The National Academies Press: The Future of Home Health Care: Workshop Summary (2015)

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The Future of Home Health Care: Workshop Summary (2015)
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The Future of Home Health Care: Workshop Summary
Victoria Weisfeld and Tracy A. Lustig, Rapporteurs
Forum on Aging, Disability, and Independence
Board on Health Sciences Policy
Division of Behavioral and Social Sciences and Education
Copyright National Academy of Sciences. All rights reserved.

THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001
NOTICE: The workshop that is the subject of this workshop summary was ap-
proved by the Governing Board of the National Research Council, whose members
are drawn from the councils of the National Academy of Sciences, the National
Academy of Engineering, and the Institute of Medicine.
This activity was supported by contracts between the National Academy of Sciences
and the Alliance for Home Health Quality and Innovation, the American Academy
of Home Care Medicine, the American Nurses Association, the American Physical
Therapy Association, Axxess, the Community Health Accreditation Program, Home
Instead Senior Care, the National Alliance for Caregiving, and Unity Point at Home.
The views presented in this publication do not necessarily reflect the views of the
organizations or agencies that provided support for the activity.
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cil). 2015. The future of home health care: Workshop summary. Washington, DC:
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PLANNING COMMITTEE FOR A WORKSHOP ON

THE FUTURE OF HOME HEALTH CARE1
BRUCE LEFF (Co-Chair), Professor of Medicine, Johns Hopkins

University School of Medicine
ELIZABETH MADIGAN (Co-Chair), Associate Professor of Nursing,
Frances Payne Bolton School of Nursing, Case Western Reserve
University
CHRISTINE E. BISHOP, Atran Professor of Labor Economics and
Director of the Ph.D. Program at the Heller School of Social Policy
and Management, Brandeis University
Barbara b. citarella, Founder, RBC Limited
Thomas e. edes, Executive Director, Geriatrics and Extended Care,
U.S. Department of Veterans Affairs
MARGHERITA C. LABSON, Executive Director, Home Care Program,
The Joint Commission
Teresa L. Lee, Executive Director, Alliance for Home Health Quality
and Innovation
ANNE MONTGOMERY, Senior Policy Analyst, Altarum Institute
IOM Staff
Tracy A. Lustig, Forum Director
Y. CRYSTI PARK, Senior Program Assistant
Andrew M. Pope, Director, Board on Health Sciences Policy
1 Institute of Medicine and National Research Council planning committees are solely
responsible for organizing the workshop, identifying topics, and choosing speakers. The re-
sponsibility for the published workshop summary rests with the workshop rapporteurs and
the institution.


IOM-NRC FORUM ON AGING, DISABILITY,

AND INDEPENDENCE1
Alan M. Jette (Co-Chair), Boston University School of Public Health,

Boston, MA
John W. Rowe (Co-Chair), Columbia University, New York, NY
Kelly Buckland, National Council on Independent Living,
Washington, DC
Joe Caldwell, National Council on Aging, Washington, DC
Margaret L. Campbell, National Institute on Disability and
Rehabilitation Research, Washington, DC
Eileen M. Crimmins, University of Southern California, Los Angeles
Peggye Dilworth-Anderson, Gillings School of Global Public
Health, University of North Carolina at Chapel Hill
Steven C. EDELSTEIN, PHI, Bronx, NY
Thomas E. Edes, U.S. Department of Veterans Affairs, Washington, DC
Terry Fulmer, Bouvé College of Health Sciences, Northeastern
University, Boston, MA
Naomi L. Gerber, Center for the Study of Chronic Illness and
Disability, George Mason University, Fairfax, VA
Robert Hornyak, Administration for Community Living,
Washington, DC
Lisa I. Iezzoni, Harvard Medical School, Boston, MA
Judith D. Kasper, Johns Hopkins Bloomberg School of Public
Health, Baltimore, MD
Kathy Krepcio, John J. Heldrich Center for Workforce Development,
Rutgers, The State University of New Jersey, New Brunswick, NJ
Nancy Lundebjerg, American Geriatrics Society, New York, NY
Rhonda Medows, United HealthCare, Washington, DC
Larry Minnix, LeadingAge, Washington, DC
Ari Ne’eman, National Council on Disability, Washington, DC
René Seidel, The SCAN Foundation, Long Beach, CA
Jack W. Smith, U.S. Department of Defense, Falls Church, VA
Richard suzman, National Institute on Aging, Bethesda, MD
1
Institute of Medicine and National Research Council forums do not issue, review, or
approve individual documents. The responsibility for the published summary rests with the
workshop rapporteurs and the institution.
vii

IOM and NRC Staff

Tracy A. Lustig, Forum Director
Gooloo Wunderlich, Senior Program Officer, Division of
Behavioral and Social Sciences and Education, National Research
Council
Y. Crysti Park, Senior Program Assistant
Andrew M. Pope, Director, Board on Health Sciences Policy, Institute
of Medicine
viii

Reviewers
This workshop summary has been reviewed in draft form by individu-

als chosen for their diverse perspectives and technical expertise, in accor-
dance with procedures approved by the National Research Council’s Report
Review Committee. The purpose of this independent review is to provide
candid and critical comments that will assist the institution in making its
published workshop summary as sound as possible and to ensure that the
workshop summary meets institutional standards for objectivity, evidence,
and responsiveness to the study charge. The review comments and draft
manuscript remain confidential to protect the integrity of the process. We
wish to thank the following individuals for their review of this workshop
summary:
AMY BERMAN, The John A. Hartford Foundation

margaret campbell, National Institute on Disability and
Rehabilitation Research
rebecca conant, University of California, San Francisco,
School of Medicine
linda decherrie, Mount Sinai Hospital
warren hebert, HomeCare Association of Louisiana
melissa o’connor, Villanova University
Although the reviewers listed above have provided many constructive

comments and suggestions, they did not see the final draft of the work-
shop summary before its release. The review of this workshop summary
ix

x REVIEWERS
was overseen by RON ACKERMANN, Indiana University. Appointed by

the Institute of Medicine, he was responsible for making certain that an
independent examination of this workshop summary was carried out in ac-
cordance with institutional procedures and that all review comments were
carefully considered. Responsibility for the final content of this workshop
summary rests entirely with the rapporteurs and the institution.

Contents
1 INTRODUCTION 1
Overview, 4
Personal Testimonies, 6
Organization of Workshop Summary, 6
2 HOME HEALTH CARE: TODAY AND TOMORROW 11

Current State of Home Health Care, 11
Home Health Care 2024: The Ideal State, 16
3 TOWARD PERSONAL HEALTH: GOING HOME AND

BEYOND 23
Taking Control—At Home, 23
Lessons from Japan and China, 25
From Mainframe to Personal Health, 27
Pillars of Personal Health, 30
Principles for the Evolution of Health Care, 32
Questions and Comments, 33
4 KEY ISSUES AND TRENDS 35

Trends in Population Health, 35
Trends in Public Policy, 40
Trends in the Real World, 41
xi

xii CONTENTS
5 THE HOME HEALTH CARE WORKFORCE 49

The Value of Team-Based Care, 49
Supporting Families, 56
Direct Care Workers, 57
Care Coordination and the Consumer Voice, 61
6 MODELS OF CARE AND APPROACHES TO PAYMENT 65

Overview of the Range of Models and Approaches to Payment, 65
Experience of Sutter Health, 72
Experience of Atrius Health, 74
Experience of the Visiting Nurse Service of New York, 77
Experience of Humana At Home, 79
Experience of Optum Complex Population Management, 82
Experience of the CAPABLE Model, 84
7 INNOVATIONS IN TECHNOLOGY 91
Evidence Base for Home Health Care Technologies, 91
Role of Telehealth, 95
Use and Development of Assistive Technology, 97
8 MAKING CONNECTIONS 105

Connecting to the Larger Health Care Ecosystem, 105
MediCaring Accountable Care Communities: Connecting Health
Care and Social Services, 109
Connecting the Data, 111
9 REFLECTIONS AND REACTIONS 117

Reflections on Day One, 117
Final Reactors Panel, 121
Final Thoughts from Workshop Participants, 127
REFERENCES 129
APPENDIXES
A WORKSHOP AGENDA 131

B SPEAKER AND MODERATOR BIOGRAPHICAL SKETCHES 137

Introduction1
A 2011 report by the National Research Council (NRC) declared,

“Health care is coming home” (NRC, 2011, p. 9). The report further noted
that although the costs of care are one driver of this change, the delivery of
health care at home is valued by individuals and can promote healthy living
and well-being when it is managed well. Living independently at home is
a priority for many, especially individuals who are aging with or into dis-
ability. However, both the complexity and the intensity of the health care
services provided in home settings are increasing.
Additionally, individuals with disabilities, chronic conditions, and func-
tional impairments need a range of services and supports to keep living
independently. However, there often is not a strong link between medical
care provided in the home and the necessary social services and supports
for independent living. Home health agencies and others are rising to the
challenges of meeting the needs and demands of these populations to stay at
home by exploring alternative models of care and payment approaches, the
best use of their workforces, and technologies that can enhance independent
living. All of these challenges and opportunities lead to the consideration of
how home health care fits into the future health care system overall.
On September 30 and October 1, 2014, the Institute of Medicine
1 The planning committee’s role was limited to planning the workshop, and the workshop
summary has been prepared by the workshop rapporteurs as a factual summary of what
occurred at the workshop. Statements, recommendations, and opinions expressed are those
of the individual presenters and participants and are not necessarily endorsed or verified by
the IOM or the NRC, and they should not be construed as reflecting any group consensus.

2 THE FUTURE OF HOME HEALTH CARE
(IOM) and the NRC convened a public workshop on the future of home
health care. The workshop was supported by a group of sponsors (see
p. ii of this workshop summary) and hosted by the IOM-NRC Forum on
Aging, Disability, and Independence,2 an ongoing neutral venue in which
stakeholders in government, academia, industry, philanthropic organiza-
tions, and consumer groups meet to discuss the intersection of aging and
disability. The workshop itself was planned by an ad hoc committee. (See
Box 1-1 for the committee’s statement of task.) Under the NRC guide-
lines, workshops are designed as convening activities and do not result in
any formal findings, conclusions, or recommendations. Furthermore, the
workshop summary reflects what transpired at the workshop and does not
present any consensus views of either the planning committee or workshop
participants. The purpose of this summary is to capture important points
raised by the individual speakers and workshop participants. A webcast of
the workshop is also available.3
The workshop brought together stakeholders from a spectrum of public
and private organizations and thought leaders for discussions to improve
their understanding of the current and potential future role of home health
care in supporting aging in place and in helping high-risk adults (particu-
larly older adults) with chronic illnesses and disabilities to receive health
care and long-term services and supports (LTSS)4 in their homes and avoid
potentially higher-cost, institution-based care. The workshop planners were
especially interested in evaluating how home health care fits into evolv-
ing models of health care delivery and payment resulting from the Patient
Protection and Affordable Care Act of 20105 and other policies, including
those resulting from potential changes in the Medicare home health care
benefit (which was designed nearly 50 years ago). In addition, the workshop
sought to explore the key policy reforms and investments in workforces,
technologies, and research that will be needed to maximize the value of
home health care and to describe the ways in which research can help
clarify the value of these services.
In this workshop, as in other settings, terms such as home health care,
home health, home health services, home care, home-based care, and other
2 See www.iom.edu/ADIForum (accessed December 5, 2014).

3 See http://www.iom.edu/activities/aging/futurehomehealthcare/2014-sep-30.aspx (accessed
December 24, 2014).
4 “Long-term services and supports” are also referred to as “long-term care,” but the former
term is now preferred as a more accurate and comprehensive description of the kinds of as-
sistance needed by people with disabilities. This workshop summary generally uses the term
LTSS, but it refers to long-term care in contexts in which the term has become standard, such
as long-term care facilities or long-term care insurance.
5 Patient Protection and Affordable Care Act of 2010, Public Law 111-148, 111th Cong.,
2nd sess. (March 23, 2010).

INTRODUCTION 3
BOX 1-1
Statement of Task
An ad hoc committee will plan a 2-day public workshop, bringing together

a spectrum of public and private stakeholders and thought leaders to improve
understanding of (1) the current role of Medicare home health care in supporting
aging in place and in helping high-risk, chronically ill, and disabled Americans
receive health care in their communities; (2) the evolving role of Medicare home
health care in caring for Americans in the future, including how to integrate Medi-
care home health care into new models for the delivery of care and the future
health care marketplace; (3) the key policy reforms and investments in workforces,
technologies, and research needed to leverage the value of home health care to
support older Americans; and (4) research priorities that can help clarify the value
of home health care.
The workshop will feature invited presentations and discussions that will
1. Provide an overview of the current state of home health care, including

the relevance of Medicare-certified home health agencies in supporting
community-based care and healthy aging in place, and an understand-
ing of current barriers to home health care (e.g., budgetary constraints,
definitions, practice-level restrictions, and the absence of meaningful use
incentives);
2. Inform understanding of the evolving role of Medicare home health care
and its role in the future by examining and exploring innovative models for
the delivery of care that involve Medicare-certified home health agencies,
home health care professionals, and other aspects of health care at home
to achieve the triple aim of improving the patient experience of care (in-
cluding quality and satisfaction), improving the health of populations, and
reducing the per capita cost of health care; and
3. Inform understanding of how to facilitate the future role of home health
care in achieving the triple aim by examining and exploring
a. The infrastructure needs for home health care, the health care system

as a whole, and the overall environment;
b. The workforce needs, that is, the supply of professionals that are
educated and trained to deliver home health care;
c. The research and measurement needs for home health care to pro-
vide high-quality and efficient care and to allow healthy aging;
d. The technology needs (including mobile, digital, monitoring, health
information, therapeutic, and diagnostic needs) to enable and support
the health care of patients at home; and
e. The policy reforms (including funding and accountable care consid-
erations) and communications strategies needed to recognize the
value of home health care and the importance of home health care
professionals as part of a comprehensive health care team.

similar terms were often used interchangeably, and with various intended
meanings. In some instances, workshop speakers and participants implied
a more strict interpretation of home health care (and other similar terms)
as including only medical services or in reference to the Medicare home
health care benefit only, whereas other speakers and participants spoke to
home health care as more inclusive of a variety of services and supports
provided in the home. This summary uses the term home health care for
consistency (except in cases of direct quotes), recognizing that each speaker
or participant may have intended a different spectrum of care. Where pos-
sible, the spectrum intended by the speaker is noted. In addition, although
the statement of task (see Box 1-1) called for a focus on the Medicare home
health care benefit, the workshop planners encouraged all speakers to also
consider home health care broadly—that is, more than just medical ser-
vices and more than just the Medicare benefit. As a result, some workshop
speakers focused primarily on Medicare home health care, but many other
topics included under a broader definition of home health care were also
discussed, to varying degrees.
overview
Workshop participants were welcomed by planning committee co-
chairs Bruce Leff, Johns Hopkins University School of Medicine, and Eliza-
beth Madigan, Frances Payne Bolton School of Nursing, Case Western
Reserve University, who began with an overview of home health care across
the spectrum of services and supports (see Figure 1-1).
Moving from left to right, Figure 1-1 shows that this spectrum ranges
from care for lower-acuity levels care to higher acuity, and from chronic
care to more acute care. It also moves from models in which there is little or
no medical doctor (MD) involvement in the home toward models in which
MD involvement is substantial. The figure shows that this spectrum starts
with informal care services provided at home, often by family members—
typically, daughters, spouses, or daughters-in-law, Leff said. Estimates sug-
gest that somewhere between 10 million and 15 million people currently
receive such care in the home.
Next, moving right, is formal personal care services—that is, paid-for
services—for people who need additional help or who do not have family at
home to help them. An estimated 2 million Americans receive these formal
personal care services, Leff said. Next is Medicare skilled home health care,
which is used for post-acute care, as well as for people in the community
who are homebound, according to the definitions of Medicare, and have
skilled home health care needs (which was a focus of the discussion over
the 2 days of the workshop). More than 3 million Medicare recipients
use those services. Farther to the right is home-based primary care, which

