggle with managing services out in the community.

“When the plan is dealing with lots of individual providers, they are creating lots of channels,” Friedell said. “Each one of those channels is limited by that individual provider’s service offerings, as well as that provider’s fulfillment capabilities. We’re trying to give the plan one channel where they can recruit and credential providers so they can then make matches in the database between services and zip codes. Then, they can start pulling data back in a normalized format — as opposed to from lots of different systems and formats — and get everybody paid on one mechanism as well.”

Other conveners that have a home-based focus include naviHealth, Signify Health (NYSE: SGFY), myNEXUS and CareCentrixin addition to provider-convener hybrids such as onehome. myNEXUS was recently acquired by Anthem Inc. (NYSE: ATNM) for an undisclosed sum.

It’s not totally fair to call all of these organizations conveners in a traditional sense, either. They do more than just — for example — convene services between the Centers for Medicare & Medicaid Services (CMS) and health systems on a bundled payment program.

At times, these types of organizations enhance relationships, naviHealth CMO Dr. Jay LaBine told HHCN.

“We are a convener, but that would be too limiting of a term,” LaBine said. “We’re actually a clinical services organization that does care management and utilization management for large health plans, while also managing post-acute care.”

On its end, Brentwood, Tennessee-based naviHealth operates under a model that’s similar to healthAlign’s. As part of its overall network, the organization works with health plans, 875 hospital collaborators and 90,000 post-acute care providers, including 16,000 post-acute care provider partners.

The company works primarily with Medicare Advantage (MA) plans, but also contracts with some risk-bearing entities such as accountable care organizations (ACOs).

“We manage the transition from the hospital, through the nursing home and then back into the community,” LaBine said. “We’re really focused on that hospitalized patient or member and ensuring that they get the best outcome in the next setting of care after they leave the hospital. Our goal is to give them more days at home.”

It does that with a high-touch, high-tech model that almost works like a concierge service, LaBine said. Through data collection and technology, naviHealth can project where each member should be during their care journey — and how long they should be there for.

That gives the plan a better idea of where its members should be and how they should be cared for. It also puts a healthy amount of pressure on the provider to improve that patient’s status in the right amount of time.

While that could affect, for instance, a provider’s near-term financials, over the long haul, companies like naviHealth and healthAlign say they give the agency a chance to do what it does best — care for its patients. That ultimately achieves better and more efficient outcomes.

In the long-term, especially in value-based care situations, that bodes well for the provider.

If involved, the companies are also more likely to initiate home-based care for a member.

“Our core model is that we manage the skilled nursing facilities,” LaBine said. “But we know a lot of people, instead of going to a nursing home, could go home and receive home health. So we’re actually replicating our model to help with home health agencies as well. And there are a number of things that we can assist with in transitioning someone from the hospital to home with home health, or from the nursing home to home with home health.”

Currently, naviHealth is expanding its model to work more with home health agencies in new markets.

Personal care focus

Both naviHealth and healthAlign are widening their scopes to hone in on social determinants of health (SDoH) for seniors.

“At healthAlign, we are also in the process of building out our network of non-traditional providers as well,” Friedell said. “We are building that network around food, transportation, errands, pest control and home modification.”

On naviHealth’s end, it has a patient navigation line of business, which is a non-clinical area striving to address SDoH in members.

“We do this when we’re at risk for readmissions,” LaBine said. “And these patient navigators — or community health workers — actually work directly with patients and families in their homes to help them take care of all the non-medical things that affect their care. And we’ve started to implement that in a number of markets.”

There are more opportunities for home-based care providers to make relationships with health plans than ever before.

A convener’s involvement can make those partnerships more seamless and more attractive for the payer, which will help the providers in the end.
“A couple health plans have contracted with healthAlign to essentially find all of the different home care providers and aggregate them in one platform to play the go-between role in terms of contracting and things like that,” Anne Tumlinson, the CEO of ATI Advisory, told HHCN last June. “And that’s my favorite kind of model.”

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