This article is brought to you by the Joint Commission. The article is based on a panel discussion that took place during a live Q&A session with Jason Vanhoose, Associate Director of Business Development for the Home Care Accreditation Services with the Joint Commission; Josie Rhoades, VP of Clinical Operations at Brightstar; and Kate Proctor, Deputy General Counsel for AccentCare. The panel took place at the Home Care Conference in Chicago held on December 9, 2021. The panel has been edited for length and clarity.
Jason Vanhoose: Today, we’re going to be talking about how data, culture, and partnerships are changing the future of home care. My name is Jason Vanhoose from the Home Care Accreditation Services with the Joint Commission. Today, we will be speaking with Josie Rhoades, from BrightStar, and Kate Proctor, from AccentCare.
Vanhoose: A little bit about myself. I’m recently new to the Joint Commission. I’ve been a nurse for 25 years and spent 18 years as a clinical in the emergency room. For the last 10 years, before joining the Joint Commission, I have been a field nurse, a director of operations and a clinical manager with one of the largest home care providers in the country. In my time as a nurse, we have seen so many changes in the industry, not only in a clinical perspective but as well as within home care.
When we look at data, Josie, how has BrightStar adapted to the different data changes recently? How do you see that changing in the future?
Josie Rhoades: I think when you talk about data in home care, one of the things that we always have trouble with is getting accurate data. We are reliant on our staff, our clients, and our patients to give us that information that we can input it. We don’t have the ability to grab claims data on everything. I think one of the focuses is really how do we get accurate data?
On the clinical outcome side, I think we also need to be looking at how we validate our data. We are getting people telling us, I went to the hospital, let’s put that in, that’s our clinical outcomes. At BrightStar, one of the things we just did, and this was not by design, we worked for the company called Avalere and the press release actually came out today, which was a study that validated our clinical outcomes.
They took a cohort similar to ours and looked at cost utilization one year before we were taking care of that client in one year after. We saw massive savings in certain conditions, so go ahead and take a look at that, but that’s one of those things that I think is really important. We have all this great quality, but how do you validate that? Focusing on validating some of that and then I think looking at data in the future is it’s not enough to just pull what are our hospital readmissions? What are ED visits?
It’s some of those things, what does medication adherence look like? What is the time to notify you of a change of condition? What were those interventions on change of condition? At BrightStar, we’re looking at change of condition, some of the outcomes that we’re looking at capturing is, one, was there a change of condition? If there was, what was done about it? Did our nurse that’s provided oversight contact the family, educate the caregiver? Capturing not only what that intervention was, but what was the time of intervention?
Then look at, past that, was there an ED visit? Was there hospitalization? We’re digging deeper into some of these clinical outcomes to just better understand our industry as a whole. If we look at some of those policies, the way I think of it is if I’m looking at changes of condition in a clinical sense for those interventions that were captured, let’s say, before 24 hours, did we have better outcomes? Do I then need to change my policy? We look at our policies to mimic that. We are then standardizing our care on best practice, so that’s another thing I think for data.
We need to get better at collecting the data. We need to standardize our data. We need to validate our data. We need to do a lot with our data.
Kate Proctor: It’s funny because Josie is on the clinical side and I’m obviously a lawyer. I was with Seasons Hospice & Palliative Care for seven years and we were merged with AccentCare late last year. I moved more into the legal department, but I was running quality and doing a lot with compliance. Now, we’re getting to do enterprise risk management, which I love. It’s so interesting but it’s the similar kinds of things, where Josie will take it and actually improve quality, which is what you absolutely want.
I then take that and say, “See? We shouldn’t have been sued for this,” or, “There wasn’t a standard of care that was violated,” or, “If it’s a government investigation. See these are the things that we do to improve our care, to make sure that there’s no fraud, waste or abuse,” and I can take what Josie’s counterpart at our organization does and say, “They’re validating all of this data. I can prove to you that we don’t have any fraud, waste or abuse,” because we have all of these reports. They’re validating and they’re looking at the policies to make things better.
It’s really interesting that everything that the clinical team and the quality teams do with bare data is enormously helpful for me and makes my job very easy, although I’m still necessary. Don’t walk into your lawyer’s offices and be like, “Yes, we don’t need you anymore.” It is enormously helpful. It’s so much easier to go into a meeting with the Department of Justice, for example, and say, “Yes, let me do a whole presentation. Here’s all of the reports that we have to prove to you that that was not whatever the allegation was, wasn’t happening, couldn’t have been happening.”