INTRODUCTION 5
Informal Formal Medicare Home Hospital

Services Personal Skilled Based- at Home
Care Home Primary
Services Health Care Care
(10 million– (2 million (3.4 million (500,000 (1,000–
15 million people) people) people) 2,000
people) people)
Low acuity High acuity

Chronic care Acute care
Little or no medical doctor (MD) involvement High-level MD involvement
FIGURE 1-1 Home health care across the spectrum of services and supports, in-
cluding numbers of individuals receiving care.
SOURCE: Reprinted with permission from Bruce Leff and Elizabeth Madigan,
2014.
involves physicians, nurse practitioners, or physician assistants providing

longitudinal medical care, which is often team-based care and which is of-
ten provided in collaboration with social services providers to a population
that is essentially homebound. Leff said that an estimated 500,000 people
receive these services, acknowledging that this number “is the most back-of-
the-envelope calculation” of the array. Finally, on the far right of Figure 1-1
are acute-care, hospital-level services provided in the home, including care
provided through hospital-at-home-type models, such as the model devel-
oped by the Johns Hopkins Schools of Medicine and Public Health.6 To
date, many fewer people receive these more intensive home-based services,
although the workshop discussion suggested that the trend is for more and
more people to receive such services.
Leff noted that the move from left to right in Figure 1-1 entails a move
from the provision of health care services to individuals with lower-acuity
levels of need to individuals with higher-acuity ones requiring a mix of
acute and chronic care services and, finally, to the provision of acute care in
the home. It also moves from models with little or no physician or medical
involvement to those in which medical involvement is substantial, Leff said.
The four principal factors driving the development and use of these
spectrum-of-care approaches are policy, payment, technology, and demo-
graphics, Madigan said. Much attention is paid to the last factor, “as we
anticipate the aging of the American population, the projected increase in
the number of people with multiple chronic conditions or functional im-
pairments, and the impact that’s going to have on the health care system,”
6 See http://www.hospitalathome.org (accessed December 24, 2014).

she said. Moreover, that growth is a constant, whereas the other factors—
policy, payment, and technology—are amenable to change.
The current array of chronic care and home-based services is not well
integrated, Madigan argued. Payments and some of the care providers
are in separate silos. “From a patient’s perspective, you can have multiple
agencies providing services, and they don’t know about each other or who
is doing what piece [of the care],” Madigan said. In a true system of home
health care, she said, services would be integrated and those providing
these services would provide care along a continuum that would involve
collaborations with partners in the community as well as those in facility-
based long-term care, because patients often end up there at least for short
periods, before going home again and receiving home health care services.
In other words, across the spectrum of care, from informal services to the
hospital in the home, what is needed is a focus “on what the patient needs
and how we can help provide that in a seamless way,” said Madigan.
personal testimonies
Personal testimony on caring for family members at home was presented
by James Martinez from Oakland, California (see Box 1-2), and Karen
Marshall, Kadamba Tree Foundation, Washington, DC (see Box 1-3).7 Al-
though their experiences with home health care are different, their stories
present two perspectives on some of the strengths and shortcomings of the
current system of provision of health care in the home.
organization of workshop summary

This workshop summary is limited to describing the presentations given
and the general topics discussed during the workshop itself. Overall, each
speaker’s presentation is captured in a section attributed to that individual.
All of the workshop discussions with the audience have also been captured
in a variety of ways. In some cases, the topics raised and the responses given
during the discussion periods are incorporated into the section describing
the speaker’s presentation. In other cases in which a new topic or line of
discussion arose, a separate section describing the new topic is introduced
at the end of the chapter. Comments made by workshop participants were
attributed to the individuals by name when possible. (If identification of
the speaker was not possible, the individual is referred to as a “workshop
7 To watch these testimonies on video, see http://www.iom.edu/Activities/Aging/

FutureHomeHealthCare/2014-SEP-30/Day-1/Session-1-Videos/2-Martinez-Video.aspx (accessed
December 24, 2014) and http://www.iom.edu/Activities/Aging/FutureHomeHealthCare/2014-
SEP-30/Day-2/Overview/32-Marshall-Video.aspx (accessed December 24, 2014).

INTRODUCTION 7
BOX 1-2
James Martinez’s Story
Home health was all new to me in 2011, when my mom was diagnosed with
pancreatic cancer. She did not want to stay at home, because she didn’t have any
health care there. I told her that if they would teach me what to do, I would take
her home and I would take care of her until she passed. And it turned out, it was
way better with home care than with the hospital. I was always at odds with the
staff at the hospital.
So that’s what happened, with the support of the Sutter Home Care people
up through hospice services, and they were there for me also, with the bereave-
ment. They never left my side.
The following year, my dad got sick. I moved out of my house at that point
and moved in with him, because he needed full-time care. I took care of him until
May of this year. I couldn’t have done it without help, giving morphine and all these
other drugs, knowing when to do it, and how to do it. I would call them, and I had
just terrific telesupport. They’d call me back in 15 minutes, and if the drugs hadn’t
worked, they would send out a nurse.
They showed me how to do everything. With my mom, I had to clean and
change and administer the medicines through a PICC (peripherally inserted cen-
tral catheter) line. With my dad, he had a nebulizer. He had air. They explained the
equipment, so there were no questions, really.
Sutter took care of me, too. They came with a social worker and a nurse. The
nurse would take care of my dad and do his vitals and all that and talk with him.
The social worker would come into the kitchen with me, and we would sit and talk
about me: how I can take care of myself, what I needed, because they said if I
couldn’t be healthy, I couldn’t take care of him.
I didn’t have any help from any of my other family members. And I was try-
ing to work and trying to do everything else that needed to be done around the
house. Eventually, I had to quit my job. My dad’s retirement income was too much,
so we weren’t eligible for me to be paid for his home care. If there was one thing
that could change, it would be to give a little bit more financial help to the family.
I’m not the only one who’s done this. There are a lot of people. There’s a
neighbor down the street. His dad passed away, and he took care of him. The two
of us would talk and get a little bit of strength from each other.
SOURCE: Presentation by James Martinez, September 30, 2014.
participant.”) Presentations are also not necessarily organized in the same

order in which they occurred at the actual workshop but have been rear-
ranged to provide a better flow for the readers of this workshop summary.
Chapter 2 presents two keynote addresses (by Robert J. Rosati and
Steven Landers, both of whom are with the Visiting Nurse Association
Health Group) that address the current state of home health care overall

BOX 1-3
Karen Marshall’s Story
Karen Marshall began her presentation by quoting former First Lady

Rosalynn Cartera:
There are only four types of people in this world:

Those who have been caregivers,
Those who are currently caregivers,
Those who will be caregivers, and
Those who will need a caregiver.
I must say, I wake up every morning and think about that quote. For the past
10 years, family caregiving has been a big part of my life. Like Mr. Martinez, I’m
a repeat caregiver. I first cared for my mother, who had cancer. And a couple of
months after she died, my father developed a heart problem. He was in his late
70s at the time and had never had any health problems. I suspect his heart broke,
because along with me he was a caregiver for my mom.
That series of events really changed the trajectory of my life and how I think
about caregiving, even though it has been a part of my life since I was a baby. My
grandfather came to live with us when I was just a baby. His aging process took the
same trajectory as many of the people in the rural neighborhood I grew up in, and
when he was no longer able to stay home, he went to live with his daughter, my
mother, who took care of him while she raised me. And when that was no longer
feasible, he went into a nursing home.
Fast forward 20 years, and when I was in college, my grandmother had a
stroke. My family helped her stay at home as long as possible, and eventually
she moved in with us. While I was home for the summer, my mother and I split
caregiving duties. A home health agency sent an aide to stay with her while we
were at work. I only remember one agency at the time, which served a pretty
broad multicounty area. That experience shaped how my family felt about home
health care for a while, and it wasn’t necessarily a positive experience. It helped
in that we could continue to work, but we were concerned about the skill and the
quality of the care, and from others in the community, we heard stories about
fraud and abuse.
Fast forward another 10 years, when my mother got sick in her early 60s.
She was just 61 when she passed away, and her care at home was private pay.
She did have private insurance. It helped that I could take a leave of absence from
my job to help care for her in the last couple of months. At the time, I was an at-
torney here in DC, right on K Street, in a large firm. That’s when my perception of
home health care began to shift, because the last time she was discharged from
the hospital we knew she was going home to die. It was very comforting for my
family to have the help of hospice. They set up the hospital bed in the bedroom.
The nurse and caseworker really helped me understand what was going on and
recognize the signs of her decline.
A couple of months after her death my father got sick. I did not see that
coming. I was still winding down my mom’s estate. I was returning to work when

INTRODUCTION 9
my father became ill, and it never really crossed our minds what would happen
after he left the hospital. Part of the reason for that is that my big sister is a reg-
istered nurse, and she was able to take him home with her. He stayed with her
several weeks until he went back to his own home, but he’d lost so much of his
independence—a lot of his life. He was a logger, and up until his mid- to late 70s,
he was going out into the woods chopping down trees every day. He’d lost his
health, which he had always had, and his strength, which he had always prided
himself on, and he had lost his spouse.
We did our best for several years to help him stay at home, which was his
wish. In retrospect, it would’ve helped us tremendously to look at the home health
care options. My dad was a little particular about how he wanted to be cared for,
and we didn’t want to disrupt his expectations that much. But it became a burden
to me. It was not uncommon for me to come out of a meeting to a voicemail that
my dad was on his way to the emergency room, a 4-hour drive away. I went home
every weekend for a long time and eventually cut back to several times a month.
It just became too difficult to juggle all these responsibilities, and eventually,
in 2009, I left my job. The financial repercussions of that choice continue to this
day. At the time I was married; I’m not anymore. I don’t regret my decision, but
in retrospect I would have made different choices, especially given all that I now
know—and have witnessed—about the options that home health care provides.
Earlier this year my father was diagnosed with dementia.
This time we are relying on home health care. We have no choice. My sister
has been on medical leave herself and can’t take additional time off. And I am
just not in a position to stop working again. So we ended up relying on a home
health agency to send in aides 24/7, which was not a long-term solution, as it cost
us about $400 a day. We were applying for Medicaid benefits, and he primarily
received his health care from the VA [the U.S. Department of Veterans Affairs],
which was a great help. This financial assistance came through at just the right
time, but still, the expenses were enormous.
I would go down there a few days every week. This was a difficult time for
him, because he was coming to grips with his diagnosis and having me in and
out was not necessarily the most comforting thing, which upset me because I was
used to being of some comfort to him. The home health aides provided continuity.
He got to know and like them. It helped to know I had eyes and ears to not only
look after his medical situation but also his well-being in other ways.
Two social workers from our local Program of All-Inclusive Care for the
Elderly (PACE) came in and did an evaluation, and they had an honest conversa-
tion with us about our options. They explained that it just wasn’t safe for him at
home. We couldn’t guarantee that a health worker would always be around. This
helped us feel better about a tough decision that we had to make. I still struggle
a bit with that. I feel bad that after all of this effort: leaving my job, all the trips up
and down I-95. Ultimately, his wish of being able to stay at home couldn’t come
true. But every time I see him now he looks healthier. His medication is being
managed properly. He’s gained his weight back. He smiles and he’s happy. And
he’s not scared anymore. I really do credit home health care for helping us cross
that bridge.
continued

BOX 1-3 Continued
I would probably add a fifth person to First Lady Rosalynn Carter’s scenario
of caregivers. I would add people who have to work with the caregiver. And that
would include my former boss, who was very sad to see me go. That would include
my coworkers, who had to pick up the slack on the days when I had to head down
I-95 to an emergency room. That would include the health care professionals who
had to tell us about my dad’s diagnosis while he was sitting there in the room.
It would include the social workers who had to break the news to us about how
difficult honoring my dad’s wish would be.
a See the remarks of Rosalynn Carter at http://gos.sbc.edu/c/carter.html (accessed De-
cember 24, 2014).

SOURCE: Presented by Karen Marshall, October 1, 2014.
and changes occurring in the field, as well as an exploration of the future

ideal state of home health care. Chapter 3 presents a keynote address by
Eric Dishman of Intel on the role of home health care in achieving his vision
of personal health. Chapter 4 examines the key issues and trends currently
framing the discussion of home health care, such as trends in population
health and public policy. The next several chapters explore the health care
workforce (Chapter 5), the models of care and approaches to payment
(Chapter 6), and the technology (Chapter 7) needed to reach the ideal
state of home health care. Chapter 8 considers how home health care can
be linked to the broader health care system, to communities, and to larger
data systems. Finally, Chapter 9 provides reflections and reactions to the
2-day workshop from the perspectives of the moderators of the two panels
on workforce and models of care and payment approaches on the first day
of the workshop, from the perspectives of individuals who presented their
reactions to the workshop presentations over both days of the workshop,
and lastly, from the perspectives of the individual workshop participants,
who described their own takeaways from the workshop.

Home Health Care:

Today and Tomorrow
During the workshop, two keynote speakers addressed the state of

home health care to provide a framework for the workshop discussions.
Robert J. Rosati of the Visiting Nurse Association (VNA) Health Group
gave a broad overview of the current state of home health care. Later, after
a panel on some of the key issues and trends affecting home health care
planning (see Chapter 4), Steven Landers, also of VNA Health Group, gave
his vision for the ideal state of home health care 10 years from now.
Current State of Home Health Care

Robert J. Rosati
Visiting Nurse Association Health Group
Rosati summarized the current state of home health care, with a focus
on Medicare home health care, and the changes occurring in the field to
provide context for discussions about the challenges and opportunities of
home health care in the future.
The Medicare Population

Population trends are driving the shape and scope of home health
care services. Most people enrolled in Medicare today have three or more
chronic conditions (65 percent), half live below the poverty line, nearly
one-third (31 percent) have a cognitive or mental impairment, and about
5 percent live in long-term care facilities (Kaiser Family Foundation, 2014).
11

In addition, although the tendency is to lump the Medicare population into

one group, about 16 percent of Medicare enrollees are individuals with
disabilities younger than the age of 65 years and 13 percent are aged 85
years and older. In addition to these challenges, Medicare beneficiaries are
often in fair or poor health, according to self-ratings, and have two or more
problems with activities of daily living (ADLs).1
Rosati illustrated the growth in the size of this population by compar-
ing the numbers of Americans age 65 years and older in 2002 (35.5 mil-
lion) and 2012 (43.1 million). Estimates for 2040 are that some 80 million
Americans will be age 65 years and older, and about 29 million of those
individuals will have some degree of disability. Meanwhile, the number of
Americans ages 85 years and older is projected to grow from 5.9 million
today to about 14.1 million in 2040, he said.
The number of agencies providing home health care in the United States
grew from 8,314 in 2005 to 12,613 in 2013, Rosati said, with Medicare
expenditures for home health care services nearly doubling from 9.7 billion
in 2001 to about $18.3 billion in 2012. Nevertheless, home health care
constitutes only about 3 percent of Medicare benefits payments.
The Medicare Home Health Care Program

People who are recognized as needing home health care are those who
have had a recent hospitalization or those who have received a physician
referral. Rosati offered several key points about eligibility for the Medicare
home health services:
• The recipient must be under the care of a physician who has estab-
lished a plan of care for the patient (a requirement over which the
home health agency does not have control);
• The care plan must include the need for nursing care or physical,
speech, or occupational therapy;
• The recipient must obtain care through a Medicare-certified home
health agency; and
• The recipient must be homebound and unable to leave the home
unaided without the possibility of risk.
Two major assumptions underlie these eligibility criteria, Rosati said: that
the physician drives the care and that the patient has certain needs (from a
clinical perspective and because he or she is homebound).
Further, Rosati added, if a beneficiary needs skilled nursing care, that
1 ADLs are the routine tasks of everyday life, such as eating, bathing, dressing, using the
toilet, transferring (e.g., from a bed to a chair), and walking across a room.

