This article is sponsored by AlayaCare. The panel took place during a live Q&A session with James Graff, Director of Quality and Value of Elara Caring, and Jennifer Gentzlinger, COO of Premier Home Health Care, moderated by Brady Murphy, Partner & Chief Revenue Officer of AlayaCare at the HHCN FUTURE event in Chicago held on September 30, 2021. The interview has been edited for clarity.
Brady Murphy: My name is Brady Murphy. I’m one of the founders of AlayaCare. Our discussion today is about social determinants of health and value-based pay. Let’s start with some examples of what you’re doing in terms of social determinants of health within your organization.
Jennifer Gentzlinger: Just a little background, Premier is our at-home care organization primarily based in the New York market. Most of the pilots and initiatives I’ll speak about today are in the New York market, specifically when we talk about incorporating home care in the broader sense and addressing the social determinants of health for our population.
We are working with a large, regional health plan in the city. They’ve identified a cohort of Medicaid-Medicare duals, duly managed under the health plan with diabetes and hypertension as two of their primary comorbidities. We have been providing home care services for them. Our average length of stay is about four to five years and we’ve been in the home with these folks for a while. What we’re really doing is trying out a new way of applying home care.
Our workforce has been trained to identify signs and symptoms of change, and they know them better than most. They’re the eyes and ears in the home, so today is different than yesterday. They understand diabetes and hypertension, what to look for when the patient starts to deteriorate, what social determinants of health exacerbate some of those declines, and we provide them with some tech platforms to report that in real-time.
That’s a pilot we’re kicking off. It’s been a very fun building process because they have an intricate quality department. They’re focused on identifying measures of success in a pilot like this, and getting white papers and other things going on the back end, which I am very passionate about. I can’t wait to see if we can expand that into additional markets with additional partners.
Murphy: What are you doing with that data once you collect it? What are the next few steps?
Gentzlinger: That’s more of an evolutionary process for us. It’s something we’ve taken away from COVID. We’re taking more of a pop health approach with home care. With that real-time data, the aides go in and at the click of a button on their phone, they’re able to tell you, “Today is not a good day. Something is wrong,” or, “Hey, we had a bunch of empty bottles in the trash can,” or, “Something’s off. The meds are still there from Saturday and Sunday.”
Things that are changing need to be reported so you can intervene quickly. That has drummed up information about when there’s a problem and also when someone’s stable. I think the absence of new data points is also really interesting, and we’ve put it all into a large internal database.
We have folks looking at population health, cutting through diagnoses and understanding if it’s post-acute, pre-acute. What did that patient look like before we had an ED hospitalization or any kind of alert for the institutional setting. What could we have done differently to avoid that ED by calling a physician and trying to come up with better ways of applying services and wraparound services to that patient .
Murphy: Alright, James. What’s your opening salvo on data and social determinants?
James Graff: Sure, it’s going to mirror the trajectory that Jennifer just spoke about. We’ve been looking at changes in conditions at Elara since 2015. We had a very basic observe-and-report telephonic system where an aide can contact the clinical RN immediately and report a changing condition. Then the RN can apply certain interventions to prevent a condition from exacerbating and leading to an emergency room or a hospital admission.
Over time, the program ebbed and flowed, and we were missing the technology to help us capture the data. We had rudimentary systems in place to help us capture and report on the data accurately. Over the past few years, we brought in IVR technology, and we’re currently conducting daily assessments with all of our aides that are in the home. They’re receiving a phone call that will list out a series of questions they can respond to and to give us a peek inside the home to see how the patient is responding or how the patient’s condition is changing.
That is all sourced over to a clinical team that can contact the aide or the client immediately and apply certain interventions. This might include education, a field nurse visit, or collaboration with the primary care physician or the health plan if other services needed authorization.
Through that system, we’re able to analyze the data to identify trends and more importantly, look back and see where there were missed opportunities — opportunities where perhaps an aide didn’t provide the correct information for whatever reason.
For example, we do 12 hours of mandatory in-service a year.We’re thinking about targeted education — 15, 20-minute videos specific to the patient’s condition so the aide knows what to look for before going into the house. We’re going to leverage that same platform. Again, social determinants are an evolution. We’re looking to leverage that platform and work toward a standardized social determinant assessment so we’re all speaking the same language when we capture this data.
Now, we’re not just sharing data with the health plan, we’re sharing this data with the primary care physician and maybe a community-based services facility as well. Everyone needs to be talking the same language, and hopefully, the use of technology, a standardized language and a standardized assessment form can get us there.
Murphy: Yes, I get to retell stories from our clients where they’re coming up with hypotheses like, “Can we do this intervention? Will it make a difference?” I heard a lot of that today, and it reminds me of a story where a client tested their theory around the structured gait analysis, or how they’re walking.