It’s incredibly useful for us too in the risk management department, the legal departments that we have accurate data that we have any data, frankly, and that we act on it. I think one of the things that home care hasn’t always been great at is actually acting on whatever data they’re collecting. If you have a whole bunch of data, but you’re not doing anything with it that you can find, it’s very easy as a plaintiff’s council or the government to come in and say, “Hey, produce for me all of this data that you have sitting around.”
The government will see it and if you haven’t done anything with it, that’s really problematic. It’s not enough just to be gathering the data. You have to take that next step of acting on whatever it says. It’s not immediate. Change takes a long time, but once you have that data, you can’t sit on it.
Rhoades: Which is interesting when you talk about acting on some of that data. Home care doesn’t have the best practice. We don’t have good research. We don’t have those things. I think the place we really do need to start acting on data is our own internal data. Start sharing or benchmarking it, that’s where we’re going to really see that quality across the industry start enhancing and improving.
Proctor: It’s also like why we do these kinds of conferences, why Josie and I hang out is because it’s helpful to know what your counterparts are doing because there aren’t articles, there aren’t these enormous amounts of data on how you should implement whatever condition it is that you’re trying to resolve. Being able to share, “Hey, this is the data we’re collecting, this is what we’re seeing, are you guys seeing anything similar?” Not being afraid of sharing that. I think maybe it’s not a waste though, but at least in hospice and sometimes in home care, it’s nice where everybody’s striving toward the same thing.
Rhoades: Quality is at the top of that list.
Proctor: Absolutely.
Vanhoose: Right. When talking about data, there’s so much data out there. Old school, when I first started, it was all paper documentation. Now, it’s all computer documentation. When you’re looking at pulling the data from BI to HCAHPS to Star Scores, how difficult is that? How has the change in data from past to present? How has that helped with BrightStar’s care in interpreting the data and what are the constraints that it causes on you?
Rhoades: I think at BrightStar, we are really lucky. We own and manage prior to our EMRs. I have the ability to pull a lot of data from there and make my own reports and things. There are still some very manual things we track. We have over 350 offices, some of them are tracking things still in Excel spreadsheets and things like that. Some of this is a very manual process. I think getting more towards some of that BI is going to be necessary because it does, it takes a lot of resources. It takes a lot of time.
Anybody that works in health care, if it’s something that takes a lot of time, you’re just not going to do it. It gets to that point. One of the things I absolutely love with the Joint Commission is the SAFER Dashboard. I look at it as a franchisee looking at BrightStar as its entirety. I can look at what findings we’ve been hit with, what our top 10 are, and I can look at us versus our competitors.
It is another way I can validate that we are a higher quality because we have less findings than our competitors, but also in a clinical sense, I know where I need to devote resources to, I can look at different things, what educational points I talk about. Every single month we have a director of nursing monthly meeting that we have people get on and we use that data. Here is what we’re finding. Here’s what’s coming down. Here’s what that finding is. It is a way of really understanding not only BrightStar as a whole but then they can use that themselves and it’s a full BI tool. It’s really, really easy to use.
Vanhoose: You did mention the SAFER data, how much time has that saved you guys?
Rhoades: I don’t even know that I could estimate it because, prior to that, we were all keeping it in a massive Excel spreadsheet, of when the surveys were, what the findings were, who the surveyor was, and it really was manually tracking that. Anybody knows who manual tracks it. You have one busy week and you let it fall through. Then at some point, you’re going to have to go through three or four months of data and input all of that because you procrastinated for four months. It saved an immense amount of time.
Vanhoose: Kate, in terms of AccentCare, how do you guys interpret the data? What are some of the challenges that you have had capturing the data? You mentioned in terms of quality and it’s not documented, it wasn’t done and things of that nature. How has that helped you guys?
Proctor: It’s helped us enormously, I think in a couple of different ways. Not just from the risk management perspective but Josie’s talking about their proprietary EMR and I’m so incredibly jealous. Once we’re up and running, then we can oftentimes write our own reports out of that data so we can collect a whole bunch of different things. When I’m looking at from a risk management perspective what does this look like, we have to have our IT team pull reports and create reports in a lot of cases.
That saves me a lot of time and our clinicians can actually do clinical work while the administration is actually looking at and gathering the data, which is enormously helpful because you want your clinicians doing clinical work, executing on the plan. That’s been enormously helpful to us. I think the other way we used it is, as an attorney, I’m very involved in negotiating contracts with partners. For example, we have inpatient units at hospitals all over the country.