HOME HEALTH CARE: TODAY AND TOMORROW 13
care must be needed only intermittently or part-time and must be provided

by a registered nurse (RN) or a licensed practice nurse supervised by an
RN. Home health aide services must supplement the care provided by pro-
fessionals. Additional services that may be provided include medical social
services and medical supplies. Said Rosati, “What’s important to look at
is what’s not covered.” Services that are not covered include 24-hour care,
meals, homemaker services, and personal care not associated with therapy
or nursing. In some states, however, Medicaid does cover these services for
low-income residents.
Medicare beneficiaries receive skilled care in the home on an episodic
basis. The skilled care is certified for a certain period of time—typically, 60
days—and skilled care can be renewed if the beneficiary needs such care for
a longer period, Rosati said. In contrast, Rosati, said, commercial insurers
typically authorize a certain number of visits (5 or 10, for example).
Unskilled services help people safely stay in their own home for the
longest period of time, and although these services are not covered by Medi-
care’s home health care program, they may be covered in other ways or
paid for out-of-pocket. A notable model of comprehensive noninstitutional
care is the Program of All-Inclusive Care for the Elderly (PACE), a program
jointly funded by Medicare and Medicaid that provides an integrated set of
services at a PACE center in the community, with some home health care
support, for nursing home-eligible recipients.2
Quality Measures
National home health care quality measures compiled for the Centers
for Medicare & Medicaid Services’ Home Health Compare website suggest
that home health agencies provide high-quality services according to key
process measures, Rosati said, with home health agencies providing:
• Checks for depression and the risk of falls 98 percent of the time,
• Instructions to family members 93 percent of the time, and
• Timely initiation of patient care 92 percent of the time.
The average performance is somewhat lower for health outcome mea-

sures, which, in part, reflects the debility of people who need home health
care, Rosati said. For example, some performance measures indicate:
• Postsurgical wound improvement or healing 89 percent of the time,

• Reduction of pain when moving around 68 percent of the time,
2 See http://www.npaonline.org/website/article.asp?id=12&title=Who,_What_and_Where_
Is_PACE (accessed December 24, 2014).

• Improvement in walking or moving around 62 percent of the time,

and
• Readmission to the hospital within 60 days 16 percent of the time.
Rosati noted that the home health care field, on average, is achieving
the same readmission rates as hospitals, although, he noted, the hospital
readmission rate is calculated only on the basis of hospital readmission in
the first 30 days after the patient is released and, therefore, is somewhat
easier to achieve.
Finally, how do beneficiaries themselves rate the home health care ser-
vices that they have received? Again, using national averages from Home
Health Compare, Rosati reported that
• Seventy-nine percent of patients say that they would definitely

recommend their home health care agency to friends and family
(whereas 71 percent would recommend their hospital);
• Eighty-four percent gave the overall care that they received from
the home health care agency a rating of 9 or 10 on a 10-point scale;
• Eighty-four percent reported that the home health care team dis-
cussed medicine, pain, and home safety with them; and
• Eighty-five percent said that the home health care team communi-
cated well.
Reimbursement
In recent years, the federal government has cut Medicare reimburse-
ment for home health care services, and in the near future, another $25
billion “will be taken out of the home health care system,” Rosati said.
Another source of cuts has resulted from states’ moves to managed long-
term care for Medicaid recipients, which has curtailed the number of hours
of patient care provided in the home. Additional reductions in commercial
payers’ reimbursements, as well as in Medicare Advantage, Medicare’s
managed care program, have occurred.
Further financial challenges result from the high level of scrutiny and
auditing to which home health agencies are subjected, which have resulted
in part from fraud and abuse in the system. Good organizations, Rosati
said, “are kind of trapped with respect to what’s being said about other
organizations.”
Emerging Innovations
Home health care providers are involved with a number of emerging
models that organize and pay for care differently. Among them are inno-

vations that were established under the Patient Protection and Affordable
Care Act of 2010 (ACA),3 such as accountable care organizations (ACOs)
and bundled payment arrangements. Specifically, Rosati said,
• Home health care organizations are finding opportunities to work

directly with ACOs to deliver community-based care.
• Home health care organizations are involved with the provision of
post-acute care services that involve the use of both home health
care and skilled nursing to provide the right level of care after
hospitalization.
• Increasingly, home health care organizations are involved with
transitional care, in which their first visit to the patient is in the
hospital and then they make perhaps one visit after the patient is
discharged.
• Home health care organizations’ patient assessment skills and ex-
perience working in the home are being tapped for evaluations of
high-risk enrollees in health plans.
The challenge is to cover the cost of these service expansions, Rosati

said. The infrastructure of home health agencies has been built around
Medicare, and these new arrangements require agencies to operate differ-
ently. Everything from software systems to care delivery models need to
be redesigned, and mind sets need to be adjusted, he said. Furthermore,
competition in these emerging arenas is significant: “Everybody wants to
be in this space right now,” Rosati said. Coordination among the various
entities providing transitional care—the hospital, the insurance company,
and others—is not easily achieved, however.
For some time, even though home health care has tended to use elec-
tronic records for both the collection of clinical information and assess-
ment, meaningful use provisions under the ACA do not apply to long-term
care. Home health care also has not benefited from the exchange of clinical
data with other providers, nor do home health agencies have the patient
portals that hospitals are required to provide their patients. Larger home
health agencies are paying close attention to reporting and analysis of
quality outcomes, but smaller ones have trouble paying for data analysis
expertise and electronic records systems.
Finally, telehealth applications (e.g., video, remote monitoring, auto-
mated calls) have been found to be effective and cost-effective by some
organizations. However, no additional reimbursement is provided for the
development and use of telehealth, a deficiency that is curtailing movement
3 Patient
Protection and Affordable Care Act of 2010, Public Law 111-148, 111th Cong.,

in this area, Rosati said. Expansion of telehealth may first need to occur
with younger populations or those more comfortable with this technology,
he suggested, reserving nurse visits for those who are not as comfortable
with its use. Howeverm telehealth can be low-tech, involving no more than
regular calls to the family.
In summary, Rosati stated,
• The demand for community-based care will grow substantially;

• Patients and families prefer care at home;
• The home is the least costly setting for post-acute, long-term care;
and
• Home health agencies have the experience, knowledge, and infra-
structure needed to support emerging models of the delivery of
health care.
Home Health CARE 2024: The Ideal State

Steven Landers
Visiting Nurse Association Health Group
VNA Health Group, which Steven Landers leads, is a large nonprofit

home health care, hospice, and community health care organization started
more than 100 years ago by Geraldine Thompson with the support of her
lifelong friend, Eleanor Roosevelt. Predicting the future of home health care
is a risky endeavor, but “for this workshop, let’s assume the future state is
up to us,” Landers said, emphasizing the importance of the task.
Advantages of Home-Based Care

Home health care offers some basic, commonsense advantages within
the continuum of health care that are as real today as when Lillian Wald
and her colleagues ventured into the squalor of New York’s Lower East
Side at the end of the 19th century, Landers said. These advantages include
• An enhanced view of patients and caregivers that leads to a better

understanding of important issues, like how they manage medica-
tions and nutrition;
• Access to health care that is most relevant to patients with physical
and socioeconomic barriers to care;
• A more intimate clinician–patient relationship “around the kitchen
table,” as Barbara A. McCann of Interim HealthCare said in the
workshop (see Chapter 4);

• Clinician expression of an act of humility that demonstrates that

clinicians have left their comfort zone to be on their patients’ turf
and that the patient and family are worth being truly known and
visited;
• Lower costs for services that are desired more by many patients;
and
• Sometimes, greater safety for frail elders, because they will have
fewer of the common complications of hospitalization, such as
delirium.
Because of these advantages, the home and community will emerge in

the future as the main settings for a myriad of health care services, he said,
adding that “the home setting and health services and supports will become
so synonymous that they may not be called home care; rather, they will just
be modern health care.”
Home-centered care is centered on the patient, offering holistic, so-
phisticated, and individualized care at home for people with serious and
disabling conditions. Landers believes that home-centered care will grow
into a major national strategy for the provision of health care because its
benefits for both payers and patients are so powerful. Nevertheless, differ-
ent areas of the country will accomplish this differently and along different
timelines, he said, and the purchasers and organizers of care may vary from
one place to another.
Meeting the Care Mission

Landers said that within the context of Medicare, the mission of home
health care is to
• Help beneficiaries, especially patients with lower levels of mobility,

safely transition to home from hospitals and facilities and continue
their recovery and rehabilitation at home, and
• Help the highest-risk chronically ill beneficiaries age in place in
home and community settings both by meeting certain primary
medical care needs and by intermittently escalating the care pro-
vided at home to avoid the need for hospitalization. Aging in place
in the home includes efforts to help beneficiaries remain comfort-
able at home in the last 6 to 12 months of life.
Emerging trends in the health care system will accelerate strategies

to provide post-acute care in the home, he said. Electronic information
exchange among providers and other technologies will improve the patient
and family experience and ensure the use of home health care services at

the appropriate intensity. In addition, transitional care models that include

posthospitalization home health care visits will become commonplace for
many more people than are now eligible for them.
For high-risk chronically ill people, organizations like Independence at
Home4 practices, patient-centered medical homes, and models of care for
advanced illness will partner with home health agencies and community
resources to reduce the amount of time patients spend in hospitals and nurs-
ing homes, improve key indicators of well-being for patients and caregivers,
use technology to improve the home health care experience, and greatly
increase the proportion of the oldest old who die at home with hospice care.
Ingredients for Progress

Four main ingredients will be needed to effect this evolution and can
be put in place by all varieties of payers and organizations:
• Development and oversight of interdisciplinary home health care

plans by physicians and advanced practice nurses informed by
proven concepts of holistic geriatric medicine, palliative medicine,
and rehabilitation medicine;
• Enhanced support during care transitions that addresses self-
management, care coordination, information transfer, and clinical
stabilization;
• An advanced capability for escalating the intensity of medical and
palliative care at home in times of decline or exacerbation of a pa-
tient’s illness or medical condition (including escalation to hospital-
like services at home); and
• The thoughtful use of advanced information technology between
encounters to aid with the management of problems that arise
between visits and to improve triage and the overall efficiency of
care.
According to Landers, the single most important issue determining

whether the potential of home-centered care is realized and the pace at
which it will be realized is the strength of the nation’s Medicare-certified
home health agencies. These organizations exist in virtually every com-
munity; employ hundreds of thousands of staff who are nurses, therapists,
other clinicians, and aides; make more than 100 million home visits per
year; and collectively, have many strong community ties. “I view many
of these agencies as local and national treasures that should be improved,
4 See http://www.iahnow.com (accessed December 24, 2014).

not torn down,” he said. He noted, however, problems with the current
licensure and accreditation framework and the imperfect payment model.
A set of policies that would support the home health care infrastructure
and help it play the role that Landers envisions would
• Tie payments to outcomes and experience and facilitate provider

participation in a diverse range of alternative payment models;
• Enable the hiring of medical directors (who would, for exam-
ple, link home health care to the services offered by other key
providers);
• Have interdisciplinary team case reviews, similar to the approach
used by hospices;
• Make the interventions used during the transition of care a cov-
ered home health care service, irrespective of whether a patient is
homebound;
• Facilitate technology upgrades to improve the flow of information
among providers and between home health agencies and the pa-
tients and families served; and
• Develop training and careers for agency staff in state-of-the-art
geriatric, palliative, and rehabilitation medicine, as well as in strat-
egies for the coordination of care.
This central role would be further aided, he said, “by making major
fraud and abuse concerns a thing of the past.” In the future, home health
agencies should be accredited not just at the time of licensure but on an
ongoing basis. Selected utilization metrics should be publicly reported.
Value-based purchasing and oversight models should reduce variability
across agencies, and efforts should be made to weed out less capable enti-
ties. If this were done, even the Medicare-certified home health agency of
2024 with the lowest level of performance would be “a serious and skilled
clinical organization with the talent, culture, and technology [required] to
be a core part of helping physicians and advanced practice nurses address
Medicare cost and quality challenges.”
The best models and approaches and the resources and policies needed
for success will be identified over time, and Landers offered the following
advice for going forward:
As we explore these different models, let’s try to minimize the importance
of the names and labels; where there are common home-centered themes
and resources that can help, we should elevate those ideas irrespective of
the packaging. We should avoid the temptation of trying to pick winners
and losers between marginally different concepts whose success is more
dependent on local execution. Instead, let’s focus on how we can ensure

that all of these well-intended and reasonably conceived efforts at advanc-

ing home-centered care are as successful as possible.
In conclusion, he said, “a bright home-centered health system is clearly and

tangibly before us if we continue to nurture the seeds of change that are
starting to grow, while taking steps to optimize rather than diminish our
home health agencies.”
Questions and Comments

An open discussion followed Landers’s presentation. Workshop partici-
pants were able to give comments and ask questions. The following section
summarizes the discussion session.
Bruce Leff, Johns Hopkins University, asked Landers about the de-
creasing emphasis on medical services and the creation of stronger links to
social services. Landers indicated that he recognizes the importance of both
medical and social supports but stated that Medicare is essentially a medical
services program and not a long-term care system and that he would not
advocate for it to become one. He also said that medical providers should
take a biopsychosocial approach to the provision of their medical care and
should make efforts to assess and coordinate social supports in high-risk
situations. Furthermore, Landers said, if people are going to age in place
at home with long-term services and supports, they will need both primary
medical services and other types of supporting services, only some of which
are covered under current Medicare rules.
In response to a question from a workshop participant on the role of
the individual, Landers said that care starts with medical care based on
evidence-based geriatric medicine, palliative medicine, and rehabilitation
medicine, all of which take a patient-centered approach using a com-
prehensive biopsychosocial assessment and a multifaceted model for the
planning of care. At the same time, he said, some of the population groups
that would benefit the most from home health care are quite dependent,
as a result of impairment in cognitive function and an inability to perform
activities of daily living. Landers explained that in these situations health
policy makers should still develop programs that respect the individual but
should be vigilant that some individuals are so impaired that the risk of
neglect and suffering without aggressive intervention is high.
Penny Feldman, Visiting Nurse Service of New York, asked Landers to
indicate the one or two most important actions that home health agencies
can take if they want to survive in the current environment. She also wanted
to know in what ways organizations representing home health agencies can
help them prepare to be vibrant agencies in the future. Landers said that
home health agencies need to embrace the role of value creation. Home

health agency staff sometimes say, “these hospitals don’t know what they’re
doing. They send these patients home that are so sick. They have all these
needs. They’re complicated. What were they thinking?” Actually, Landers
said, these are exactly the situations in which home health agencies have the
most opportunity to create value. Their value cannot be established on the
basis of the provision of marginal services but can be established on the ba-
sis of the provision of services that produce health and cost outcomes that
are different from those that they would otherwise be without home health
care. A second benefit of acquiring an attitude of value, he said, would be
to eliminate efforts to manipulate the system, for example, making an extra
visit to obtain additional reimbursement. This speaks to the parallel need
for a culture of accountability in places where it does not exist today.
Feldman further asked if anything in the existing Medicare home health
care benefit could help home health agencies have greater flexibility and
even with their survival. At the national level, Landers said, the develop-
ment of a common vision for where home health agencies need to be in
the future would enable stronger advocacy for some of the policy issues.
Because health care is so different from one locale to another, the vision
needs to focus on broad themes and resources. In sum, he said, “What are
the carrots and sticks that can get us closer to value rather than waste?”


