One of the major components around CMS Quality Strategy goals in the home health setting is to “reduce inappropriate and un-necessary care.” Those objectives, combined with the Home Health Value-Based Purchasing Model (HHVBP), which is gradually being rolled out by many home health agencies, aim to move-away from-volume-based reimbursement to a quality-of-care model.
But how does this shift in strategy translate to engagement between clinicians and their home health patients? Jennifer H., an administrator for onehome with a nursing background, mentioned several key principles to embrace the quality-of-care model:
- Tailored visits to address specific patient needs: Focusing on the patient’s specific challenges allows the clinician to teach and train the patient without unnecessarily extending the clinician’s involvement associated with that episode of care. This approach enhances patient engagement and ultimately facilitates the achievement of the patient’s goals.
- Front-loading Visits: Front-loading visits means placing a greater emphasis on initial encounters to ensure alignment with the patient’s goals. This early focus helps set the tone for the care plan.
- Patient Accountability: Encouraging patients to take ownership of their health and well-being is crucial. Empowering patients during each visit to actively participate in their own care contributes to better outcomes.
Prioritizing specific goals is pivotal in this approach. “If the patient and ordering physician’s primary concern is diabetes management, that should take priority before addressing other chronic conditions. Essentially if that was the patient’s key point of need, focus there first, rather than getting too general and broad early on,” Jennifer emphasized. This targeted approach ensures that care is tailored to the patient’s unique needs and aligns with the ordering physician’s home health order.
The practice of scheduling visits within a shorter timeframe coupled with high touch case management, enables clinicians to “make more confident decisions regarding the need for additional care,” noted Jennifer. This approach gives the clinician the chance to monitor the patient’s response to the current care regimen and possibly direct the patient back to the PCP or outpatient therapy, earlier than planned. Yet, it may also help facilitate extensions of care when warranted. All these actions contribute to the quality-of-care model that CMS aims to establish with HHVBP.
Patient accountability is also another vital aspect of value-based care in home health. Clinicians work to empower patients to continue improving their health even when they are not present. While assessing each patient’s circumstances, including their living environment, current chronic conditions and caregiver situation, clinicians determine the level of accountability that is feasible. For instance, patients could feel empowered and educated to complete some of their physical therapy on their own when clinicians are not present. In many cases, the “patient owns their part in rehabilitation and recovery, and as a result, their health goals are met,” remarked Leah B., a dedicated onehome RN. It is our hope that we see more value-based home health implemented in care plans, which onehome has successfully been able to model to drive positive healthcare results and satisfaction for all stakeholders.