One Agencyʼs Formula

Say Goodbye to Wet-to-Dry Wound Care Dressings

The home health agency (HHA) market has seen increasingly more change in ownership transactions. Little is known about the organizational characteristics and quality of care of HHAs after ownership has changed. To examine whether an HHA change in ownership was associated with different quality-of-care outcomes, patient volume, and staffing levels. Using current HHA change of ownership files linked to publicly available Medicare HHA data, this staggered difference-in-differences analysis evaluated ownership change transactions of Medicare-certified HHAs from quarter 1 of 2016 to quarter 4 of 2019. Pretransaction and posttransaction HHA characteristics and quality-of-care outcomes were compared between HHAs that changed ownership and up to 8 matched controls. The transactions in the main analysis included (1) when an HHA remained as for-profit with a change in ownership and (2) when an HHA changed from nonprofit/public to for-profit ownership. The data were analyzed between November 2023 and September 2024. The primary outcomes were HHA-quarter measures of star ratings, the individual quality measures that compose the star ratings based on the Outcome and Assessment Information Set, and claims-based quality metrics, such as hospitalizations and emergency department visits. The secondary outcomes included HHA year measures of Medicare patient volume, per capita payments, and staffing levels (full-time equivalents and minutes per visit). The main dataset included 294 Medicare-certified HHAs that changed ownership, matched with 2330 controls. In 3 years after an ownership change, quarterly star ratings increased by 0.18 (95% CI, 0.05-0.31) relative to matched controls, with greater increases among HHAs that converted from nonprofit/public to for-profit. No significant improvement was observed in the 60-day rates of hospital admissions or outpatient emergency department visits. Further, no significant changes were observed in the number of Medicare beneficiaries, but per capita payments increased within 2 years post-ownership change. Significant reductions were observed in full-time equivalents of registered nurses (-17% [95% CI, -31% to -3%]) and home health aides (-26% [95% CI, -39% to -13%]), as well as per-visit minutes for skilled nursing care (-5% [95% CI, -9% to -1%]), physical therapy (-3% [95% CI, -5% to 0%]), and home health aide care (-11% [95% CI, -15% to -6%]). In this difference-in-differences analysis of Medicare-certified HHAs, ownership change was associated with higher star ratings and Medicare per capita payments, but not with claims-based quality measures. Reduction in staffing levels after ownership change raises concerns about implications for quality of care.

President's Page: Multiskilling Offers Keys to Career Success

Telehealth is a tool being considered by home health agencies (HHAs) to help manage costs. Most HHAs in the United States rely on Medicare reimbursement as their primary revenue source. With the implementation of a new payment system in October 2000, HHAs went from a cost-based, fee-for-service payment to a per episode prospective payment reimbursement model. For HHAs, the revenue goal changed from maximizing the number of visits under feefor- service to maximizing the number of patients and managing the episode within the prospective payment reimbursement formula. This paper addresses whether or not there is a financial business case for telehealth in HHAs. For this research effort, building a business case involved identifying and measuring the factors that contribute to the financial effectiveness of the home health organization. Utilizing a return on investment breakeven analysis model, we investigated the financial impact of telehealth, utilizing data from 32 HHAs in the Commonwealth of Pennsylvania. The breakeven analysis demonstrated that telehealth can have a positive impact on the HHA's financial position. Results indicate that HHAs should seriously consider the use of telehealth as part of their agency's care delivery model.

Background: Home health agencies (HHAs) are often affiliated with hospice agencies and commonly care for patients with serious illness within the Medicare program. HHAs may therefore provide a potential opportunity to facilitate timely referral to hospice when appropriate. Objectives: To determine if patients cared for by HHAs affiliated with hospice agencies experience differential hospice use and care patterns. Design: Nationally representative cohort study. Setting/Subjects: 1431 decedents in the 2002 to 2017 Medicare Current Beneficiary Survey who received home health in the last year of life in the United States. Measurements: Primary independent variable was HHA hospice affiliation. Primary dependent variable was hospice enrollment; secondary dependent variables were hospice live discharge and length of stay. Results: The 27.3% of decedents cared for by a HHA affiliated with a hospice had greater education levels and wealth and were more likely to live in the Midwest and Northeast. In adjusted models, HHA-hospice affiliated decedents had greater odds of enrolling in hospice compared to those cared for by HHAs not affiliated with a hospice, corresponding to a hospice enrollment rate of 51.0% for those cared for by HHAs affiliated with hospices versus 39.7% for HHAs not affiliated (p = 0.004). There were no differences in hospice length of stay or live discharge rate by hospice affiliation. Conclusion: Medicare beneficiaries cared for by HHAs affiliated with hospices are more likely to enroll in hospice at the end of life. This has implications for improving hospice access through home health incentives and models of care.