Toward Personal Health:

Going Home and Beyond
Eric Dishman
Intel
Dishman described his long association with the problems of the provi-
sion of health care in the patient’s home and home-based primary care and
the ways in which Silicon Valley–style technologies can help from his per-
spective as general manager of Intel’s Health Strategy & Solutions Group.
Despite the accomplishments with which others credit him, Dishman began
by talking about what he termed his failures. “I’ve spent 30 years trying to
take health care home and have mostly failed at doing so, because it hasn’t
scaled yet.” These capabilities—from care models to payment models and
technologies—have not become widely available to enough people.
Taking Control—At Home

Misdiagnosed with a rare form of kidney cancer at age 19 years,
Dishman spent the next 23 years being told he would die within 1 year
(until a correct diagnosis and a subsequent successful kidney transplant
in 2012) and sitting in cancer clinics and dialysis clinics with people who
were mostly in their 70s and 80s. As a result, he developed an interest in
aging. He had the youthful “tenacity and ferocity” to try to “change the
barriers that were making the experience of illness worse than it needed
to be.” Professionally, he began on this path studying nursing homes and
two decades ago attempted a telehealth start-up for chronic care. Now he
is involved in research and development at the corporate level, running a
global health and life sciences business.
Three years before his cancer was diagnosed, Dishman became per-
sonally familiar with the panic that family caregivers feel when his grand-
23

mother, who had been diagnosed with Alzheimer’s disease, nearly burned
his grandparents’ house down. He used his early-days computer to try to
create an alert system (“an intelligent sensor network with remote connec-
tivity”) that would trigger when his grandmother went into the kitchen and
turned on the oven in the middle of the night. Although this early experi-
ment in the development of a technology to help seniors live independently
actually failed, he said, “That was the hook. I took the bait at that moment
and have never let it go.” There have to be ways to change care models
and use technologies to help with the exact problems that Karen Marshall
mentioned (see Chapter 1, Box 1-3), he said, “and that I was experiencing
back then.”
His first experience with chemotherapy taught him more about assert-
ing “consumer control.” He was given a dose that was too high, and it was
physically devastating. Thereafter, in 21 more rounds, he insisted that the
chemotherapy be low dose, given over long periods of time, and delivered
at home as much as possible.
One difficulty that Dishman has encountered is that neither paper
records nor the emerging electronic health records of today include a field
for patient goals. He taught his providers to use the file nickname field to
insert a few words about the goals he wanted his care organized around:
snow and exercise. This was to remind them that when they developed his
evolving treatment plan, they were not to aim for longevity but for preserv-
ing his opportunities to ski and get exercise.
Dishman was adamant about maintaining control because over the
long course of his illness he nearly died three times, each time because of
system-related problems and not the cancer per se. First was the “too-much-
at-once” initial chemotherapy, second was a hospital-borne infection, and
third was overmedication from a care team whose members “weren’t keep-
ing track of each other.” It took determination to get care provided in the
way in which he wanted. As recently as 8 years ago he was told, “We can
only do home care for people age 65 and above. That’s all we’re set up for.”
The next-to-last round of chemotherapy took place at home, by self-
infusion, and cost one-tenth of what a center-based procedure would have,
Dishman said. He learned to operate remote patient-monitoring technolo-
gies. Yet, he says the system—from the hospital to the oncologist to the
payers—fought him every step of the way. He told them, “You have the
studies now, thanks to the [Institute of Medicine] and others, that show
hospitals are dangerous places. I’m incredibly immune compromised, and
you’re insisting I continue to make the pilgrimage to the medical mainframe
to do this?”
These two seeds—independent living technologies for seniors and
patient-centered goals, both of which are focused on doing as much care
as possible at home for as long as possible—have grown and intertwined.

TOWARD PERSONAL HEALTH 25
Lessons from Japan and China

In Asia, where Dishman has recently been working intensively, the need
to invent home-based care models is a necessity because of the demograph-
ics of the population and other challenges. For example, Intel is helping
Japanese communities that were devastated by the Fukushima earthquake
and tsunami recover. Their former centralized health care services and
clinical records system was destroyed. As they rebuild, Dishman said, they
are working toward a home- and community-based care model that is not
centralizing its capacity, technologies, and documentation.
In China, the scale of the population and the concomitant challenges
can be hard to imagine. By 2020 or 2025, China will spend more than the
United States on health care, Dishman said, even though they are spending
far less per capita than the United States. One of the challenges in dealing
with the aging population in China is the one-child family. “They now have
an average couple trying to take care of four, sometimes eight people, if the
great grandparents are alive.” Despite a centuries-long cultural tradition of
filial piety and ancestor worship, the Chinese government in 2013 joined
some other countries in adopting a law saying that people had to take care
of their aging parents’ financial and spiritual needs.
China’s growing elderly population, combined with its extreme eco-
nomic challenges, “is driving some really innovative things,” Dishman said.
For about a decade, Intel staff have been thinking about old-age-friendly
cities and the technology infrastructure that would enable such cities. A
policy challenge that the Chinese face, as do many countries, is the separa-
tion of the medical care and social care sectors. The sectors need to combine
their resources with private family funds to enable a team to decide in a
comprehensive, flexible way what an individual or family needs most. This
is in contrast to payment systems that require funds to be used in specific
ways.
Analysis of the numbers of doctors and nurses in China, especially ones
trained in geriatric care, stacked up against the growing need indicates such
a sizable gap that it is clear that the country cannot rely on a physician- and
nurse-driven model. “Most of these people will never even come close to a
physician or nurse in their lifetimes,” Dishman said. The country will need
to adopt a community health worker–driven model that can also enlist fam-
ily members and neighbors “in some pretty intensive ways.” China’s second
big challenge is how to finance long-term care services and supports, he
said. They do not have any program akin to Social Security, for example.
Intel brought in experts from around the world to demonstrate dif-
ferent community-based care models, focusing on the quality of the result
and not the payment model or technologies employed. That exercise built
Dishman’s appreciation for the U.S. Department of Veterans Affairs home-

based primary care program and convinced him that “the future of care is
team based, collaborative, holistic, and in the community.” According to
Dishman, China is now trying to develop a strategy focused on creating a
community care workforce, infrastructure, and business model. In truth,
such a model can serve people of all ages, so the argument for it can be
based on universal design principles, he said. The model that the Chinese
are trying to build is a “care-flow services network” that will allow many
different agencies and companies—government service providers, benefit
providers, medical service providers, or family—to use a common infra-
structure to deliver care in the community and, at the same time, allow
substantial innovation in the applications used and services provided. They
are trying to go to scale—especially to economic scale—with such a model.
The Chinese are already building smart platforms based on activities
of everyday life—railway use, communications, shopping, and phones and
other devices—and want to build platforms to provide services of daily liv-
ing, like housing, laundry, and food, plus health management and medical
services, Dishman said. They are not thinking about health care in isola-
tion, as often happens in the United States, assuming that “everything else”
is somehow taken care of. They have in mind a whole social engagement
platform that includes the services needed for safe and secure living. The
desire for such a comprehensive and integrated service system has emerged
in Intel’s ethnographic work in the 92 nations where it has studied the
aging experience, he said, and in conversations with seniors, their family
members, and health care professionals.
In the beginning, the Chinese envisioned a system that would be opera-
tionalized at the street level. It was difficult for the people at Intel to envi-
sion a viable entity and infrastructure at that level of the social hierarchy,
but they went along with the idea for a while, finally asking, “How many
older people do you have on this particular street?” When the answer came
back 893,000, “street-level” organization began to make a lot of sense.
Dishman, using U.S. marketing terms, said that in urban areas, the Chinese
hope to “build a branded sense of identity” among all the people who live
on a particular street.
In villages, in contrast, one infrastructure would serve the entire popu-
lation. Indeed, part of the challenge for the Chinese in designing this
comprehensive service system is dealing with the scale differences from
small rural settings to medium-sized towns to the existing large cities.
One approach is to start over. Some 20 new megacities that will have this
old-age-friendly city infrastructure in place are being built from scratch.
The national government’s current 5-year plan includes starting these old-
age-friendly cities initiatives, and by 2020, the Chinese hope to provide 90
percent of care for older people in their homes.
Both in Japan—where a tsunami erased the existing system—and in

China—where there is little installed infrastructure—planners are not bur-

dened by past care models and can think about service delivery anew, along
with the business model that will support it, and, finally, the technology
needed to make the new models a reality. In contrast, the historic need to
defend existing industries that do not want to disappear and that may be
reluctant to transform is entrenched in the United States.
From Mainframe to Personal Health

In the United States, what business processes and innovation tech-
niques can change the model of care?, Dishman asked. “For a long time,
I’ve been calling this a shift from mainframe to personal health,” Dishman
said. Many workshop participants described the impetus for such a shift:
the demographic imperative. By 2017, Dishman said, “we will have more
people on the planet who are over the age of 65 than under age 5 for the
first time in human history.” Aging populations and rising health care costs
are phenomena worldwide. Many countries are “dealing with the triple aim
[improving the quality of patient care, improving population health, and
reducing the overall cost of care],” he said, even if they do not call it that.
They worry about preventing the same costly chronic conditions that they
see today in the cohorts that follow. They see the need for elder services
outstripping the workforce, producing health care worker shortages and
creating immigration challenges around the world.
What they desire is to “shift left,” that is, to get more people on the end
of the health continuum with lower levels of chronic disease, lower levels of
functional impairment, lower costs of health care, and a higher quality of
life (see Figure 3-1). Even for people with health problems, care can often
be moved left in the diagram in Figure 3-1, he believes, from acute and
residential care to home health care.
Innovations in policy or technology may help accomplish the move to
the left in the diagram in Figure 3-1. The migration of technologies that
help that happen is already occurring, Dishman said, especially in other
parts of the world. He suggested that this migration of technologies raises
significant questions for the United States, including the following:
• What are the safety and security implications?

• What does this migration mean from a regulatory perspective?
• How can skills be shifted so that people can start performing tasks
considered to be the purview of the people on the right of the dia-
gram in Figure 3-1, because there will not be enough capacity on
the right?
• How is time shifted to the left in the diagram in Figure 3-1 so that
preventive care and fundamental primary care can be done to pre-

vent those bad events that force people to the right of the diagram
from ever happening?
Dishman noted that when his Intel team proposes any research or prod-
uct development or policy work, it is held against this model and assessed
for whether it will move care toward the left of the diagram in Figure 3-1
or help keep it on the left. It is not that hospitals and other institutions will
disappear, he said, but they will be smaller, and capacity will exist elsewhere
in the community. Capacity will be distributed to the home, the workplace,
and elsewhere.
The Intel workforce was a test population for this concept, which was
tested in three phases. At first, the effort was to encourage employees to
sign up for consumer-directed health plans and to start to think differently
about their relationship with their health plans. The second phase was the
establishment on the Intel campus of Health for Life centers that included
primary care and provided employees with risk assessment and follow-up
coaching, as desired. Now, the company requires its providers to deliver
home-based health care as the default model, to use telehealth and mobile
technologies, and to track quality goals for individual employees and the
workforce as a whole, which are the basis for payment.
Dishman acknowledged that Intel is learning as it goes along and is still
“struggling to figure out this distributed capacity.” However, the workplace
is a key node of care now and will become larger. He noted that this ap-
Intel Strategy for Innovation: Place-shift, Skill-shift,
proach flies in the face of some 230 years of hospital history, which says
Time-Shift from Mainframe to Personal Health
Timing & Expertise of Intervention
Home Care
Independent
Community Clinic
Healthy Living
Chronic Disease
Management
Residential Care
Quality Assisted Living
of Life Skilled Nursing Acute Care
Facility
Specialty Clinic
Community
Hospital
ICU
Cost of Care
FIGURE 3-1 Intel strategy for innovation: shifts in place, skills, and time from the
mainframe model to the personal health model.
Intel Health & Life Sciences Where Information and Care Meet 25
NOTE: ICU = intensive care unit.
SOURCE: Reprinted with permission from Eric Dishman, Intel.

that, if you have a medical problem, you “make a pilgrimage to a place

where the experts can be with their experts’ technology, and you time share
that system, just like we used to time share the early computers.” Continu-
ing the analogy, he said, “We couldn’t conceptualize back then that the
power of personal computing was going to be that it would become truly
personal. . . . It’s yours and you can do with it what you want.”
Health care needs to move similarly from a mainframe model to a
personal health model, Dishman said. The mainframe model is simply the
wrong tool for the job for the vast majority of care, he said. Around the
world, Intel social scientists have mapped out people’s key nodes of health
care, and although they mention their local hospital—for the most part,
in a positive way—as their node of care, many other nodes of care exist.
Furthermore, the people who are key to their care are not just hospitalists
but also therapists, gerontologists, and the librarian who is helping them
find information on the Internet. Every person has a different configuration
for their “lived reality of health.”
In the future, the health care system will not be sustainable, he said,
unless it first has an information system, a reward system, and a model of
care that takes into account that sort of community-based care, with the
home—and probably the workplace—being key nodes. Step one of mov-
ing from the mainframe to the personal health approach is distributing the
capacity, he said, which depends on skill shifting, place shifting, and time
shifting toward the activities that are leftward in the diagram in Figure 3-1.
The second requirement, he said, is for all the separate body parts
and systems and for all the cellular-level understandings to be reintegrated
into whole-person care. Even though the development of specialty care
has been important in providing an understanding of the science behind
health and illness, specialists easily become unintentionally biased by the
drugs that they study, the problems that they understand, and the treat-
ment approaches that are making their careers successful, he said. Patients
who understand that their clinicians may have different backgrounds and
motives seek second, third, fourth, and fifth opinions. “You don’t know
what blinders any individual who is making these life-and-death decisions
for you have,” he said.
The application of big data analytics to claims data may produce more
robust risk assessments at the population level but may not inform the
choices of an individual patient, Dishman continued. Consumer-generated
data coming from smart phones and health applications can also feed the
system to develop a model of care for the individual patient. For example,
Intel is working with The Michael J. Fox Foundation for Parkinson’s
Research to capture consumer-generated data on Parkinson’s disease in a
search for ways to monitor disease progression more carefully, to titrate
medications more accurately, and to differentiate the different kinds of

Parkinson’s disease to look for treatment targets. “We have to have an

informatics that can personalize care down to that level,” he said.
Finally, the inclusion of family members and neighbors as part of the
care team requires new kinds of training and creates new kinds of care
workers, as is happening in China, he said. Also required are incentives
to track the quality of care that neighbors and family members provide.
Technology can help with both monitoring and “anticipatory analytics” to
assess the likelihood of problems, such as falls or medication lapses, before
they happen. At the same time, efforts are needed to shore up social support
and social networks. “If you can’t maintain the social network, then you
have to rely on institutional systems,” he said.
Pillars of Personal Health