It has been enormously helpful to be able to walk into a meeting with hospital executives and say, “We are providing high-quality care. If you let us have a unit in your hospital, this is how we’re going to improve your outcomes, and here’s how I can prove it because at other hospitals, where we have this, we have all of this data on reducing readmissions, mortality rates,” those kinds of things. It’s just enormously helpful to be able to walk in with that spreadsheet or sheet, fact sheet and say, “Do you want to talk to our other hospital executives because they’ve had extraordinarily good experiences?”
Being able to go into a meeting with hospital executives who do have a lot of data and act on a lot of data is incredibly helpful in creating those partnerships and then really long-lasting because then their boards, obviously, want to see how their outcomes are progressing. Quarterly, we have to reproduce those results which hospital but once you have the framework for it, and you know what hospitals are looking for, it’s pretty easy to run and keep track of faster so that if there does become an issue where maybe there’s a care issue, you can respond to it much more quickly and hopefully before the next quarterly meeting.
Rhoades: I also think one of those two is talking to your different partners and referrals and things like that. People will pay for quality.
Proctor: 100%
Josie: If you can prove that quality, you can get better rates.
Proctor: Nursing homes particularly especially when you walk in and say, “Look at how well we can reduce your readmissions,” because that’s also what they’re looking for to get referrals. Being able to show your partners, your referral sources, how you can help them improve their quality has been a really, really helpful tool for us in terms of growing and expanding.
Vanhoose: As a home care nurse, one thing I always said was I had this saying and anybody that knows me and would ask me what that would be is that if you don’t provide quality, there is no quantity.
Proctor: That’s right.
Vanhoose: The quantity will come as long as you provide quality. If we don’t have that quantity, then we don’t have a business. Let’s talk about partnerships. Partnerships are key and they’re essential moving forward. Kate, what kind of partnerships are you looking for? How are you leveraging these partnerships going forward?
Proctor: We’re also looking for partners who have data and will share it with us. You’re only as good as the information that you have. When we’re looking at even a home health partner with your hospice is seeing how their data shows that they’re providing high quality care. At nursing homes, it’s a huge deal because ultimately, you don’t want to be liable for something. We don’t want to be liable if they’re not providing high-quality care. They don’t want to be liable for providing poor care, obviously.
Being able to show them, “Hey, here are outcomes,” because you know any of you who’ve ever talked to a referral source knows that the thing they remember is the bad outcome. That is what they will remember. They won’t remember that family who called and said, “I loved my hospice nurse so much.” That’s lovely, but what they remember is, “That hospice nurse was so horrible and never showed up.” That’s what they remember. That’s what everybody remembers.
Being able to say that was a one-off or there was an explanation, “Do service recovery for that incident.” Also, say, “Look, the vast majority of our outcomes are really good,” if assuming that is true. If it’s not true, fix it.
Vanhoose: Josie, how has that affected BrightStar’s care and where you guys are looking now, and where you are looking in the future in terms of partners?
Rhoades: You can look at it multiple different ways. I think I can look at it as internal since we’re a franchise system. I see our independently owned offices as our partners. How do I work with them? How do I help them give the best clinical quality because that then helps us all at BrightStar as a whole? That leads to better outcomes, better partnerships, better rates. Helps us with standardization so we are acting more like a network rather than each individually owned and operated. I also look at that when we talk about external partners.
The amount of people I talk to today about things has been fabulous to hear their opinions on things and partnering with like-minded people whether it’s in regards to their clinical outcomes, whether it’s in regard to some really cool innovations like Hospital at Home, SNF at Home, and things like that. It really is looking at those partners that have the same vision, have the same passion as well as strive for that high level of quality.
Proctor: We’re working with a hospital that has developed a whole virtual model of care in one particular state, the one that they’re in. Some of my counterparts were like, “I just don’t know if we can really use that.” I’m like, “I’m 100% sure we can. We’re getting a meeting with them because I think it’s cool. I think virtual is where we have got to be going.”
When they can say, “Look, this is the kind of people that we’re partnering with. These are the patients we’re caring for out of our virtual care center, we can say great because we don’t have enough staff basically anywhere.” How can we take that virtual? How can we do internal monitoring in a house without actually having to have a clinician there or without having a nurse but you can send a social worker things like that.
Honestly, being able to have these conversations and jumping off of what you are doing, what you are finding in your area and taking them even if it doesn’t seem like it’s going to apply to your particular sector is enormously helpful.
Rhoades: Then give them information out to health care.
