Home Health Agency Ownership and Quality of Care Outcomes Among Medicare Beneficiaries

Medicare restructured home healthcare reimbursement from a cost-basis to a 60- day risk-based prospective payment system (PPS) in 2000 to implement the value-based payment model for home healthcare services. Currently home healthcare market in the U.S. is dominated by the presence of for-profit (FP) agencies instead of being primarily served by not-for-profit (NFP) agencies. Using data from the 2016-2018 OASIS for beneficiaries participated in the Medicare Current Beneficiary Survey (MCBS) (N=6,115), the current study examines whether home health agency ownership status is associated with length of stay (LOS) and discharge outcome Medicare home health care patients. Our first outcome variable is discharge status (modeled via ordered probit) with three categories: discharge to the community, inpatient hospital and other long-term care facilities. The second outcome variable is LOS and two dummy variables LOS ≤ 30 days and LOS ≥ 99 days were modeled via binary probit. The key independent variable was the ownership status of the agency (FP vs. NFP). Patient level covariates includes demographics (age, gender, race/ethnicity, marital status), comorbidity index, agency characteristics (metropolitan statistical area, hospital-based). Patients in FP agencies were 5.1% (p<0.01) less likely to discharge to community, 15.3% (p<0.001) less likely to have LOS ≤ 30 days but 7.5% (p<0.001) more likely to have LOS ≥ 99 higher compared to patients from NFP agencies under the PPS. Our results have important implications for clinicians, patients and healthcare professionals to be cognizant about the influence of agency ownership on the delivery of healthcare services in home healthcare sector.

Abstract P852: “They Were Wonderful...They Helped a Great Deal”: Patient and Caregiver Reports of Home Health Care as a Transition of Care Practice After Ischemic Stroke

Background: Transitions of care (TOC) following ischemic stroke (IS) are complex for patients and caregivers; the post-hospital discharge period is stressful, fragmented, and often carries with it a fear of new stroke. Improvements in education, medication management, and support for community integration following discharge to home could ease TOC challenges and assist in reducing hospital readmissions. Methods: Diagnosis-driven certified home health agency (CHHA) referrals for IS patients were initiated at a Comprehensive Stroke Center as a TOC improvement with a goal of decreasing “missed” referrals for patients not previously considered but eligible for CHHA services. Patients discharged to home (50 patient/caregiver dyads) were interviewed 30 days following hospital discharge to solicit feedback regarding CHAA services. Results: Of those contacted, 27 (54%) received CHAA services. Three patients/caregivers (11.1%) responded with neutral feelings regarding the visit, 24 (88.9%) responded that the visit was helpful. Eleven respondents had no comment/opinion when asked how the visit was/was not helpful. The remainder of patients had responses that could be grouped into domains including encouragement/concern for me ( n = 4), teaching/guidance ( n = 4), therapy/exercise ( n = 6), functional improvement/independence ( n = 2), medications ( n = 3), blood pressure management ( n = 3), and home health agency staff ( n = 2). There were multiple positive comments such as one patient who reported that the home care nurse was “very good... called right away and got the outpatient therapy transition arranged.” A patient with a new diagnosis of diabetes felt that education and concern for how things were going was very important to understanding and managing this new diagnosis. Multiple patients reported the importance of medication reconciliation after discharge and specific comments regarding the CHHA staff included, “Really helpful. They were wonderful... they helped a great deal.” Conclusions: Positive experiences regarding TOC practices strongly supported referral for CHHA services. Comments regarding the services suggest that increasing CHHA referrals could meet perceived needs of IS patients and caregivers in the transition from hospital to home.

CAPABLE Transitions: A Home Health Agency-Based Intervention to Optimize the SNF-to-Home Transition

Community Aging in Place-Advancing Better Living for Elders (CAPABLE) consists of an interprofessional team of a registered nurse (RN), occupational therapist (OT), and handyworker that delivers an in-home client-specific package of interventions to optimize function. CAPABLE aims to reduce functional impairment, home hazards, and acute medical services use and is being widely disseminated. To expand CAPABLE to older adults transitioning from the skilled nursing facility (SNF) to home, we developed CAPABLE Transitions, which makes several important modifications to CAPABLE. First, CAPABLE Transitions will be implemented within a Medicare-certified home health agency (CHHA) and delivered to CHHA clients. Second, it will be delivered to CHHA clients with and without dementia. Adding urgency to CAPABLE Transitions’ development, including persons with dementia has the potential to decrease high utilization of services and meet care transition needs. Third, it includes an initial RN care transition visit. Fourth, its services are more intensely delivered at the beginning of the intervention, shortly after SNF discharge. Beginning in the fall of 2020, CAPABLE Transitions will be tested in a feasibility study of 60 older adults discharged from post-acute SNF care to CHHA services in Rochester, NY. We have designed this 3-year feasibility study to consist of yearly recruitment waves that will enable us to iteratively assess and refine the intervention. Following this study, we hope to test CAPABLE Transitions’ effect on improving home time, quality of life, and the use of acute medical services in order to assist older adults in aging in place.

Developing a Strategic Group Typology for Home Health Care Agencies

Considering the growing interest in Home Health Care, an important area of examination relates to the strategic decisions made by home health agency leaders. The purpose of this study is to explore the existence of strategic groups in the home health industry using Porter’s generic strategies. A secondary analysis of data on agency resource deployment and scope characteristics were combined with secondary agency market and organizational characteristics. Hierarchical cluster analysis was used to examine the existence of strategic groups. The relationship between group membership and organizational and market characteristics was examined using chi-square and analysis of variance (ANOVA). Data from 7,715 home health agencies were explored in this analysis. A four-cluster solution emerged yielding sizes of cluster 1 = 1,682, cluster 2 = 1,731, cluster 3 = 3,763, and cluster 4 = 539. Cluster 1 was classified as the cost leaders with the lowest resource deployment and lowest scope. Cluster 2 was classified as the differentiator group with the highest scope and second highest resource deployment. Cluster 3 was classified as the both cost leader and differentiator group with the second highest scope and second lowest resource deployment. Cluster 4 was classified as the stuck-in-the-middle group with the second lowest scope and highest resource deployment. Using Porter’s generic strategies, the results showed evidence that strategic groups exist in the home health industry. Furthermore, home health agency strategic groups are significantly different based on market characteristics.