Dishman identified the three pillars of personal health to be care any-
where, care networking, and care customization. The care anywhere con-
cept represents the shift from institutions to mobile, home-based, and
community-based care, with the understanding that today home health
care can include a much broader range of options and produce care whose
quality is much higher than that of traditional notions of home health care,
tightly circumscribed as they are by policy, staff training, reimbursement,
and client expectations.
Care networking includes the technology infrastructure, business mod-
els, and organizational models that allow care to be shifted from solo to
team-based practice, along with the information technology systems that
connect all these people and devices. Clinical decision support tools today
are geared to the information needs of individual clinicians and not to
teams of providers and not to trained family members and neighbors. Ide-
ally, everyone in a care network for an individual should receive data up-
dates and information on any changes in the care plan as the patient’s goals
change or new clinical data or caregiver observations emerge. Dishman
said, “Groupware for care decision support will be a key capability going
forward.”
Care customization manages the shift from population-based to person-
based treatment. Although that includes personalization based on genom-
ics, it also means the use of people’s smartphones with intelligent algorithms
that help them, for example, take their medications on time. Early experi-
ments demonstrated that consistent positive behavior change is possible,
as long as clinicians communicate with people in the way in which they
prefer. Delivering the support for behavior change is easy to do now; “the
hard part is figuring out what works and what does not” in the context of
mass customization.
Several shifts of the health care system that would shore up the three

pillars are needed, Dishman said, and they can be supported by technology.
Some examples include the following:
• Moving from professional care to more self-care. Dishman’s group

has taught frail seniors to do self-care. These individuals are able
to provide self-care if the technologies are usable and the benefits
(the value proposition) to them are clear. Even if only 20 percent
of patients can take on self-care, it would move the needle on cost,
quality, and access, Dishman indicated. That 20 percent of patients
would be the classic early adopters, and over time, more people
will be able to take on the self-care tasks.
• Moving from transaction-based care to care coordination. Software
tools can facilitate such a move by supporting teams, as mentioned
above, and providing status reports in real time.
• Moving from “medical-ized” records to “life-ized” ones. Data
that are broader than the data that are traditionally of interest to
the medical community need to be included in the records for the
patient, although whether those data will be included in different
data systems or in some way combined into a single system has yet
to be determined.
• Moving from stand-alone technologies to integrated ones. Tele-
health and remote patient monitoring increasingly will not rely on
specific devices but will be embedded into everyday devices. Tech-
nical and policy challenges exist, Dishman said, “but that world is
coming.”
“We have to get out of this mind set that everything we need to do
needs to be expensive, purpose built, and started from scratch.” Dishman
said the future will also leverage technologies already on the diffusion-of-
innovation path. They also will become increasingly less expensive and
more widely available. An example is the automated external defibrillator,
now a not-uncommon piece of consumer electronic equipment. The result
is the consumerization of medical devices and the medicalization of con-
sumer devices.
Another trend, he said, will be to enable clinicians to provide care
wherever they are: in the clinic, in the hospital, in someone’s home, or in a
community health center. The tablet computers that they carry will use an
infrastructure that gives them access to all the information that they need,
although he said that the technology industry will need to develop ways to
facilitate the work flow for highly mobile clinicians.
For care customization, the shift to genomics and proteomics is hap-
pening rather quickly in cancer and rare inherited disorders, Dishman said,
and the computing power needed is also becoming less expensive and more

widely available. Predictive modeling will enable more precise and therefore
more effective therapies. Analysis of the information obtained by sequenc-
ing of a patient’s genome and analysis of the parts of the body that control
the immune system, metabolism, or any other system that has gone wrong
will allow custom drugs to be delivered.
The incorporation of patient goals and care plans into a medical record
“is actually a pretty difficult machine-learning problem,” Dishman said.
Although the creation of a database field called “patient goals” is relatively
simple, the analytics that would allow the system to adapt to these goals
and suggest ways to achieve them are not. Another data management
problem that technology may be able to solve is automation of at least
parts of the lengthy documentation tasks that home health care workers
are currently required to perform. The time that it takes to complete these
tasks subtracts substantially from the time that they have to spend with
their clients, or if they hurry the job, the care activities that they perform
may not be recorded—or reimbursed.
The results from the first attempt to use any of these systems have not
been 100 percent accurate, even though they may have been a vast improve-
ment over those obtained at the baseline, before implementation of the new
system, Dishman said. This is another lesson from this work: “Will we wait
and say the technology has to be perfect before we can actually use it?” he
asked. The better approach will be to iterate over time, and even “the ‘good
enough’ may provide some powerful interventions in quality.”
principles for the evolution of health care

Rather than a focus on technology, Dishman suggested a set of prin-
ciples that will facilitate the evolution of health care and the previously
described “shift to the left” (see Figure 3-1):
• Shift the place of care to the least restrictive setting.

• Shift skills to patients and caregivers and stop fighting the licensure
and protectionism turf wars.
• Shift the time of care so that it is proactive and not reactive.
• Shift payments from individual providers to teams of providers of
care and shift payments so that outcomes that reflect the use of a
holistic approach are achieved.
• Shift the technology used from specialized equipment to everyday
life technologies, but do it within a framework that does not start
with technology.
The starting point for these changes, Dishman said, is the social cov-
enant that asserts, “We as a culture have decided this is how we’re going to

set ourselves up for people who need care and those who provide it.” From
that, evolve government policy and a framework that includes a financial
system. Within that framework is a networked model of care that has a
work flow. Within that model of care is embedded the technology. In other
words, to use innovation to overcome the demographic dilemma, the social
covenant and care models need to be used as the starting point, he said. All
the other fundamental decisions about care models, work flows, workforce
needs, and optimization of resources for results, followed by determination
of sustainable business and payment models, need to come before it is de-
termined what technology infrastructure is needed to support it.
Dishman said that home health care today is “relegated to a niche,”
to an additional capability to be added to the mainframe model. His chal-
lenge to the workshop participants was to think about the workforce and
business models that will be needed so that home- and community-based
health care can become the default and hospital-based care—according to
the mainframe model—becomes the exception.

An open discussion followed Dishman’s presentation. Workshop par-
ticipants were able to give comments and ask questions. The following
section summarizes the discussion session.
Steven Landers, Visiting Nurse Association Health Group, asked about
the immediate opportunities to achieve benefits from the expansion of home
health care, short of conceptually changing the whole health care system,
even, he said, if the kind of evolution toward “care everywhere” is the ul-
timate goal. Dishman responded that those who provide home health care
and long-term services and supports, even though they are sort of a back-
water for mainframe care and are often not taken seriously, are the parts of
the system that actually understand what needs to happen in the new care
model. Dishman said that at Intel he teaches a course on leadership and that
one of the principles that he teaches is that great leaders balance between
practical thinking and possibility thinking and must be able to do both. He
believes that home health care could be one of the disruptive forces that
make the rest of the health care industry recognize that whole-person care
is needed, especially for older people but also for people of all ages.
Erin Iturriaga, National Institutes of Health, noted that Washington,
DC, has 14 villages that are part of the village movement, according to the
World Health Organization’s age-friendly city model, and that each village
is attached to a wellness center. Nationally, she said, the movement is look-
ing for support from cities and states rather than support from the federal
government. She asked Dishman if he thought that this model, which
sounds similar to what is happening in Japan, could work in the United

States. Dishman responded that by use of the village model, it should be

possible to innovate in terms of the care model, the payment model, and the
technology used and that if the village model is used long enough this mode
of organization will become natural for the people who are involved. He
suggested that these villages can become locations for real-life experiments.
In general, real-life experiments are hard to come by, he said. Instead,
people merely test pieces of a model or test them for too short a period of
time and with workers who have to do their old jobs as well as whatever
new components that the experiment includes.
Gail Hunt, National Alliance for Caregiving, said that on the previ-
ous day of the workshop it became clear that a lot of pressure exists to
push more and more of the caregiving tasks off onto the family caregiv-
ers, whether or not they are willing or able to handle them. Shifting of
skills must require an assessment of the primary caregiver’s capacity, Hunt
said, as well as that of other family members who would be able to help.
Dishman agreed, stating that this is part of his model. The term “family
caregiver” can include neighbors and, in some cases, community health
workers with various levels of training. Whoever it is, he said, that person
is assessed for both their ability and willingness to perform needed tasks,
and there are some incentives for them to be assessed. They may be trained
in multiple areas—a little home repair, some social work, and clinical care
relevant to chronic disease. “I don’t know what to call that person,” he
said. The multiple demands that come into play are part of why the system
that assesses quality needs to track the care being provided and make sure
that caregivers are not overwhelmed.
Amy Berman, The John A. Hartford Foundation, expressed concern
that progress toward supporting good-quality care at home is moving too
slowly. In part, she said, this is because not enough geriatric expertise with
which to develop the core of these infrastructures or the decision-making
support exists and that not enough physicians and nurses are available to
care for the older population. Dishman agreed that when no standards are
in place, experts from mixed disciplines should be brought in to identify
best practices. “One of the things that health care is not good at, almost
anywhere in the world, is having a formal and iterative innovation pro-
cess,” he said. In pilot tests, people focus on the wrong problems, they do
not learn from past innovations, and they do not have an iterative mind
set that, once they have met a baseline set of safety and security standards,
says, “We don’t have to get it all right in the beginning.”

Key Issues and Trends
Larger contextual issues (e.g., population health, payment policy) have

implications for how home health care may need to change to meet future
needs. This chapter describes three presentations that explored overarching
trends currently being seen and how they may affect planning for the future
role of home health care.
Trends in Population Health

Tricia Neuman
Kaiser Family Foundation
Home Health Care Under Medicare and Medicaid

In home health care, the typical silos of Medicare and Medicaid do oc-
casionally interact and overlap, but they are not truly integrated, affirmed
Neuman. Medicare is an entitlement program that covers Americans ages
65 years and older and people under age 65 years with permanent dis-
abilities in a uniform way across the country. Medicaid, by definition, is
more complicated because of the combination of federal requirements and
the different eligibility and benefit rules of each of the 50 states. The low-
income people who are eligible for Medicaid and who receive home health
care services often are also covered under Medicare (and are referred to as
dually eligible), which is their primary coverage.
Medicaid is frequently thought of as a program for long-term services
and supports (LTSS), but home health care is not really that entity, Neuman
35

said. Home-based medical services (including nursing services; home health

aides; and medical supplies, appliances, and equipment) are mandatory ben-
efits under Medicaid, but the broader array of home- and community-based
services is optional.1 Even so, states may impose limits on their Medicaid
home health care programs. Five states have put limits on program costs,
and 25 states and the District of Columbia limit service hours. The benefit is
typically covered under fee-for-service arrangements, although many states
are moving toward the use of capitation, she said. As in Medicare’s home
health care program, a physician needs to provide a written plan of care
for recipients to be eligible for home health care services.
Mandatory benefits for individuals who qualify for Medicaid home
health care include part-time or intermittent visits by a registered nurse;
home health aide services provided by credentialed workers employed by
participating home health agencies; and appropriate medical equipment,
supplies, and appliances. Physical and occupational therapy and speech pa-
thology and audiology services are optional benefits. Fifteen state Medicaid
programs allow recipients to arrange their own services, including provid-
ing payment to family caregivers. These self-directed services programs have
generally proved successful in reducing unmet patient needs and improving
health outcomes, quality of life, and recipient satisfaction at a cost compa-
rable to that of traditional home health agency–directed service programs.
In the traditional Medicare program, which uses fee-for-service pay-
ments, it has been relatively easy to track how much that public insurance
pays for various types of services, including home health care, Neuman
said. However, as increasing numbers of Medicare and Medicaid beneficia-
ries are moving into capitated plans, estimation of the number of people
receiving services, how much they are receiving, and what government
source is paying for these services becomes harder. Under fee-for-service
programs, Medicare currently pays the largest share of home health care
expenditures (44 percent), even with its relatively narrow eligibility criteria,
followed by Medicaid (38 percent) (see Figure 4-1). Private health insurance
and other third-party payers pay about 10 percent, and another 8 percent
is paid out-of-pocket. Neuman noted that the amount of out-of-pocket
spending is probably understated, because no reliable ways of capturing
these data exist.
Home health care remains a relatively small piece of total Medicare
and Medicaid spending. As noted above, the Medicaid expenditure may be
an underestimate because such a large percentage of Medicaid recipients
1 The broad category of home- and community-based services includes assistance with activi-
ties of daily living (ADLs), such as eating, bathing, and dressing; assistance with instrumental
activities of daily living (IADLs), such as preparing meals and housecleaning; adult day health
care programs; home health aide services; and case management services.

KEY ISSUES AND TRENDS 37
Medicaid Medicare
38% 44%
Out of Pocket
8% Private Health Other Third-Party
Insurance Payers
7% 3%
FIGURE 4-1 Total home health care spending, 2012: $78 billion.
NOTE: Estimates of national health care expenditures on home health care also include
spending on hospice by home health agencies. Total Medicaid spending includes both
state and federal spending. Home health care includes medical care provided in the
home by freestanding home health agencies. Medical equipment sales or rentals not
billed through home health agencies and nonmedical types of home care (e.g., Meals on
Wheels, the services of workers who perform chores, friendly visits, or other custodial
services) are excluded.
SOURCE: Kaiser Family Foundation analysis of National Health Expenditure Data,
by type of service and source of funds, calendar years 1960 to 2012. Reprinted with
permission from Tricia Neuman, Kaiser Family Foundation.
are in managed care plans, which are paid on a per capita and not a per
service basis.
Who Is Served?
The utilization of home health care rises with the number of chronic
conditions and the functional impairments that people have, Neuman said
(see Figure 4-2).
About two-thirds of all Medicare home health care users have four
or more chronic conditions or at least one functional impairment. “When

26%
16%
13%
10% 10%
6%
5%
4% 3%
1%
0 1 2 3 4 5+ 0 ADLs IADLs 1 or 2 3+ ADLs

or IADLs Only ADLs
Number of Chronic Conditions Inability to Perform ADLs and IADLs
FIGURE 4-2 Percentage of beneficiaries using home health care, by characteristic,

2010.
NOTE: ADLs = activities of daily living; IADLs = instrumental activities of daily
living.
SOURCE: Kaiser Family Foundation analysis of Medicare Current Beneficiary
Survey, 2010. Reprinted with permission from Tricia Neuman, Kaiser Family
Foundation.
you are talking about [people receiving] home health care,” Neuman said,
“you’re talking about a population that is often physically compromised
and cognitively compromised. These are people with multiple challenges.”
Although most of these challenges arise in the context of aging, they also
face the population of people with disabilities covered by Medicare.
Neuman presented data indicating that home health care usage overall,
the number of home health care visits per user, and Medicare spending per
user all rise with age, as does the use of many other health care services,
including inpatient care, skilled nursing care, and physician services, and
the use of some drugs (but not hospice care). The age–per capita spending
curve for each of these services has a peak. For example, Neuman noted
that physician services and outpatient drug spending peak at age 83 years,
declining thereafter, and that after age 89 years, hospital expenditures start
to drop. Spending on home health care does not peak until age 96 years,
and spending on skilled nursing facilities peaks at age 98 years.
Although only 9 percent of the traditional (i.e., non-managed care)
Medicare population receives home health care services, the health care
spending for these individuals accounts for 38 percent of traditional Medi-

care spending. This is another reflection of their high degree of impairment

and need. Neuman posed fundamental questions about these patterns of
care, including the following:
• Are beneficiaries receiving care in the most appropriate setting?

