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Research shows better outcomes with MD team
Here’s an ad that you won’t see in many newspapers, at least not yet: "Home Care Opportunities for Physicians . . ." But that’s exactly what was said in an ad recently placed by The Visiting Nurse Association (VNA) of Greater Philadelphia.
The large home care agency, which has about 250,000 visits in southeastern Philadelphia, has added a physician and nurse practitioner service to its home care operations.
"When you look at the breadth of our services, we’re typical VNA with everything from prenatal to hospice and all kinds of specialties," says Lynn T. Rinke, RN, MS, executive vice president CEO. "What we missed was the ability to prescribe and diagnose, and you can only do that with doctors and nurse practitioners."
The idea of a home care agency employing a full-time physician in a role other than medical director was so novel that the agency’s managers spent several years overcoming all of the legal and regulatory obstacles.
One hurdle — which was recently eliminated — making it far easier for other home care agencies to hire physicians, was a change in the Stark II regulations that permits home care agencies to employ physicians and pay them an uncapped salary.
"When the Philadelphia VNA set up its physician home care program, it had to abide by the federal regulations that said a home health care agency that employs a physician could not have that physician sign-off on plans of treatment if the physician was paid more than $25,000 a year," Rinke says.
Regulation change necessitates
This regulation forced the VNA to form a parent corporation called Philadelphia Home Care that has two operating entities, the VNA of Philadelphia and HouseCalls. The doctors and nurse practitioners are hired by HouseCalls.
"That way the referrals can go between the VNA and HouseCalls," Rinke says.
Other home care agencies will have a much easier time establishing a physician home visit program because they can simply hire the doctor, Rinke notes. "The main hurdle is that home care people don’t see themselves as being at the top of the food chain; but if you have the doctor, you are at the top of the food chain."
As complicated as it was to establish, why did the VNA want to provide physician home care services?
"Our colleagues don’t understand why this makes so much sense," Rinke says. "From a purely financial perspective, it makes us the primary care provider, and now we have the patients."
For example, when the interim payment system went into effect, many home care agencies, hospitals, and other providers began to merge, form affiliations, and otherwise join forces. In Philadelphia, that meant one large university hospital that used to refer some 400 patients a year to the VNA began instead to refer those patients to the home care agency with which it became affiliated. By owning a physician home care business that can also see patients who may need other home care services, the VNA replaced that 400 patient referral source, Rinke explains.
"In the course of any 12-month period, 95% of those patients will need home care," she says.
This is because the physicians are seeing homebound patients who typically have chronic conditions.
Home care docs save ER costs
"Most of these patients haven’t been seen by a physician for a number of years, and most have accessed emergency rooms when they had some exacerbation of their condition," Rinke says. "Then they go home and there is no follow-up, so it’s an expensive way to treat people."
As an alternative, the HouseCalls physicians and nurse practitioners will visit the patient’s home, sometimes as often as once every four to six weeks. Those visits help to prevent emergency room visits and returns to the hospital, an outcome that the VNA plans to measure as the program evolves. (See story on how HouseCalls program works, p. 31.)
A recent study, conducted by Veterans Affairs (VA) researchers and funded by the VA Health Services Research & Development Program and the VA Cooperative Studies Programs, already shows positive outcomes associated with physician home care services.
The VA has a home-based primary care program that is physician-led, but also consists of nursing, therapy, social work, and dietary services, says Frances Weaver, PhD, deputy director of the health services research and development center at Hines (IL) VA Hospital. She’s also a research associate professor at the Institute for Health Services and Policy Research at Northwestern University in Evanston, IL.
The VA study found that patient satisfaction was higher with the team-managed home care program than with customary care, and patients experienced an improved health-related quality of life. Costs were higher, however, averaging 12% more than the customary care group.
"So what it boiled down to is a cost-quality trade-off," Weaver says. "How much additional dollars are you willing to pay to provide care that results in higher satisfaction of care and improved health-related quality of life and reduced caregiver burden?"
Exploring quality outcomes, saving money
The Visiting Nurse Association of Philadelphia benefits in multiple ways, both financially and from a quality perspective, from being linked to a physician home care service. And while the overall health care cost impact has not yet been assessed, Rinke predicts it will save dollars in the long run because those patients will not enter nursing homes as early as they might have without the service.
Another Medicare change of recent years that has made physician home care visits more lucrative has been the change that has Medicare Part B recognizing nurse practitioners as primary care providers in all regions. Previously, they were recognized only in rural areas.
"Prior to the change in the Balanced Budget Act of 1997, we were looking at how we could afford to have doctors on staff because doctors are expensive," Rinke says. "But with the right mix of doctors and nurse practitioners, you should be able to make it work."
The program’s goals are threefold: to improve patient care outcomes, become financially viable, and achieve replication of the physician home care services model among other home care agencies.
Quality outcomes that will be analyzed and explored include:
• functional status;
• symptom management;
• medication management;
• emergency room visits;
• hospital admissions;
• nursing home admissions;
• inpatient length of stay;
• patient and family satisfaction.
In fact, the service has already resulted in one 15-year nursing home resident being discharged to her daughter’s home, Rinke says. A young woman lost her father to a sudden death when she was a teen-ager; soon after his death, her mother had a stroke and had to be admitted to a nursing home. "This woman vowed to her mother that when she could she’d bring her home," Rinke recalls. "So many years later, this daughter is bringing her mother home; without our services, she could not do this."
The HouseCalls service is building toward financial success, and it already has become successful clinically and with regard to patient satisfaction, Rinke says.
"People love their visiting nurse; multiply that by 10, and that’s how they feel about their nurse practitioner," Rinke explains. "Patients are just so thrilled that we are willing to come to their home and provide them with necessary care."
Although the results of patient satisfaction surveys have not yet been tabulated, the return rate of the actual surveys is about 80%, double what it has been for the traditional home care agency. "And 80% of the surveys we get back have notes from patients who’ve taken time to handwrite a note specifically about their care, naming every practitioner who they have had encounters with and naming office staff who were helpful to them on the phone," Rinke says.