They did a test and control group, and their theory was, “Let’s do interventions of pressure stockings to figure out what it will do for improving gait analysis? They were able to prove the intervention, paying for it out of their own pocket to have these pressure stockings. But when they compared the test group to the control group, all the indicators of gait were much more positive as a result of that theory coming to life. In home care, I think we need to use more structured initial assessments, gather the data and be predictive about it.
I want you guys to share some of the insights you’re getting from the data and how you’re bringing it to your health partners. Is that helping your bill rates? How are you making more money? How are you saving? It’s so hard in this margin compression world. How are you using the data to drive business?
Gentzlinger: We had to go back and standardize the clinical collection of data. If anyone’s in the home care space, you start out with an initial assessment, you have certain contractual and regulatory requirements, and they’re in there every 60, 90, 180 days for frequency. How do you structure your clinical documentation to be a routine data point that you’re measuring internally for your own KPIs of, “Okay, are we stabilizing this patient?”
Unfortunately, most of us in the long-term care space don’t look at getting healthier and coming off of our service. We need to look at other data points of satisfaction of care. Do you understand your care plan? Do you feel lonely and distressed? And how can I keep that person happy at home? We had to go back to those questions and adjust the way we applied our nursing supervision for our home care workers.
Then, similar to a program that James just outlined, our workers go through very care plan-specific questions on a daily basis. Based on the goals we set out in our care planning process, we have to determine how our aides are helping them maintain those goals or reach those goals, and how that impacts our health plan partners.
Back in 2016, we entered into our first value-based payment arrangement, and it was based on quality incentive measures and potentially avoidable hospitalizations outlined by New York state. That got the ball rolling, but focused on diagnoses like sepsis, anemia, and electrolyte imbalance, which in our population makes up probably 2% to 3% of hospitalizations.
We were compliant and we drove down the hospitalization rates for our population by about 30% in our first two years. On the Medicaid base, you’re not paying for the hospitalization, so it was incidence-based as our measurement of success. Our first measurement year fiscally tied was 2018, and we brought home about $500,000 in savings internally, shared with other network providers, which was a big win for us and kind of brand new in that space.
We’ve exploded since then, with 14 value-based payment arrangements through a variety of different health plan partners around New York. We’re entering into risk arrangements in New Jersey and Massachusetts in 2022, which will be our first outside of the New York market. For us, it’s all about savings. I think part of the struggle for home care providers is always the back office payment, right?
We had to come up with the intervention. We had to put up the cost to build it, train all of our workers, get all this up and running, and then hope that it was going to work. Fortunately, it all panned out and everything was okay, but I think it’s part of the health plan education process to say, “Look, this costs us money, and if you’re going to have savings on the back end, we want to have a piece of that pie.”
Fortunately, through the pandemic, and I think everyone seeing the value of home-based care, it’s been helpful in our contract negotiations accessing some of those different dollar savings and contract opportunities for increased rates to help with the margin compression.
Graff: She couldn’t be more right about the margin compression. I know Premier. Premier got in very early and that was advantageous for them. They were out in front of the quality and value arrangements taking place, and they have a head start on a lot of monitors out there.
When we rolled our patient monitoring system into our technology platform, we also took our electronic health record and we built in some of the UAS questions that mirrored the metrics for which the DOH was holding us responsible. For example, when our RNs were going out to do assessments, we were asking the questions, “In the past 12 months, did you get a flu shot. Have you experienced increased pain? In the past 30 to 90 days, have you fallen with a serious injury?”
We were able to compare ourselves with the metrics that were coming from the UAS assessments in New York, but also we were able to drive future assessments based on that data by applying interventions and working with the aide. The one important thing in the equality and value-based mindset is that the aide is a very critical part of the team.
They’re the eyes and the ears in the home. They’re the ones seeing the patient on a daily basis. They’re the ones who can tell if there’s a change from Monday to Tuesday. Then, it’s important that you give them an easy access mechanism to report changes to the clinical team so they can act quickly in real-time to prevent hospitalization.
Murphy: I want to get your take on the role of technology. We just closed a big funding round and you can tell us how we’re going to spend all this money on our software to make it better for you and everyone here. Jennifer, from a technology point of view, software or hardware, where do you see this going for Premier in the next few years?
Gentzlinger: We are putting tech in the home. The wearables are super important when integrated into our data feed, but our goal is to help them to understand the care plan and flexibility with that.
We’ve been working with AlayaCare on making adjustments to the app to fit our needs as an organization. Care plan flexibility is big. I don’t want my nurses to only adjust a care plan every 180 days because that’s what the regs tell me that they have to do. The app allows you to adjust goals, interventions and tasks for the aide to do, with ADL and IADL flexibility, and certain days and times.
All of that is communication between the office and field staff and the supervisor. That’s huge, along with incorporating the IDT from the care manager, health plan or primary care physician. I think broader access to tech allows us to amplify what we’re already doing there in the long-term space.