• Are they receiving good-quality care in the place where they want
to be?
• Does this pattern of care optimally balance federal, state, and fam-
ily budgets?
• How will the nation finance care for an aging population?
Overall, the use of home health care services has increased in recent
years, Neuman said, reflecting both an aging population and the rise in the
incidence of chronic conditions noted earlier. However, spending on home
health care, which had been rising concomitantly, has leveled off in recent
years, even though home health care serves more people. It is not absolutely
clear why this is, Neuman said, and then suggested that it may be due in
part to payment reductions from the Patient Protection and Affordable
Care Act of 2010 (ACA)2 and greater recent efforts to address fraud in
some pockets of the country.
Effects of Policy Changes

Neuman stated that policy changes can spur innovations affecting
home health care. These innovations are often aimed at the integration
of systems of acute care and LTSS for dually eligible individuals and the
development of team-based geriatric care. An example of such innovations,
she said, includes the American Academy of Home Care Medicine’s Inde-
pendence at Home initiative.3
How well home health care will fit into emerging models of care re-
mains uncertain, Neuman said. Home health care is a relatively small player
in these system reforms, and it will take effort to ensure that it can continue
to play its important role, she said.
2 Patient Protection and Affordable Care Act of 2010, Public Law 111-148, 111th Cong.,

3 See http://www.iahnow.com (accessed December 24, 2014).

Trends in Public Policy

Douglas Holtz-Eakin
American Action Forum
Holtz-Eakin began his remarks by underscoring the “fundamentally

unsustainable health care cost trajectory” that the nation is on, “even with
the good news we have had about the pace of health care spending in re-
cent years.” Federal budget deficits will grow relative to the gross domestic
product, and in a decade, interest payments are projected to be larger
than the U.S. Department of Defense budget, producing a tight money
environment.
At the center of these difficulties, he said, are the programs that pay 80
percent of the home health care bills: Medicare and Medicaid. Medicare is
spending its funds faster than payroll taxes and premiums are replenishing
them and will come under increasing financial pressure. Medicaid faces
similar pressures, especially at the state level.
The home health care industry’s financial condition looks especially
precarious, said Holtz-Eakin, with some 40 percent of home health care
providers expected to be in debt in just a few years. Moreover, new U.S.
Department of Labor rules mandating overtime pay for workers not previ-
ously receiving it will boost agency costs, he said, if and when they go into
effect. In the home, LTSS have been provided by family members, but in
the future, this source of care will be less available, because family members
will be working.
Despite this combination of pressures, opportunities also exist, Holtz-
Eakin said. Keeping frail elders with chronic diseases and disabilities out of
acute care could save a lot of money, so “the opportunity at the front end
to really solve the Medicare cost problem is a serious one.” Research also
suggests that home health care can play a substantial cost-saving role in
post-acute care as well. To take advantage of such opportunities, the home
health care sector will be required to document not just their cost savings
but also the quality of the care that they provide. The combination of lower
cost and high quality creates a value proposition for policy makers and
taxpayers, Holtz-Eakin said. Further, the traditional dichotomy between
health care services and LTSS needs to end, he believes.
Holtz-Eakin said that policy makers are “trying to fix these programs
at the margins,” when what is needed is “a fundamental rethinking of how
we deliver all these services.” Further, he believes, the voters will want to
go with comfortable proposals, and “I’m not sure that will be enough to
get this right going forward.”
Although technological advances have helped resolve a large number
of major policy problems, in this situation, it is not clear what such an

advance would be, he said. For example, what agency will approve new
health technology devices? Are health care applications going to be regu-
lated by the U.S. Food and Drug Administration (FDA) or by the Federal
Communications Commission? When a service crosses state lines (as with
telehealth), difficulties with state-based licensing and scope of practice
regulations may arise.
Trends in the real world

Barbara A. McCann
Interim HealthCare
Several trends help describe the reality of U.S. home health care, as
McCann sees it from her perspective as a medical social worker.
Limitations in the Design of the Medicare Home

Health Care Benefit for Today’s Population
Most people are unaware of home health care services until a moment
of crisis, when a staff member from the hospital, inpatient rehabilitation
center, or nursing home advises them that their loved one is being dis-
charged and arrangements for care in the home need to be made, McCann
said. Thousands of Medicare beneficiaries who are older or have disabilities
and their families have had to face this crisis and are receiving home health
care, but the benefit is a poor fit to their needs, McCann said. Designed
almost 50 years ago, the home health care benefit emphasizes recovery from
acute illness and the opportunity for health improvement, and it presumes
that the beneficiary’s health problems will end. It does not emphasize well-
ness or prevention, and it does not pay for comfort care or palliation at
the end of life.
Patients receiving Medicare home health care services must be home-
bound, and once they are no longer confined to home, the benefit ends.
However, “chronic disease goes on, [and] medications continue to come
into the house,” McCann said. At that point, home health care providers
have no one to hand the patient over to or transition to for ongoing care
and coordination. Patient-centered medical homes solve this problem, she
said, but they are far from universal.
Managing Continuous Transitions

Despite these challenges, home health care is being reinvented to serve
as an important piece in the continuum of chronic care. In accountable care
organizations, with their capitated structure, some providers are working

around the strictures of the Medicare home health care benefit and ensur-
ing that patients receive the needed services. Transitions not only between
care settings—especially hospital to home—but also during the period of
time after a physician’s visit are times when patients definitely need help,
even with an issue as basic as communication. “They can’t remember what
they talked about or who they told about which symptom,” McCann said,
“and they certainly can’t remember what the doctor told them to do or
what medications to take.”
McCann noted that the home health care nurse can sit with the patient
and family member or other caregiver and review medications, dosage
schedules, and other medical instructions to help the family become orga-
nized about the patient’s health care needs. “The reality of health [care] in
the home is the reality of the kitchen table. That’s where health decisions
are made, and that’s where health is managed,” she said. Later in the work-
shop, Thomas E. Edes, U.S. Department of Veterans Affairs, agreed with
this characterization, saying “the gold standard of medication reconcilia-
tion happens at the kitchen table.”
The most typical problems, McCann said, are
• Remembering to take medications,

• Knowing what the symptoms of problems are and when and from
whom to seek help,
• Verifying that the individual or family member(s) makes an ap-
pointment with the community physician within 1 to 2 weeks
post-discharge and that the individual has transportation,
• Making sure that reliable arrangements for meal preparation are
in place, and
• Checking the patient’s ability to perform ADLs safely or whether
arrangements are needed to make these activities easier or safer so
that the individual can stay at home.
Finally, as a social worker, McCann emphasized the need for socializa-

tion by asking, “How [do] we keep people engaged daily?” Taking care of
all of these important dimensions of care will be important to each patient
and family well past the 30 or 60 days of Medicare’s home health care
benefit or a post-acute care service.
Data Shortfalls
McCann said that many health care data exist but that almost no
information on home health care is available. Since 2000, whenever a
Medicare or a Medicaid patient has received skilled care, nursing services,
or therapy at home, providers have had to collect more than 100 pieces of

data about that patient and service. This requirement holds whether the
patient is covered by traditional fee-for-service Medicare, Medicare Advan-
tage, Medicaid skilled care, or Medicaid managed care. “We have data on
millions of episodes of care sitting in a database somewhere that have not
been analyzed,” she said.
Although home health care providers receive some performance in-
formation, they do not know what combination of service timing, staff
specialty, or coverage type results in better (or worse) patient outcomes.
Nor do the available data reflect what additional personal care and sup-
port services not paid for by Medicare and Medicaid that the patient has
obtained privately. It may be that these services make crucial differences to
patient well-being.
New Program Models

McCann has encountered a number of hurdles to collaborative work in
home health care that need to be overcome. For example, physicians assess
pain differently than do physical therapists, and physical therapists assess pain
differently than do home health agency personnel, she said. Nor do these
three groups assess dependence in ADLs in the same way, making it more dif-
ficult to assess change or improvement. Furthermore, little common language
for the establishment of outcome measures exists, she said.
Collaboration is likewise a feature of the demonstration programs for
dually eligible individuals, she noted, in which the goal is better program-
matic coordination throughout the continuum of care. This is to be ac-
complished through the integration and alignment of federal Medicare and
state Medicaid funds into a single source of financial support for social as
well as medical needs.
Home health care does not mean that a person is always in the home,
McCann said. It may mean having a smartphone application that reminds
a person to take medication;4 it may be the availability of a nurse or phar-
macist via email or the telephone. Responsive cognitively appropriate and
age-appropriate communication systems would help avoid unnecessary
911 calls.
This work involves more than managing illness; it means taking a well-
ness, preventive, and habilitation approach. She said, “I may not be able
to [offer full rehabilitation to you], but I can help you live better in your
home.” McCann concluded, “This is what we have to remember about the
beauty of home care: it’s at home.”
4 A participant noted that FDA has a guidance on mobile applications.


An open discussion followed the panelists’ presentations. Workshop
participants were able to give comments and ask questions of the panelists.
The following sections summarize the discussion session.
Definitions
Mary Brady, FDA, said that a standard definition of home health care
is needed. The definition used by FDA’s Center for Devices and Radiological
Health includes concepts of wellness and the usefulness of devices not only
in the home but also at school, during transport, or wherever a person is
and includes whatever devices are needed to keep healthy those who are
living well outside of a clinical facility, she said.
Families
Amy Berman, The John A. Hartford Foundation, asked how home
health care should respond to the declining numbers and availability of
family caregivers. In current policy, she said, these individuals are not part
of the unit of care. Innovations to address that problem have not worked
well, said Holtz-Eakin, but “the key to solving it is to get away from the
silos” and to provide a broader range of services. Neuman emphasized that
the data on the performance of some innovative models may not be avail-
able for a number of years. She said, “We need to get more evidence about
how well those systems are working for seriously impaired people before
we think that managed care and capitation will be a solution for care, even
though they may be clearly a solution for budgets.”
One workshop participant commented that home health care needs to
address not only cognitive and physical impairments but also the emotional
needs of patients dealing with a new diagnosis and family members dealing
with the exigencies of patient care.
Chris Herman, National Association of Social Workers, commented
that difficult transitions do not end for families when hospice or home
health care services appear. They reemerge each time that a new practitioner
in that program goes into the patient’s home. Practitioners must continue
to weave those programmatic connections together and help people under-
stand them, she said. Neuman agreed, stating that the issue of transitions
also needs to be thought about outside the hospital-to-home context. People
in retirement communities, assisted living facilities, and other settings may
not have family nearby for the kitchen-table conversations that McCann
described.
Cynthia Boyd, Johns Hopkins University, asked about what is being

done to improve communication among patients and caregivers at home,

home health care providers, and the rest of the health care system. McCann
reiterated the importance of making sure that patients and their families
understand their situation, what can be done about it, and whom to call.
This information can be conveyed in multiple languages, through the use
of drawings, or in other imaginative forms of communication so that indi-
viduals and families understand what is happening and what options they
have. However, what is often needed, she said, is to have someone available
to answer questions at the moment that they arise. Call centers that are
linked to pharmacies can help individuals get answers to questions about
medications. Sometimes, just having a live person to talk to can reduce a
person’s anxiety. Communication of patient and family concerns back to
other parts of the health care system is relatively easy in some of the more
progressive patient-centered medical homes but is not so easy in other care
environments. Said McCann, it should be explicit “who is responsible for
those transitions and staying coordinated across time.”
Jimmo v. Sebelius
Herman also asked about the anticipated impact of the Jimmo v.
Sebelius case5 and the resultant changes to Medicare for beneficiaries.
Workshop participant Judith Stein, Center for Medicare Advocacy and
a lead counsel in the case, responded. The case was brought on behalf of
Ms. Jimmo and others as a national class action, she said, to address a
long-standing problem that Medicare coverage is regularly denied on the
basis of beneficiaries’ restoration potential and not on the basis of whether
they require skilled care. For many people with long-term and chronic
conditions, the likelihood of health restoration may be negligible, yet skilled
care may well be required for them to maintain their condition or to prevent
or slow its worsening. Stein said that the Jimmo case should help people
receive the benefits that they are entitled to under the Medicare law and
that will allow them to stay at home.
Cost of Care
Several workshop participants raised the issue of cost throughout the
workshop. Namely, is home health care less expensive than the equivalent
5 “On January 24, 2013, the U.S. District Court for the District of Vermont approved a
settlement agreement in the case of Jimmo v. Sebelius, in which the plaintiffs alleged that
Medicare contractors were inappropriately applying an ‘improvement standard’ in making
claims determinations for Medicare coverage involving skilled care (e.g., the skilled nursing
facility, home health, and outpatient therapy benefits)” (CMS, 2014).

care in a nursing home setting? Neuman responded that no good studies

of this question have been conducted. The provision of comprehensive
services full-time in the home would be more expensive than the provision
of those services in a nursing home. Holtz-Eakin said that the focus should
be on value and not just cost. What is needed, he said, is acquisition and
analysis of the data on home health care to identify quality outcomes and
best practices. As an illustration, Andrea Brassard, American Nurses As-
sociation, noted that her research on intensive home health care services
in New York City in the 1990s found that these services did delay nursing
home admissions and mortality among the sickest population. Holtz-Eakin
noted that many studies have documented successful provider experiences
and cost-saving business models with particular patient populations. How-
ever, to be suitable for adoption as part of the Medicare benefit, a study’s
positive findings need to be generalizable to the population as a whole, he
said, because “Medicare is for everybody.”
According to Brassard, the requirement that a physician sign off on or-
ders for home health care or have a face-to-face encounter with the patient
is inefficient and creates delays in dealing with patients’ problems. In most
instances, she said, a nurse practitioner (NP), clinical nurse specialist, or
physician assistant should be able to do this certification. Although the U.S.
Congress has been concerned that allowing other health care profession-
als to certify that a patient requires home health care would increase costs
by increasing the demand for home health care, the current inefficiencies
are also costly, she said. Brassard asserted that the problem will become
more acute in 25 to 30 years, when predictions indicate that one in every
three primary care providers will be an NP; today that number is one in
five. The Congressional Budget Office (CBO), which determines the cost
of proposed legislation, has difficulty with projections that are long term,
given that congressional policy making is mostly short term. Moreover,
said Holtz-Eakin, CBO measures only costs, and if proposed legislation has
nonmonetary benefits, organizations need “to get policy makers to advocate
on behalf of those benefits.”
Erin Iturriaga, National Institutes of Health, raised the issue of the
growing population of aging individuals in prisons. To save money, she
said, states are releasing older long-stay prisoners early, shifting the costs
of their care from the prison system to other payers, including Medicaid.
Data on inmate health are not part of typical health care databases, and
states have no way of budgeting for this influx.
Combining Medical Care and Social Needs

Michael Johnson, BAYADA Home Health Care, noted that different
definitions of home health care seem to be constricted by the requirements
of the programs that are paying for it. A broader conceptualization of

home- and community-based services may be needed. He asked how the

Medicare focus on disease and drugs can be rebalanced with considerations
about prevention and pre-acute care or about improving function, nutri-
tion, and maybe even cognition. Holtz-Eakin responded that the current
programs, as they exist, are not built for the future. The country’s approach
is ad hoc, he said, and was invented through regulation and minor policy
changes. Although it makes sense to take outcomes, including functional
outcomes, as the focus, the Medicare program was designed almost five
decades ago to serve people with acute-care stays and is now being asked
to serve a population whose biggest problems are chronic diseases. The
recent Senate Commission on Long-Term Care6 concluded that although
significant program changes are needed, to provide more LTSS, there is no
clear way to pay for them, Neuman said. She agreed that working with
people early (providing pre-acute care instead of only post-acute care) to
prevent functional decline would be an important strategy. Which provider
will do this is uncertain: “There are a lot of people competing for that
space,” she said. The mind set that long-term care is nursing home care
must change, said McCann. Today, long-term care is simply the reality of
chronic disease, aging, and disability. The evaluation of models from other
countries—especially Australia—may help change that perception.
Bruce Leff, Johns Hopkins University School of Medicine, asked if the
breakdown of silos among programs will emerge from new business mod-
els, including a greater penetration of managed care, or if it will require
another big political battle. Holtz-Eakin predicted that both are likely but
that change can certainly build on some of the essential organizational in-
novations currently under way. Regardless of the delivery model, however,
payment should be made on the basis of patient outcomes. Meanwhile, it
should be possible to build on Medicare Advantage and expand what it
covers to include not just traditional health care services but also a con-
tinuum of health and social supports.
Terrence O’Malley, Massachusetts General Hospital, asked if realign-
ing health care payments through accountable care and managed care
organizations is increasing awareness of the importance of social factors in
health. That does not seem to be happening as quickly as anticipated, he
said. The panelists counseled patience, because promising new models are
still only promising and it is too soon to pick winners. If these new models
are allowed to run a while, the ones that are successful in reducing costs
and improving quality will be revealed, Holtz-Eakin said. The ACA was
just the beginning of a health care reform process that will continue for
many years. What this workshop is about, he said, is getting home health
care right in the end.
6 See http://ltccommission.org (accessed December 24, 2014).