Proctor: 100%.
Rhoades: I think home care is very misunderstood. Some of the things that we do in the home and what can be done. We need to all be better about speaking to that because they’re not aware that you can do hospital at home. You can do certain infusions at home, wound care at home, virtual telemonitoring. There’s some really cool stuff that people aren’t aware of.
Vanhoose: How do you all share that information internally with your franchisees?
Rhoades: We do a ton of newsletters, information, meetings. Within BrightStar, we have coaches that also help support the office and things like that so we have multiple ways that that information gets out. Town halls.
Proctor: We have regional structure so the regional teams meet with the national leadership team and it gets disseminated. Anything gets disseminated that way, including policy changes, things like that. Also, most of our sites use the same basic format for information that they’re providing. SNFs, for example, on the quality of care that they provide, and so that the same basic form. It looks very similar if you’re at a particular nursing home in Miami versus Tampa. It’s going to look very similar so that they know what they’re looking at, they can share it internally themselves as well. That’s been enormously helpful. Standardizing things has just been incredible.
Vanhoose: Or keeps it consistent across the board as well.
Proctor: Yes, exactly.
Rhoades: People know what they’re getting.
Vanhoose: That’s good. Lastly, let’s move on to culture. Culture can mean many things to many different people from corporate culture, what is that definition from your external customers, your internal customers? How are they affected by decisions that are made? In terms of culture, I think we all try to provide the same high-level quality care and consistency across the board. How would you say, Josie, in terms of BrightStar’s culture, how has it changed, especially in the light of pandemics, the way you used to do things, and going forward? How do you continue to retain staff and grow?
Rhoades: There’s five big-ticket items there. I think culture, we are at a point in health care that we need to be focusing more on culture, we need to be focusing on our staff, making sure that they’re happy, making sure that they trust people, I think that’s one of the things. Anytime that you’re on our clinical team at Franchise Support Center, I think it is really big, so that the culture that they trust us, and they can come to us. That culture of safety that they can come and say, “Hey, this happened,” or, “I just realized I wasn’t doing A, B, and C, what do I need to do.”
I think that one of the biggest things is to make sure that people are comfortable coming to us and feel safe coming to us, no matter what that is. I think that stems through a lot of that is if they trust their company, if they trust their clinical team in regards to nurses, which I work with most often. That flows down to they’re happier, you have better retention. That positive energy flows into each individual office that we have, each individual location, so it really is culture starts from the top and it is in every aspect.
Proctor: You also have better quality. Having that non-punitive culture, especially when somebody finds something wrong is super critical because otherwise, you have no idea what’s happening, and you won’t be able to get accurate data and you’ll never know what’s going wrong in order to be able to fix it. People want to do the right thing. I believe, believe that. Being able to give them the reason behind why we have a particular policy for us has been enormously helpful because otherwise, it’s just, “Well, corporate said do this.”
You don’t want that there’s always a reason behind what we’re doing, and it’s usually to improve their lives or the patient’s lives. Being able to explain that and not being punitive when they miss it is, I think, super key to improving culture.
Rhoades: That’s how you continuously improve quality over time as you take even those isolated events and say, “Can this happen?” We’re going to be talking about risk. Could this happen? Could this happen on a bigger scale?
Proctor: Taking action as quickly as possible, regardless of what the potential outcome is. A long time ago, and I think health care has really changed in this manner. When I first started, a lot of times, it was, “Okay, sweep it under the rug, it never happened. As long as they don’t sue us, we’ll be totally fine.” Now, really it’s, “Okay, fix it immediately. If they sue us, we’ll at least be able to fix it.” That’s been super critical for us is not being the people who are so afraid of the risk that you’re not innovative, that you’re not doing the right thing for patients.
Vanhoose: If it’s not documented, it wasn’t done, correct?
Proctor: That’s right. That’s right. Please document.
Vanhoose: I think one of the biggest things was challenging culture. Just something that I’ve seen, in my experience, was when somebody refers to home health, refers a patient to home health, and you’ll hear that it’s the patient population. They don’t want anybody in their home, or how do you overcome that, and how do you, with that culture, do you with your staffing and patient ratio? How do you all plan for that?
Rhoades: I think when you talk about home health and home care, one of the things that I look at in regards, I know COVID came up or pandemic came up with one of your questions, but I think that’s one of the things I’ve seen change with the pandemic is you now have customers that are consumers. They’re looking at that, outcomes from different places. They’re more involved, they’re looking at, “I don’t want to go to the hospital, I want my care in my home. I don’t want to send my loved one to a facility because there’s risk involved.