Physical and Cognitive Function Trends in Post-acute Care after Total Joint Arthroplasty in Medicare Beneficiaries: 2013-2018

To quantify racial, ethnic, and income-based disparities in home health (HH) patients' functional improvement within and between HH agencies (HHAs). 2016-2017 Outcome and Assessment Information Set, Medicare Beneficiary Summary File, and Census data. Not Applicable. We use multinomial-logit analyses with and without HHA fixed effects. The outcome is a mutually exclusive five-category outcome: (1) any functional improvement, (2) no functional improvement, (3) death while a patient, (4) transfer to an inpatient setting, and (5) continuing HH as of December 31, 2017. The adjusted outcome rates are calculated by race, ethnicity, and income level using predictive margins. Of the 3+ million Medicare beneficiaries with a HH start-of-care assessment in 2016, 77% experienced functional improvement at discharge, 8% were discharged without functional improvement, 0.6% died, 2% were transferred to an inpatient setting, and 12% continued using HH. Adjusting for individual-level characteristics, Black, Hispanic, American Indian/Alaska Native (AIAN), and low-income HH patients were all more likely to be discharged without functional improvement (1.3 pp [95% CI: 1.1, 1.5], 1.5 pp [95% CI: 0.8, 2.1], 1.2 pp [95% CI: 0.6, 1.8], 0.7 pp [95% CI:0.5, 0.8], respectively) compared to White and higher income patients. After including HHA fixed effects, the differences for Black, Hispanic, and AIAN HH patients were mitigated. However, income-based disparities persisted within HHAs. Black-White, Hispanic-White, and AIAN-White disparities were largely driven by between-HHA differences, whereas income-based disparities were mostly due to within-HHA differences, and Asian American/Pacific Islander patients did not experience any observable disparities. Both within- and between-HHA differences contribute to the overall disparities in functional improvement. Mitigating functional improvement inequities will require a diverse set of culturally appropriate and socially conscious interventions. Improving the quality of HHAs that serve more marginalized patients and incentivizing improved equity within HHAs are approaches that are imperative for ameliorating outcomes.

Postacute Care: A Guide for People With Dementia and Their Caregiver

Home health agencies (HHAs) provide vital community-based services for older adults. Under-resourced HHAs that are disconnected from broader community emergency planning efforts may struggle to maintain services during emergencies. As climate-related disasters become more prevalent, HHA services are increasingly at risk, and policymakers have focused on the services they provide to older adults. This study explores the relationships between the Veterans Health Administration (VHA) and contracted HHAs to identify opportunities to extend VHA emergency resources to HHAs and staff to assist them during disasters. We interviewed 19 stakeholders from 6 Veterans Affairs medical centers. Data were analyzed through rapid qualitative analysis. VHA and HHA staff focused primarily on their disaster response during emergencies with little knowledge of each other's protocols. VHA emergency managers lacked direct relationships with staff overseeing HHAs but had strong internal partnerships with clinicians and were knowledgeable about the needs of veterans who were disabled and homebound. VHA staff demonstrated an interest in partnering with HHAs to identify resources that could be shared during emergencies. Creating a pipeline of support through existing relationships and resources has the potential to strengthen VHA protections for older adults during emergencies, help them age safely in place, and provide a model for other health systems to collaborate with community-based practitioners.

This study explores the emerging conflict and cooperation between two types of organizations providing home health care to chronically ill and terminal patients--the hospice and the home health agency. Exploratory results suggest that the variables of size (terminal patient load), and competition (the number of other home health agencies in an area) influence relationships between home health agencies and hospices. It is also suggested that recent Medicare regulations may encourage mergers between agencies and hospices in addition to the existing modes of cooperation and referrals.

This study by Baier et al.1 sought to illustrate the decision-making process that occurs in hospital discharge planning when case managers engage with patients and families in selecting a home health agency. Case managers and home health consumers were qualitatively asked about their respective roles in the decision process, as well as their knowledge of existing public home health quality reports. No participants were aware of public quality reports. Case managers described presenting a list of available home health agencies to consumers, who in turn generally felt they had little information to guide their decision and often asked case managers for a recommendation. However, case managers felt unable to assist further in the process, citing federal laws protecting freedom of patient choice2 as preventing them from doing so. The major limitation in this study is the unexpected fact that none of the participants were aware of public quality reporting for home health agencies, effectively truncating the discussion to observations about how uninformed the decision-making process was and conjectures about how public quality reports might be used. While it is tempting to attribute case managers’ limited helpfulness in home health agency selection to the federal laws guaranteeing freedom of patient choice, the more immediate obstacle is a lack of awareness about the availability of a neutral source of quality reporting that consumers could directly access online. Other limitations include the lack of generalizability since participants were drawn solely from Rhode Island, and the relative lack of participants who were patients rather than family members. Not to its detriment, this study raises more questions than it answers. Future work could seek to test interventions in which quality reports are provided to home health consumers prior to their selection of an agency, with various patient-level and system-level outcomes3 compared against a control. In the larger context of transitional care,4 the relative importance of higher quality home health agency selection for patients post-discharge remains to be seen. Likely, the most effective interventions protecting patients in the transient period of increased vulnerability following hospitalization5 will be multifaceted.