The Home Health Care Workforce
Many different people make up the home health care workforce, in-
cluding professionals (e.g., nurses, physical therapists, physicians) and di-
rect care workers (e.g., home health aides, personal care aides), along with
individuals and their families. As in health care in general, home health
care depends on a team of individuals working together. In one panel of
the workshop, four speakers addressed the role of each person on the home
health care team (as well as the team itself) and how to facilitate their roles
in ways in which they will be needed for the future ideal state of home
health care.
The Value of Team-based Care

Thomas E. Edes
In the U.S. Department of Veterans Affairs (VA), the home-based pri-

mary care program uses a team approach in its pursuit of the triple aim:
improving the patient experience of care (quality and satisfaction), improv-
ing population health, and reducing per capita care costs. Edes began with
the story of one particular veteran, which is presented in Box 5-1.
Home-Based Primary Care in the VA

In the VA, Edes said, home-based primary care is comprehensive, lon-
gitudinal primary care delivered in the homes of veterans with serious
49

BOX 5-1
A Veteran’s Story
Edes related the story of a 74-year-old veteran with advanced Parkinson’s

disease who was struggling to manage at home. Not surprisingly, Edes said,
he was developing significant depression. He had been falling a lot. He had lost
40 pounds and had aspiration problems, dementia, and hallucinations. He was
treated with deep brain stimulation, but that had not helped him much. He still
had serious problems with his gait, muscle spasms, and tremors; and he had
difficulty swallowing.
After several hospitalizations, the medical team recommended transition to
a nursing home, but the veteran refused, saying, “I’m going to die if I’m admit-
ted to a nursing home.” The health care team took his preferences to heart and
rewrote the care plan. Instead of the nursing home, he was discharged to home
with home-based primary care and home health aide services. Even if it did not
change his prognosis, home was where he wanted to be.
The U.S. Department of Veterans Affairs (VA) home-based primary care
team worked with his caregivers so that they understood his daily care and sup-
port needs. The social worker helped him identify a caregiver for support and
socialization through the Veteran Directed Care program (which the VA has in
more than half of the states) and connections with the community and identified
sources of support for his daily care needs. The rehabilitation therapist provided
the help necessary for the veteran to increase the amount of exercise that he
received and prevent falls.
In addition, the nurse helped explain a complicated medication management
regimen and trained caregivers in the Heimlich maneuver if aspirations occurred.
The dietitian worked on improving the patient’s nutrition to help him gain weight
and taught techniques in preparing foods to avoid triggering esophageal spasms.
Meanwhile, the psychologist tackled the problems of isolation and depression. In
short, the full team continuously worked to find solutions, including ways to ad-
dress new problems that arose.
As a result of these comprehensive, integrated efforts, after a year in the
program, the veteran displayed a remarkable improvement in health status: he had
about half the rate of falls as in the year before enrollment (9 versus 16) and only
one hospitalization (versus 5 the previous year), and his weight stabilized. On the
psychosocial side, he was less isolated and more involved with his community,
which he said improved his quality of life.
Equally important, he felt that he had recovered some of the control over his
life that his disease had eroded, and his goals were met: no nursing home, no feed-
ing tube, fewer hospitalizations, and greater activity and community engagement.
SOURCE: As presented by Thomas E. Edes on September 30, 2014.

THE HOME HEALTH CARE WORKFORCE 51
multiple chronic diseases and disabling conditions who are too sick to go
to the clinic. Care is provided by an interdisciplinary team that comprises
a nurse, a physician, a social worker, a rehabilitation therapist, a dietitian,
a pharmacist, and a psychologist. Since 2006, those teams have included a
mental health professional, because “if we do not effectively manage our
patients’ mental health conditions, we will not effectively manage their
medical conditions,” Edes said.
This is, admittedly, an expensive team, but, Edes said, “We cannot af-
ford not to have that expensive team.” He then described the population
that these teams care for: men in advanced stages of disease (a 24 percent
annual mortality) with, on average, more than eight chronic medical con-
ditions. About half are dependent in two or more activities of daily living
(ADLs), just under half are married, and 30 percent live alone. For those
with a caregiver, 30 percent of the caregivers have activity limitations as
well, he said. With respect to diagnosis, half of the patients have diabetes,
one-third have cancer, 40 percent have depression, about one-third have
dementia, 20 percent have schizophrenia, and 20 percent have posttrau-
matic stress disorder. Although home-based care from the interdisciplinary
team is available to veterans regardless of age, most in the program are
older, and the proportion of the veteran population age 85 years and older
is growing, as it is for all Americans, but it is growing at a much faster rate
for the veteran population.
Even though the veterans in this population have high mortality rates,
on average, they receive home-based primary care for more than 300 days.
To make this program affordable, Edes said, it must focus tightly on the vet-
erans who are in the 5 percent who account for half of the VA’s health care
costs and not on the 50 percent who account for only 4 percent of costs.
“Almost anything you do in that latter population will raise costs,” he said.
The goal of the program is to support veterans so that they may remain
at home for as long as is feasible with optimal health, safety, independence,
and purpose—and at lower cost. Achievement of that goal, Edes said, de-
pends on
• Increases in veterans’ access to home-based services,

• Minimization of avoidable hospital days, and
• Prevention or optimization of nursing home care.
Differences from Medicare

Edes drew a distinction between the VA home-based primary care
and traditional Medicare home care. The two organizations have different
target populations, different processes, and different outcomes. The VA’s
program provides longitudinal, comprehensive, interdisciplinary care to

TABLE 5-1 Comparison of the VA Home-Based Primary Care and

Medicare Home Health Care
VA Home-Based Primary Care Medicare Home Health Care
Targets complex chronic disease Targets remediable conditions
Provides comprehensive primary care Provides specific problem-focused care
Does not require skilled care Requires skilled care
Does not require the patient to be Requires the patient to be homebound
homebound
Accepts declining status Requires improvement
Uses an interdisciplinary team Uses professionals from one discipline or a
multidisciplinary team
Provides longitudinal care Provides episodic, post-acute care
Reduces hospital days Has no definitive impact
Has a limited geography and intensity Is performed anywhere, anytime
SOURCE: Adapted from Beales and Eades, 2009, with permission from Elsevier and Thomas
Edes.
veterans with complex chronic diseases and complements Medicare home

care, which has more limited purposes, as shown in Table 5-1.
Edes noted that the VA program covers key gaps in Medicare home
care that had been emphasized by previous speakers, including the inclusion
of people with complex, multiple chronic conditions and not merely those
with post-acute care needs or remediable conditions; it takes a more com-
prehensive approach to the provision of care; and it has a focus on patient
needs and not homebound status. Edes said that the care team members
are truly interdisciplinary and work together to create a unified plan of
care for each patient. Moreover, they recognize that they are likely to be
the patient’s care provider for the remainder of his life. These advantages
have helped the VA program reduce the numbers of hospital days and total
costs for this high-acuity population.
Where the Medicare home care program is especially helpful to vet-
erans, he said, is in providing post-acute care, providing care on a high-
frequency basis (albeit for a short time), and providing care outside the
geographic reach of the VA home care programs.
Program Outcomes
In 2002, Edes said, the VA analyzed the impact of home-based primary
care involving more than 11,000 veterans before and after implementation

of the primary care program (Beales and Edes, 2009). The researchers
found that program participants had 62 percent fewer hospital days and
29 percent fewer admissions, 88 percent fewer nursing home days, and a 21
percent reduction in the 30-day hospital readmission rate. Furthermore, the
net cost to the VA was 24 percent lower when the home-based primary care
program was implemented, after the cost of the program was accounted
for. Currently, some 34,000 veterans receive these services, and enrollment
continues to grow. Furthermore, 38 percent of these veterans live in rural
areas. Pilot tests are being conducted with the Indian Health Service to
expand the program’s reach into American Indian populations. Additional
analysis has shown that the VA’s cost reductions have not been achieved
by shifting costs to Medicare. In fact, Edes said, veterans’ enrollment in
home-based primary care achieved a 25 percent reduction in combined VA
and Medicare hospital admissions and a greater reduction—36 percent—in
combined hospital days. The result was a 13 percent reduction in combined
Medicare and VA (net) costs.
Edes said that results like these meant that the model was included as
part of the Patient Protection and Affordable Care Act of 2010 (ACA)1
as the Independence at Home demonstration program, along with a fi-
nancing structure to support it. Like the VA home-based primary care
program, the Independence at Home model targets complex, chronic, and
disabling conditions; provides interdisciplinary, longitudinal care in the
home; emphasizes skills in geriatrics care; uses electronic health records;
and uses evaluation metrics that include quality and satisfaction, as well as
reductions in the number of inpatient days. At a minimum, Independence
at Home demonstration sites are projected to produce a 5 percent cost sav-
ings, and if they achieve more, the additional savings will be shared with
the site. The demonstration is in its third and final year and is operating in
14 single-practice sites and in three consortium projects.
Recently, Edes noted, results from a large 5-year, propensity-matched,
case-control study of a similar model involving about 700 intervention
patients and three times as many controls were reported (De Jonge et
al., 2014). This program provides services to mostly frail elders in the
Washington, DC, area using an interdisciplinary team. Edes said that it
produced a 17 percent reduction in the total cost of care for the patients
receiving the intervention. Some components of care—home health and
hospice—were more costly for the intervention group, but these costs were
more than offset by the lower costs associated with the reduction in receipt
of care in hospitals and skilled nursing facilities and fewer subspecialist
visits. Again, he said, the conclusion is that home-based primary care does
1 Patient

reduce the cost of care for carefully selected individuals but does so only
for those who are the most frail. Edes estimates that the Independence at
Home model, if it were expanded nationwide, could save the Centers for
Medicare & Medicaid Services more than $6 billion per year.
Researchers face methodological challenges in studying these new mod-
els. Edes said, “Robust methods of analysis are needed in addition to
randomized controlled trials to meet the challenges of evaluating complex
interventions involving diverse populations with variable comorbidities
receiving individualized care in a rapidly evolving healthcare system” (Edes
et al., 2014, p. 1955). The complexity of the patients, the services, and the
new organizational structures exceed the ability of randomized controlled
trials to trace the effects of these programs.
In an analysis of costs, the Congressional Budget Office found that
Medicare costs per beneficiary rose 29 percent between 2000 and 2005,
but in the VA, per patient costs rose only 2 percent. This difference, Edes
said, is largely attributable to the VA’s development of programs specifically
for people with serious, complex comorbidities. During those same years,
the cost of home hospice services paid for by the VA increased more than
400 percent, the number of inpatient palliative care consults grew 25-fold,
the amount of home-based primary care that it provided increased 55 per-
cent, its medical foster home placements nearly tripled, and its home- and
community-based services increased 87 percent. Still, overall costs rose only
2 percent.
In 2013, more veterans died in VA hospice inpatient units than in
intensive care or other hospital units combined, Edes said. Among those
enrolled in home-based primary care and in medical foster homes, about
two-thirds die at home. Finally, the overall number of veterans in long-term
care increased about 30 percent between 2000 and 2010 because of the
sharp rise in the number of veterans aged 85 years and older.
Medical Foster Homes

Edes spoke briefly about the Medical Foster Home program, another
long-term care alternative of the VA with costs about half those of nurs-
ing home care. This program merges the adult foster home concept with
an interdisciplinary team providing home-based primary care. In this case,
the foster care provider is taught how to care for the specific patient, and
the VA makes any necessary modifications to the home. These foster care
providers commit to providing care for the remainder of an older veteran’s
life and for 3 years for younger veterans, after which the commitment is
renewable.

Centrality of Teams
For the 5 percent of the VA patients who account for half of the sys-
tem’s health care costs, teams are essential, Edes said, and perform the
following roles:
• Provide personal and caregiver support services;

• Provide comprehensive, interdisciplinary, and longitudinal clinical
and home care;
• Provide palliative care in all settings;
• Ensure the optimal use of and alternatives to hospital and nursing
home care;
• Introduce appropriate assistive technology in all settings; and
• Ensure that transitional care is integrated into all settings; this
integration moves beyond care coordination to the actual presence
of members of the team in the home and community, and the es-
tablishment of relationships with staff, patients, family caregivers,
and other community partners.
When teams have such a central role, they can increase access to care,
improve its quality, and reduce its costs, Edes believes, because so much
waste is inherent in mismanaged transitions.
In addition to the use of teams, the management of transitions, and
integration, technology is another key to improving home care, he said.
The VA already has a robust electronic medical records system (the VISTA
system), but it may not be accessible in the home or in geographic areas
where Internet service is unreliable. For the present, the VA has developed a
software package that includes 1 year’s worth of a patient’s medical records
on a laptop. The importance of mobile electronic documentation will in-
crease as point-of-care diagnostics and hospital-at-home programs become
more prevalent, he said.
Edes concluded that too many people see the growing population of
people with multiple chronic disabling diseases and their concomitant need
for long-term services and supports (LTSS) as the problem and the source of
the unsustainable rise in health care costs in the United States. However, he
said, a refocus on the kinds of services that best serve the small number of
people who incur most of the health care costs can both reduce costs and
greatly improve the quality of care.

