The Expansion and Shift Into Community-Based Care

President and CEO, National Association of Home Care & Hospice

President and CEO, MatrixCare

SVP Home and Hospice Division, MatrixCare

Bill Dombi: I see the shift coming in multiple forms, coming from a DC-based advocacy organization. I’ve seen the shift coming from a policy perspective, both effecting Congress as well as regulators, but I see it in the marketplace and in the clinical focus and approach taken, as well.

Did this get triggered by the pandemic or did something else happen because of the pandemic that affects community-based care? I think it’s a combination of growth in the awareness of what’s capable of being provided safely, effectively, and economically at home, as well as the actual delivery of services and the relationships between providers of care. From the perspective side of it, the awareness side of it, we have just seen a remarkable acceleration in the understanding of what the breadth and depth of healthcare at home is. That comes from the public as well as from the healthcare sector.

But it also comes from policymakers and regulators, as well. I think the odd part is that home care has been one of these hidden values out there in healthcare, but we saw the pandemic kind of open eyes and ears to understand what that breadth and depth can be. But from a practical perspective of delivery of care, the pandemic looked for places that they considered both accessible and safe to deliver in the middle of a very infectious disease.

Bill Dombi: There are serious investments happening in healthcare providers to become community care providers, also significant intellectual investment in crafting policies and changing laws to facilitate the delivery of health care at home. Did the pandemic cause this? I think the pandemic triggered an acceleration of what was naturally occurring in the first place, but let me finish by saying, that doesn’t mean all these other locations of care hospitals, nursing facilities, and physician offices will be outmoded. No. I think that this just becomes another option available for the delivery of care. I think it’s an exciting opportunity and exciting period for healthcare at home in just so many different dimensions.

Steve Pacicco: We do see a lot of our customers developing or implementing piloting programs in community-based care that are underway. They are looking to extend into the home regardless of where they started. We see diversification of providers.

We see senior living and assisted living businesses diversifying as well, building kind of informal networks to deliver care into the community. I use the term, Navin, informal networks. We’ve talked to assisted living providers that will want to deliver a better quality of care and keep people in that setting as long as possible. In order to do so, they need relationships with home health, palliative care, home care and hospice providers. They’re trying to narrow the number of agencies that they work with. Obviously, new models of care.

Bill Dombi: ​I think the best advice I could offer would be to recognize that health care at home is a different business, in almost every element of it. It’s a different business with maybe the biggest potential exception being patient population, because we are shifting those patients home, but it’s different from a staffing perspective, from the nature of the financials, the scheduling of care, of the reimbursement models, and even how you get your business. If you’re a brick and mortar entity, you’re going to try to get capture referrals from your own operation, but it probably is necessary that you get referrals beyond that. And then even in terms of issues of oversight and risk, since their staffing tends to be a combination of full-time staff and part-time staff. On a visit basis, financials need to look at the cost of time that involves going between one patient’s home and another patient’s home.

It’s just one illustration. Scheduling often is a big financial factor, as well as the staff availability factor. You really don’t want to set up a scheduling so that Mary Smith has to drive 25 miles to her next visit when you could organize it so she takes a shorter path to a patient who is closer. But the reimbursement models, episodic versus per diem, compared to the nursing homes, and then that partnering with many others in the community, relative to referrals ​​​are considerations.

I think the first thing any brick and mortar healthcare provider has to understand is this is not just something you plug and play. You don’t just say to your staff you’re now going to start caring for people at home. One of the things that stands out on the staffing side, and this is very, very, important is that you’re sending someone out on their own into the field.

And, yes, you can have virtual connections on a real-time basis, but still that nurse in someone’s home is an independent practitioner at that point. You need to have a competency level that recognizes the judgments are going to need to be made sometimes too quick to call a supervisor and say, what do I need to do? It’s certainly distinct from going down the hall to the nurses station in the hospital or in the nursing facility and saying to an RN, come quick with me to see this patient.

Bill Dombi: The one thing that I would be continuing to have in the front of my brain as we see this acceleration of healthcare at home is that quality and patient outcomes still matter, if not more than ever. The greatest step in preparation is in delivering those high-quality services and achieving the best outcomes for the patients and presenting that in terms of value, efficiency, and efficacy of care in the home because payers like managed care plans. They don’t just want to take a home health agency to deliver care, they want an effective home health agency and they’re looking for evidence of that.