Home health agencies (HHAs) have been collecting OASIS data and submitting it to their state agencies since 1999. As a result of these submissions, it is anticipated that agencies nationwide will receive their first set of risk-adjusted outcome reports in spring 2002. These reports will enable each agency to identify outcomes on which it can focus its quality efforts through the Outcome-Based Quality Improvement (OBQI) process. The Centers for Medicare & Medicaid Services funded a pilot project to provide OBQI training and technical support to HHAs in five states through their quality improvement organizations (QIO), formerly known as peer review organizations (PROs). Since April 2000, the PROs have trained approximately 417 volunteer HHAs in the five states. This article describes the implementation of this pilot project, provides an overview of the OBQI process, and discusses the implications for national OBQI implementation.

Many older and disabled individuals regularly receive valuable services from home health agencies (HHAs). The unilateral termination or reduction of such services by an HHA may exert a significant impact on the life of a client who has come to depend on those services. The prerogatives of Medicare-certified HHAs to terminate their relationships with clients are constrained today not only by contract and tort law principles, but also by federal statutes and regulations establishing Conditions of Participation, including provisions concerning clients' rights. A recent important federal judicial decision interpreted and expanded the legal responsibilities of HHAs to provide formal notice to their Medicare clients before terminating or reducing home health care services to those clients, regardless of the reason for ending or altering the relationship. This article critically discusses the background, holding, and practice implications of the 2004 Lutwin v. Thomson decision, which imposes these notice requirements on HHAs.

Home health care serves over 5 million Americans “aging in place”. In January 2016, home health value-based purchasing model (HHVBP) was introduced and piloted in 9 states in the US with a purpose of improving care quality and efficiency, and expanded nationwide in 2023. This study aimed to examine the impact of HHVBP on business operation of home health agencies (HHA), including ownership changes. This is a longitudinal study using 7 years (2013-2019) of data from two national data sources. A dummy variable was used to indicate whether an HHA is in a state with HHVBP or not. Ownership measures included both the type and changes of ownership between 2013-2017. A total of 14,334 HHAs (95,137 agency-years) were included in analysis. Of the 14,334 agencies, about 19% were in HHVBP states, 88% continued business in all study years, 1679 were new agencies and 49 agencies discontinued business. In HHVBP states, 363 out of 2781 (13%) were newly added, compared to 1316 out of 11,553 (11%) in non-HHVBP states. Agencies in HHVBP states were more likely to be public agencies (e.g., 6.08% vs. 4.97% in 2013; 5.62% vs. 4.60% in 2018), though it slightly decreased over time; and experience changes in ownership and particularly the years after the implementation of HHVBP (e.g.,2.44% vs. 2.38% in 2013; 7.03% vs. 4.39% in 2018). The HHVBP can have a significant impact on the operation and ownership type of home health agency, which in turn may impact availability and quality of home health care.

The purpose of this study was to examine how agencies in South Carolina that provide in-home health care and personal care services help older and/or disabled clients to prepare for disasters. The study also examines how agencies safeguard clients' records, train staff, and how they could improve their preparedness. The relevant research and practice literature was reviewed. Nine public officials responsible for preparedness for in-home health care and personal care services in South Carolina were interviewed. A telephone survey instrument was developed that was based on these interviews and the literature review. Administrators from 16 agencies that provide in-home personal care to 2,147 clients, and five agencies that provide in-home health care to 2,180 clients, were interviewed. Grounded theory analysis identified major themes in the resulting qualitative data; thematic analysis organized the content. Federal regulations require preparedness for agencies providing in-home health care ("home health"). No analogous regulations were found for in-home personal care. The degree of preparedness varied substantially among personal care agencies. Most personal care agencies were categorized as "less" prepared or "moderately" prepared. The findings for agencies in both categories generally suggest lack of preparedness in: (1) identifying clients at high risk and assisting them in planning; (2) providing written materials and/or recommendations; (3) protecting records; (4) educating staff and clients; and (5) coordinating disaster planning and response across agencies. Home health agencies were better prepared than were personal care agencies. However, some home health administrators commented that they were unsure how well their plans would work during a disaster, given a lack of training. The majority of home health agency administrators spoke of a need for better coordination and/or more preparedness training. Agencies providing personal care and home health services would benefit from developing stronger linkages with their local preparedness systems. The findings support incorporating disaster planning in the certification requirements for home health agencies, and developing additional educational resources for administrators and staff of personal care agencies and their clients.