You need the ability to communicate from one specific place. You don’t need to spend all that time documenting what was already in there; it is tactile and flexible as you’re operating. I think that’s the next big space for us, and that’s where we want to focus and keep it from that pop health multitouch place.
Murphy: One thing we’re going to try to do more with both of you is the family portal, getting the data from the family members. You talked about this daily survey like, “Do you feel better or worse than yesterday?” Pulling that data in and using it as a pivot point to be predictive as well. It’s just processing all the data. James, over to you, what are you going to be doing in tech?
Gentzlinger: There’s a ton of data to process. One of the conversations I had earlier touched on the documentation needs and the burden that documentation puts on the RNs, in terms of getting the information onto the system. I think that’s going to be a huge turnaround. Something needs to be done in that field. I think that’s something that would impact the industry positively.
Murphy: Speed of entry.
Graff: Speed of entry. It becomes actionable more quickly. It’s all done in real-time, and you can prevent anything from worsening and all.
Gentzlinger: Just expanding on that, James, when you can collect information about a patient every day and cross-section it to see what that person looks like without the personal identifiers, it helps tremendously. You look at that from a population standpoint of who fits into that bucket, what they look like as they’re declining and what is happening to them in the home setting.
Then, you look at payers of private pay, Medicare, Medicare Advantage, Medicaid, looking at different socioeconomic populations. As we talk about social determinants of health, what are some of the barriers that you can start to anticipate before somebody declines? What can you do with that data to turn things around by predicting decline and change?
Murphy: We talked about what you can do on Monday that’s a little bit different, and I like to think about a report around speed of inquiry to first visit. We see a lot of our agencies measure how long it takes from inquiry to first visit.
It’s like a competition that they have. Clearly, the insight is that the faster you process this, the more money you’ll make and it becomes competitive. Do you have any Monday morning insights about what people can do to challenge their tech vendor for a report?
Gentzlinger: Our tech vendors are technically built into our teams, and there’s a fiscal reward for turnaround times. We have a competitive board between our intake department to who can turn it around and get it into the system. It all goes into our tech platform and they’re held pending. We utilize that time pending to measure the KPIs our intake department is held to.
Murphy: I love it.
Gentzlinger: We push a lot. [laughs]
Murphy: James, what can you tell us on Monday?
Graff: There are a couple of things that help patients stay safe and healthy in the home. One is the aide arriving on time. We run an aide lateness report and look at it on a weekly basis to make sure aides that are consistently late are spoken to. The next level to that is looking into continuity of care reporting. Meaning, we want to know how many times an aide shows up for their scheduled shifts.
The only way you can identify changes in conditions is if the aide is familiar with the patient. Especially now with COVID, you got replacement aides going in and almost cycling through the homes consistently. This results in a loss of some of that data. We want to get back to looking at continuity of care Monday through Friday. That’s it.
Murphy: Another client with the most on-time caregivers score their visits. They use a balanced scorecard of a number of different ADL completion on time. They bring this all together and again, they make it a contest. It’s performance management.
Often, they’ll bring in the scheduler as well because sometimes you’re only as good as where you’re getting scheduled. We’re seeing a lot of reports that put all schedulers on a bell curve and help them understand what is a great scheduling performance. If they are two standard deviations away from the norm, unlike the positive, that’s fantastic. You’re using these data points to spur conversation so they understand.
Gentzlinger: For the caregivers, we do retention bonuses and encourage them to hit certain metrics. It’s a tiered factor, so if you hit five out of five, you’re qualifying for X number of bonuses per quarter. We found it really helps with retention. I haven’t unlocked the key to the recruitment issue as of late. I think where everyone is still in the same boat and struggling with that, but if I can keep the ones I have, I know I’m doing something right.
Graff: She brings up a good point. Rewards for those who are on time, those who are scheduled and those showing up for their scheduled times are very important. They are the most important aspect of your business besides the client.
Murphy: We went from social determinants for the client to employees, but that makes sense because it’s the hardest thing in home care across the world.
Graff: Well, COVID showed us they were the first to not get service. That’s a social determinant right there. They had no access to service in the home, so that’s a prime example for that.
Gentzlinger: I think social determinants of health, when you get into the home care space, apply to both your employees and your patients. A lot of our patients are in the Medicaid space or under Medicaid health plans, and a lot of our home care workers live in the same building. When you talk about healthy food deserts and access to care, there are a lot of synergies between being an employer and being a quality care provider.
It’s tough to try and educate a workforce on social determinants of health while being respectful to the fact that they may be going through it themselves. Social determinants of health always come back to incorporating both lines.
To learn more about how AlayaCare can help your organization ensure operations are consistent across multiple locations with real-time information updates for key stakeholders, visit alayacare.com.
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