🔒Homecare seeks Medicare payments

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A Hartford area homecare agency is scheduled by Nov. 1 to join a national study conducted by Harvard Medical School examining the effects homecare providers have on reducing unnecessary client hospitalizations and lowering healthcare costs.

Right at Home, which has 280 franchisee offices across the country participating in the study, hopes the data ultimately could help make its case for homecare agencies to receive Medicare reimbursements for their contribution to cost containment.

The study's findings could also have implications for Connecticut and other states that have adopted policies in recent years to encourage home care over institutionalized settings like nursing-home and assisted-living facilities, which are thought to be higher costing.

“Nobody's studying it in the way we're doing it, especially not with this national population, so this is really the first evaluation of its kind,” said David Grabowski, professor of healthcare policy at Harvard Medical School and the study's principal investigator.

Key to the study is leveraging technology from homecare software company ClearCare Online that Right at Home caregivers use when they clock out from that day's client care. Instead of simply clocking their departure, Harvard added questions that a caregiver will answer on whether they noticed any change with the client during the shift, which could include things like changes in skin, ambulation, eating and toileting. Affirmative responses are sent immediately to case managers who decide the next course of action, such as a nurse's visit or a call to a doctor or family member.

“We believe that being proactive and catching those things sooner and prompting the caregiver is a benefit for the client,” said Mike Flair, vice president of franchise business solutions for Right at Home in Omaha, Neb., where the company is based.

Previously, Right at Home caregivers would report changes in condition to case managers, in addition to noting them in log books in clients' homes, but the new system proactively prompts caregivers at the end of each shift to ensure they're not forgetting to report any changes.

The real-time reporting is key, Grabowski said.

“I really think that's the big intervention here, this kind of reporting in real time at the end of a shift that allows the care manager to address something before it escalates into a problem that may necessitate a hospitalization,” Grabowski said of the study, titled, “The Intervention in Home Care to Improve Health Outcomes.”

Grabowski expects to collect data on more than 10,000 individuals during the study, which began last year and will run through 2017.

“We'll have a really big number of care encounters to base any sort of inferences we have here on, so that's really exciting,” he said.

In preliminary observations from early adopters of the model, caregivers reported a change in condition after 2 percent of all shifts.

The most common condition change was the care recipient seeming different, like reduced alertness or talking less, amounting to 40 percent of changes, Grabowski said. Another 20 percent were mobility changes, 16 percent were skin-condition changes, 10 percent were toileting changes and 14 percent were changes in eating or drinking.

“It will be important as we follow this to see the impact here that it ultimately has, but I think so far we're definitely seeing value just in terms of tracking where patients are at in terms of their changes in condition,” Grabowski said. “We've also introduced some of the hospitalization tracking as well around when individuals go to the hospital so they can have a real-time sense of not just when there's a change in condition, but also any sort of hospitalization, to look at not just … changes, but also the outcomes here.”

Local participation

Harvard has brought groups of Right at Home offices into the study in phases to provide control groups against which to measure the effects of real-time intervention on preventing hospitalization. About 140 offices had been brought in before the group of 70 coming online by November and the final group of 70 will go online next spring.

Offices such as Right at Home in Hartford County have served as a control group until they go online with the intervention reports.

Harvard can look at offices that had the intervention technology and those that did not, and compare the rate of hospitalization. “So that's a cornerstone of the whole program, reducing hospitalization,” Flair said.

Robert Scandura, CEO and owner of Right at Home for Hartford County, is excited to have Harvard conducting the study.

“As a person who cares about caring for the elderly I think this Harvard study is a great thing,” Scandura said. “However, as a businessman, I feel that having the Harvard study separates us from everyone else and sets Right at Home as the industry leader.”

He said his caregivers already call in clients' changes in condition right away, but the ClearCare reports will give Harvard the data it needs to track the impact of real-time interventions as they're made.

Scandura's Right at Home office, based in Wethersfield, is the franchise's largest in the world based on revenue, according to Flair and Scandura. Scandura said he has about 250 clients and more than 300 caregivers. Nonmedical client services include help toileting, bathing, cooking, errands and other personal care, plus medication reminders.

Scandura's office does not provide nursing care, but he has 10 RNs who help oversee cases as an “extra set of eyes” on clients.

Most families pay for the care themselves or through programs like long-term care insurance, Scandura said. About a sixth of his clients qualify for Connecticut Community Care Inc. (CCCI) coverage, which applies to income-qualified clients moving from a nursing facility to home care and who are moving into homes that are insured and bonded, such as Right at Home, he said.

“Essentially, they'll pay us to keep people at home, take care of people at home,” Scandura said. “If this was done on a national level, just think about the savings that the government could have.”

That's the point Right at Home hopes the Harvard study makes as the industry tries to play what one executive called a more prominent role in the healthcare continuum.

“We're a lower-cost option,” Flair said. “We're not replacing the medical profession … but we're able to supplement what the healthcare providers are doing with some pretty, what we call low-tech, low-skill type intervention and this one is a prime example of it.”

Harvard also aims to apply a numeric value to the cost of reduced hospitalizations, he said.

With that kind of data, Flair hopes the Harvard study helps get home care a “seat at the table” in the national healthcare discussion.

“As the healthcare system is evolving and pushing more care out into the home, we hope … to be sort of in line to receive reimbursement for providing care for someone in order to … keep them from going back to the hospital,” Flair said, noting most private- duty homecare agencies are not reimbursed by government insurance.

“Right now, there's a fairly large chasm between home care, what we do, and home health care and care professionals,” he said. “I don't mean this in a negative way … we're sort of stepchildren in the grand scheme of health care. We're looked at as kind of way out there and we're trying to … align ourselves closer to healthcare providers, meaning, yes, we're kind of at the lower end of that in terms of complexity and skill sets and so forth, but we still play an important role. We hope to get more attention from healthcare policymakers and the government in general in terms of the value of home care.”

If home care can save healthcare costs, healthcare dollars can stretch further, he said.

Ideally, such care would qualify for Medicare reimbursement, he said. Since 2008, Connecticut has adopted a program that incentivizes the elderly and disabled to join community-based or homecare programs, rather than checking into nursing homes, as a way to lower long-term care costs to the Medicaid program, which spent $1.19 billion last fiscal year on nursing homes, according to the Department of Social Services (DSS).

Right at Home sees clients all the time who would benefit from home care, Flair said, but because there's no government reimbursement, families typically end up footing the bill.

Personal touch

Back in his Wethersfield office, Scandura's affinity for the elderly is evident in the many thank-you letters tacked to an office wall, many from family members thanking Right at Home for its care of a mom, dad, uncle, brother, sister, etc.

He's especially fond of World War II veterans for whom his office has cared and one wall contains a framed uniform and Navy Cross of a veteran, along with a framed letter from a relative who gave Scandura the items as a thank-you for caring for Private Whitney W. Jacobs of Manchester. Jacobs, of the U.S. Marine Corps Reserve, was awarded the Navy Cross in 1942 for extraordinary heroism in the Battle of Guadalcanal.

Scandura said he got choked up when the family gave him Jacobs' items. Scandura said he's a World War II buff who volunteered when he was at the University of Connecticut to drive veterans to area legion posts and memorials, or out to lunch or events, and he enjoyed hearing their stories.

Before he met his wife, he lived for about 20 years with his grandparents after college and enjoyed the impact he had on their lives, taking them to dinner, shows and sharing their company.

He worked first in the technology industry before joining Right at Home about 10 years ago.

“As many headaches as you can have in this business, when you get one letter saying, 'I don't know what I would have done without you,' that kind of makes my day,” Scandura said.