Most people are happy at home. The majority of people, I think we heard somewhere today 98% or something, want to be in the home. Combine that with our data, combine that with some of the really cool innovative things we’re doing, I think it’s going to show a very different picture of what people and patients think of home care and home health.
Vanhoose: Right, and I think in terms of the PI and the things that the data that you guys are gathering for PI, I think it helps. It’s the overall outcomes, which is helping the quality metrics. One of you mentioned I think, Kate, is the one person that complains, well, guess what that affects your age cap scores. It’s usually that one person that fills it out, and it was mailed out to 300 people. Do you guys have any other things that you want to elaborate on when it comes to data, culture, or partnerships before we conclude?
Rhoades: No, I mean, I think it’s been very clear talking to people today that we need to do better. The people in this room need to do better about outcomes, and how do we look at those, how do we benchmark those, how do we get that information out, so it’s more accurate, more usable, and people can be held to higher standards.
Proctor: Yes, and sharing it both internally and externally.
Rhoades: Externally for transparency.
Proctor: Not being afraid, people that may be competing with you in the same area. Not everybody is a great provider, but there are enough of them that are doing the right things, and to share best practices because we really do need better best practice documentation.
Rhoades: Better data, better research.
Vanhoose: I think we’ve heard some good overall lectures today. Just listen to the brainstorming ideas. I think the one thing that we all can agree on is that we set ourselves apart with a higher standard of quality and patient safety. I think if we align with those goals, that is going to be our best outcome for our patients which, in terms of the corporate world, that’s going to help you overall.
Proctor: Yes, exactly right.
Vanhoose: We have a question from the audience, can you talk about the accreditation survey process? How painful is it for a home care agency when the clients may vary?
Rhoades: I mean, I think I am a huge fan of the Joint Commission. I think the Joint Commission gets a really bad rep. Maybe it’s partially my relationship with him but it is. Again, we talked about punitive people asking our clinical leaders to come to me if there’s something. The Joint Commission is similar, the Joint Commission is out there to do that very same thing, that they’re focused on education and improving quality overall. Yes, surveys or surveys.
In order to be accredited by the Joint Commission, it’s showing that you are of a higher quality standard than somebody that is not. There are going to be things that you do. It’s not that hard.
Proctor: No. I think the other thing is, especially Joint Commission for us, at least when you walk into a hospital and want to have a unit there or partnership there or even get a referral from there, you can say, “Look, you’re accredited by Joint Commission. I’m accredited by the Joint Commission.”
Rhoades: They understand that.
Proctor: It’s a piece of the puzzle, you just have to sort of skip over. Also, I think again, we actually have both the Joint Commission and CHAP. I will say both of them are also really interested in improving their own processes.
Rhoades: The idea of being flexible, there’s unannounced surveys and you’re not always going to be aware, but things like in the pandemic flipping a virtual survey.
Proctor: Or when you’re rolling out a new EMR being like, “Can you just please not come to that week?”
Rhoades: Yes, blackout date. Some of those things that I think people don’t understand some of the flexibility because most people know Joint Commission in a hospital sense, so it is. I laughed about it because the alert would go to every single unit and it would be like the six or seven suits that are walking down the hospital and people scatter. Not the same in home care. It’s a different environment. It’s an environment of learning.
Vanhoose: I know you’ve been in home care and in health care for just a few days and this one question here, when I say how painful, how have you noticed the survey process or the overall stigma? Have you seen that change or a shift?
Rhoades: Yes, because I think more people are focusing on quality. Before, it was seen in this bad light, like, “Oh, we have to do this.” People are choosing to do this. This is something they choose to do to prove that they are that high quality. I think if anybody who lives in Illinois has ever had a survey by the Illinois Department of Public Health, Joint Commission is a breeze.
Proctor: Very true. It is much more collaborative now than it was 10 years ago, very much so, at least with accrediting agencies. Not all states are collaborative.
Rhoades: It is. It’s a very collaborative process and I think that’s little by little starting to change people’s mind about what that survey looks like.
Vanhoose: One more follow-up question to that. You talked about referral sources and hospitals and being the Joint Commission accredited. Now that you guys are certified and accredited, has that overall impacted your referral volume, you think?
Rhoades: I absolutely think so. People know that in health care. People want to work with people who are Joint Commission accredited.
The Joint Commission offers unbiased assessment of quality achievement in patient care and safety. To learn more visit https://www.jointcommission.org/.
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