One thing we’ve been watching is the degree to which horizontal integration is occurring. What I mean by that, is the home health agency also operates a hospice in a non-medical home care program and is engaged in palliative care, may do infusion therapy or pediatric private duty nursing so that it becomes essentially a one-stop shop for its relationship with payers and with other parties to health care.

For referral purposes, but also for finding yourself in a network with managed care, horizontal integration seems to be very important. The other option is a close partnering with those other parts of healthcare at home so that free standing home health agency may have a place in the future, but it has a better place in the future if it has ready, willing, and able partners along the horizontal spectrum to deliver other healthcare services at home.

The patient doesn’t want to go through a constant transitioning from one company to another while in the home setting. The patient who leaves the hospital and is getting restorative therapy services from a home health agency and then is transitioning to a Medicaid home and community-based services program for continuing personal care supports, that transition has a lot of costs, but a human cost, even to the patient who would love to continue somebody they think is delivering quality care.

Bill Dombi: The last thing to mention in terms of what’s going on and who’s going to be a winner or loser and how best to deal with such things as consolidation, is workforce. The greatest pressure on healthcare home today is a workforce where the demand exceeds the supply and that’s in variety of disciplines, nursing, personal care, home care aides, and the like. And so a strategy for being a winner and one that helps deal with the integration and looking to partnering is taking whatever steps necessary to acquire and retain a high quality workforce.

One weakness in healthcare at home has been the retention rates and the turnover. As a business, the strategy has to include one of the best actions taken for recruitment and retention in a climate where there’s not enough workers to go around. If you want to be a winner in the business overall, you’ve got to be a winner in getting that workforce to come work for you.

Steve Pacicco: Now just picking up on some of the things Bill talked about, because I think we focus our innovation around these two issues of, I’m using Bill’s words, acquiring and retaining a high quality workforce, quality, and patient outcomes. We believe as well that providers that deliver high quality and strong patient outcomes will win and you need to retain a high quality workforce. Those are the cornerstones of where we focus innovation. We think on that second point about quality and patient outcomes, we think that risk will continue to be passed down. It’s going to be two-sided risk, both clinical and financial. We believe, Navin, that efficient care is high quality care and efficient care enables higher workforce engagement and higher engagement is going to lead to retention of that workforce. We really focus on these two things of risk and efficiency. ​

Steve Pacicco:When we think about technology considerations, so much of it is about the workforce issue. It’s interesting though, not only is the business different, but the technology demands of delivering technology in the home are higher and different than what they might be in a skilled nursing environment or assisted living precisely because of what you said, that person’s out there by themselves. If there’s any challenges with the technology from, how do I do something to anything else, they’re out there on their own. Today, most clinical information is captured when a patient is standing in front of a clinician.

I think there’s opportunities to begin to break that model and capture this information on an ongoing basis. A big focus on usability is another technology dimension, training services, or a handful of things we’re doing to address that workforce issue. Beyond that, interoperability and talking about this a bit, the agencies aren’t doing it themselves, and you need really, really strong interoperability data and analytics, but it’s a whole solution and Navin, we believe there’s product, technology services, and the company. The company’s got to be stable.

Bill Dombi: I think the overall culture of health care at home is well situated to connect in with technology to advance together into delivery of services at home. From a user perspective, it’s got to be the right technology for them, which brings culture into it as well. I think when people are looking at their workforce in terms of hiring, they need to know where’s that person stand on technology and they need to know from their technology partner, whether or not the cultures of that partner and they themselves are in sync because it is that kind of holding hands together, walking down that path of care, to deliver your services to people who are very, very vulnerable.

I’m very bullish on the role of technology. I’m very heartened to find out that finally others are recognizing that technology plays a big part in delivery of healthcare services. I would not hesitate to put health care at home from a technology standpoint up against pretty much every other sector of healthcare. The days of high touch are still there, but boy, they are absolutely married to high tech as well. So again, very bullish on it and look forward to partnering with MatrixCare and asking them to help lead us towards that interoperability, which might be the holy grail.

Steve Pacicco: The company’s got to have a strong vision for the future. The agencies need to feel confident that we’re going to innovate, that we understand where the market’s going, and we’re not just the right partner for today, but the right partner over time. We’re accessible, we’re available, we’re open, responsive, we’re consultative. We listen. Those are culture things. And though it’s partly technology, it’s partly culture within an organization like MatrixCare that I spent a lot of time on, because I think that is the secret sauce in being responsive and delivering great solutions.