Supporting Families
Gail Hunt
National Alliance for Caregiving
Hunt began her remarks by emphasizing one of the themes of earlier

presentations, which is the importance of the patient–caregiver dyad and
how it is at the center of a set of relationships that includes home health
care providers, physicians, nurses, therapists, and all the other health care
providers. Families and other caregivers play a major role in implementing
a patient’s care plan—diet, exercise, medication, and so on. For that reason,
she said, “we need to think of the family caregiver as a member of the care
team” and to build scalable models of care that are truly patient and family
centered and that can accommodate people with multiple chronic condi-
tions. Lessons on ways in which to do that may come from states that have
created strong home- and community-based care programs that involve not
just medical and health care professionals but also individuals who provide
supporting services, such as personal care, companionship for people with
Alzheimer’s disease, and transportation. “If they can’t get to the doctor’s
appointment, the whole system kind of falls apart,” she said.
Skilled providers of home care play an important role in training fam-
ily caregivers, Hunt said. They can also assess both the ability and the
willingness of caregivers to meet the demands being placed on them. Some
needed services may be too physically or emotionally difficult for a family
caregiver to perform (e.g., ostomy care), and the caregiver may require aid
from an external source.
Technology—for example, medication reminders, pill dispensers, and
passive monitoring systems—can help not only the patient but also the
family caregivers, Hunt said, by helping the caregivers manage their time
or providing them with efficient ways to connect to the care system. Such
aids must be affordable, as they are likely to be paid for out-of-pocket. The
developers of technologies need to work with caregivers to design useful,
affordable new tools, Hunt suggested.
Hunt identified barriers to the vision of improving caregiver support.
These included a lack of data on the return on caregiver investment; the
generalizability of existing models; and current Medicare restrictions, such
as the requirement that a patient be homebound or a lack of reimbursement
for telemedicine in urban areas. Other countries (e.g., Australia) have in
place systems for providing long-term assistance to family caregivers, she
said. She added that the United Kingdom has also overcome some of the
barriers, even for parents of children with disabilities who face a lifelong
caregiving responsibility.
Finally, she said, patient goals and patient-reported outcomes are es-

sential in assessing the quality of care. “It is not so much what we did for
the patient as what did the patient want and what did the family want?”
Direct Care Workers

Robyn I. Stone
LeadingAge
Next to the family, people in the direct care workforce are probably the
most important component of the home care system, Stone said. In think-
ing about whether the problems being discussed at the workshop should
be defined as home health care, home care, home- and community-based
services, or personal care, she decided to talk about all of these, because
direct care workers are present in all of these permutations of the care-at-
home sector.
Even though many programs may fit under the broadest rubric of home
care, Stone believes that it is important not to use these terms synony-
mously. It is not just a matter of semantics, she said, but confusion shows
up in the data about home care and becomes ever greater in discussions of
new service delivery models. Data are collected for at least three categories
of direct care providers: home health aides, home care aides or personal
care attendants, and hospice aides. Within those are further subcategories.
Housekeeping and companion services may or may not be considered in-
home care.
Types of Direct Service Workers

The two categories of workers who provide most of the hands-on
functional assistance for patients are home care aides and personal care
attendants, Stone said. They assist with basic ADLs and personal care (see
Chapter 2 for a description of ADLs); they may also assist with instrumen-
tal activities of daily living (IADLs).2 In some situations, they may also be
trained to manage medications. They are the workers who have one-on-one
relationships with patients, they serve as liaisons with family caregivers, and
they provide emotional support. More importantly, “direct service workers
are really the eyes and ears of the care system,” Stone said. They perform
this key observation role in conjunction with family members and when
no family member is present. In the next 25 years, because of increased
childlessness and the divorce rate in the United States, the number of family
caregivers will decrease, Stone indicated. Although relationships between
2 IADLs are complex skills that a person needs to live independently, such as shopping,
preparing meals, using the telephone, taking medications, and managing money.

family caregivers and direct care workers are often good, they also can be
“really terrible,” she said, “with a lot of tension between the two.”
Although the number of direct care workers is expected to grow
48 percent between 2010 and 2020, Stone said, these two key occupational
categories (home care aides and personal care attendants) are expected to
grow 70 percent, and after that, as more Americans reach age 85 years,
the demand will likely grow even faster. Wages in this sector are low and
have been stagnant for the past decade, she said. Benefits vary widely, and a
high proportion of direct care workers are employed only part-time, which
further impedes access to benefits. Enforcement of a U.S. Department of
Labor plan to extend minimum-wage and overtime protection to home care
workers has been delayed as a result of states’ concerns about the potential
impact on Medicaid programs and industry concerns that families could
not afford the increased cost.
“When we think about what we pay them, we wonder how we can get
anybody to do this work,” she said. Nationally, the people who do take
it up are mostly non-Hispanic, middle-aged women. About half are white,
and about 35 percent are black, although Stone predicts more diversity
in this workforce in coming years, along with the greater diversity in the
population of elderly individuals.
The work situation of hospice aides is somewhat better than that of
home care or home health care aides, Stone said, as they receive higher
wages and have greater access to employer-sponsored health insurance and
other employee benefits. Hospice aides are also more likely to be employed
full-time and to stay in their jobs. Hospices’ more generous wages and
employment benefits—as well as the somewhat better training—may result
from the higher reimbursement rate for hospice services. “We need to be
thinking about bringing the rest of the direct care workforce up at least to
where the hospice workers are now,” Stone said.
Training Requirements
For Medicare- and Medicaid-certified providers, home aides and hos-
pice aides must have 75 hours of training and pass a competency exam. No
federal training requirements exist for home care and personal care aides,
and the amount of training varies by state, with many states having no re-
quirements whatsoever. Stone said that a lack of training also may hamper
consumer-directed services, such as cash and counseling.3 Training for the
3 Cash and counseling is “an approach to long-term personal assistance services in which the
government gives people cash allowances to pay for the services and goods they feel would best
meet their personal care needs and counseling about managing their services” (RWJF, 2013).
Under cash and counseling programs, individuals determine who will be paid for provision
of personal care services (including family members) and how those services will be provided.

eyes and ears function is especially important, Stone stated, since research
has shown that home health aides observe a change in a patient’s condition
5 days before a nurse does.
Recruitment and Retention

Problems of low pay and a lack of training suggest to employers and
families a lack of competence among direct care personnel, Stone said,
rather than a shortage of workers, per se. When the local economy is poor,
recruitment is not a problem. Stone’s organization, LeadingAge, includes
in its membership about 6,000 nonprofit agencies that provide services to
the aging population, from nursing homes to assisted living facilities, home
health agencies, continuing care retirement communities, low-income hous-
ing developments, and many others. When the economy begins to improve,
employee turnover among the members begins to rise, she said.
High turnover rates lead to a lack of consistency in care and a succes-
sion of individuals providing care in the home, which can negatively affect
both the physical and mental well-being of the recipients of care, Stone
said. High turnover rates are also hard on an agency’s remaining employees,
because when the agency is shorthanded, workloads increase. They can
potentially affect both the quality of care and the quality of life, she said.
Turnover also increases costs for employers and the health care system as a
whole. With the cost of replacing a home care worker averaging $4,500 and
turnover rates of between 60 and 75 percent, the total costs are enormous.
Stone said that other factors affecting workforce recruitment and reten-
tion are the stereotyping of the industry (which is especially true for nursing
homes) and working conditions. Home care work can be isolating, with
workers having no real sense of community with the other members of an
agency’s workforce. This area has not been well researched, Stone said.
Improving the Direct Care Workforce

According to Stone, principal strategies to resolve problems with the
direct care workforce for home-based care include the following:
• Competency-based training that includes good clinical placements;

• Improved supervision focused on coaching and mentoring;
• Protocols for resolution of problems;
• Continued staff development and career advancement potential,
but not necessarily career ladders (“Not every home care aide or
personal care attendant wants to be a nurse,” Stone said.);
• Policies that permit direct care workers to specialize in, for ex-
ample, dementia care or medication management;

• Procedures that allow frontline workers to be engaged as part of

the care team;
• Improved wages and benefits;
• Training around the challenges of caring for people who have mul-
tiple comorbidities and who take multiple medications;
• Training in signals and symptoms of functional decline, depression,
social isolation, and the impact of dementia; and
• Training in managing family dynamics and cultural competence.
As an exemplary program, Stone cited the Personal and Home Care

Aide State Training (PHCAST) Program, a six-state demonstration program
funded through the ACA.4 North Carolina’s PHCAST project, for example,
is a four-phase program that develops career lattices and career ladders,
is involved with the state’s high schools and community colleges, and has
established certifications for different levels of training. She also cited
the Eldercare Workforce Alliance’s advanced direct care worker concept,
which, again, proposes career lattices so that workers can become home
care and personal care aides with more advanced capabilities. Finally, she
noted the Service Employees International Union Healthcare NW Training
Partnership, a competency-based apprenticeship program in Washington
State involving a school and labor management partnership intended to
deliver training to the state’s 43,000 home care aides.5
Meeting Future Needs

In the long term, Stone predicted, the emerging gap between the need
for home care and the available workforce will grow because of a declining
availability of individuals able to provide informal care, a decline in the
availability of people in the age groups who want to hold these types of
jobs, and an increase in demand for home care services brought on by an
aging population and shifts of care from institutional settings to the home
and community. Although technology—robots, for example—may fill part
of the need at some point, for the foreseeable future, “a significant human
capital need” will remain, Stone said, although technologies may comple-
ment that need.
Also important is the development of new worker pipelines, as the
North Carolina PHCAST project did with high school students. Older
workers, the unemployed, new immigrants, and former family caregivers
may provide new worker pools. The new long-term service delivery models
4 See
http://bhpr.hrsa.gov/nursing/grants/phcast.html (accessed December 5, 2014).
5 See
http://www.myseiubenefits.org/training-partnership-recognized-white-house-expansion-
apprenticeship-program (accessed December 5, 2014).

being developed, primarily under the ACA, will not happen without invest-
ment in this key workforce, Stone said.
Care Coordination and the Consumer Voice

Henry Claypool
American Association of People with Disabilities
The agencies that provide personal care services in the Medicaid en-
vironment operate on thin margins, and managed care organizations are
expanding in this area, increasingly affecting how states deploy their home-
and community-based service systems. Claypool sees an opportunity to help
these organizations understand the importance of the direct care workforce.
It would be a fundamental error for them to adopt a “rigid clinical frame”
and deploy resources solely on the basis of a medical model, he said. If
they did, the provision of any service outside medical care—that is, all the
social services needed by patients with chronic medical conditions and their
families—would be deemed a service that increases costs.
Among the many changes in the health care environment in recent years
are the consumer-directed workforce and the independent living movement,
both of which involve the provision of care in the home. According to
Claypool, research shows that a majority of older adults want more control
over the workers who come into their home, including when they come
and what they do. Programs that offer this greater control are consumer
directed. The independent living philosophy can help guide the thinking
about how this workforce is deployed and how people with clinical train-
ing can guide that process. Independent living services provide services
related to ADLs. They are important functional tasks and, in the Medicaid
world, are distinct from clinical tasks. “We have to think about this as not
skilled versus unskilled, which is a framing that I think is harmful to the
workforce,” he said.
The idea of career ladders is grounded in the skilled care frame and
considers home care workers to be the bottom rung. However, Claypool
said, “we should value that role and invest in it appropriately. We are
actually adding value by helping people remain direct care workers.” The
promotora6 model, he believes, can be adapted to enable direct care work-
6 A promotora is a community health worker used in Hispanic communities. “As trusted
members of their community, promotoras provide culturally appropriate services and serve
as a patient advocate, educator, mentor, outreach worker, and translator. They are often the
bridge between the diverse populations they serve and the health care system” (Rural Assis-
tance Center, 2015).

ers to take on as much responsibility as they possibly can to assist people

with chronic conditions and difficulties with ADLs.
Encouraging direct care workers to expand in these areas can be done
in ways that complement nurses’ roles, freeing registered nurses to practice
at the top of their training and scope of practice, he said. The promotora
model also embodies the idea of health promotion, reinforcing the “inde-
pendent living philosophy and values that come with it, [which] are es-
sential to allowing the workforce to really understand how they can work
with individuals.”
In addition, he suggested that attention be given to health-promoting
activities related to diet and exercise. Direct care workers from the same
socioeconomic strata as their clients understand the challenges faced by
people who live in food deserts, who are unaccustomed to balanced meals,
or who have no good options for exercise. Even helping a person develop
the strength to walk to the bus stop can be helpful. (Claypool noted that
knowledge of how to navigate fixed-route public transportation systems
encourages independence, because they are more reliable than paratransit
systems.) Direct care workers can potentially serve as “force multipliers,”
he said.

Education and Training

Margherita C. Labson, The Joint Commission, asked how prepared the
professional staffs of home health agencies are to conduct the types of train-
ing suggested for direct care workers. Stone said that she does not believe
that they are trained in this at all. Stone cited a 2008 Institute of Medicine
(IOM) report that addressed a lack of training in geriatric competencies
across the entire workforce (IOM, 2008). She said that a systemic lack of
investment has produced a shortage in the number of faculty to be trained,
with home care receiving the least investment of all. Claypool said that or-
ganized labor has stepped forward in a number of states, like Washington,
to develop a training infrastructure.
Michael Johnson, BAYADA Home Health Care, said that a bit of an
“educational arms race” is under way. He noted that all physical therapists,
occupational therapists, and pharmacists are now (or will be) trained at the
doctoral level. He asked if health care professionals are becoming overedu-
cated to do some of the things that they used to do. Is there someone who

can do the work just as well for less? Johnson answered his own question,
saying that direct care workers can perform many tasks.
Engaging Individuals and Their Families

Johnson also raised concerns about engaging the family in care. If the
family’s perception is that the only person who can do the job is a clinician
with a doctoral-level education, he said, problems arise. Family caregivers
are disempowered; they do not believe that they can do the tasks required
of them. Another consequence of this trend, Claypool said, is that it may
be more difficult to integrate teams in which some members have obtained
their advanced degrees and others have little formal training. Members of
the team with little formal training may have additional and long-standing
socioeconomic disadvantages and cultural differences with other team
members, as well, yet their perspectives can be of great value because their
backgrounds reflect the backgrounds of patients and families. “When we
wake up to this one day, I hope we have not disempowered them to such
an extent that they no longer share their wisdom,” Claypool said.
George Taler, Washington Hospital Center, asked if, when the VA en-
rolls someone in the home-based primary care program, a mechanism is in
place for assessing the ability and willingness of caregivers in the home to
provide care, the caregivers’ integration with the service community, and
the household’s financial resources that can be directed to care. According
to Edes, the VA’s home-based primary care program does not require that
veterans have a caregiver in the home. Any assessment of questions of this
type would be made by the social worker or nurse. The VA also has a good
track record with finding people in the community who want to be caregiv-
ers under the medical foster home model. Gail Hunt said that a number of
assessment tools have been developed to determine the ability and willing-
ness of family caregivers to perform needed tasks. The basic criteria have
been identified, but no universal tool exists, and it is not clear how widely
these basic criteria are used. Part of “ability,” she indicated, depends on
what the tasks are and the physical or time limitations of the caregiver. In
addition, Claypool said, at some point it may be useful to assess the willing-
ness and ability of patients to adopt the use of technology, as home-based
diagnostic and treatment options are rapidly expanding, but many older
adults believe that technology is difficult to use, he said.
Teams of Care
Johnson further asked about what has been done to help teams be
successful, so that the people who are accustomed to being the leaders and
somewhat expected to take that role—primarily physicians—have the com-

petency to know when to lead and when to follow. Do direct care work-
ers, who also should be part of the team, feel competent enough to lead,
or do they always follow? Edes said that to address some of the dynamics
that arise in interdisciplinary teams, the VA conducts interdisciplinary
team training. In addition, every team member takes a leadership role on
a rotating basis. The home-based primary care providers are the VA staff,
and they rely on community providers for home health aide and hospice
services. It can be harder to embrace these non-VA staff as team members.
At the same time, Edes believes that involving family caregivers in the de-
velopment of care plans has helped them integrate with the care teams. In a
home care housing program under way in Camden, New Jersey, Stone said,
a promotora/community health worker model is being used. In that model,
the promotora is doing most of the frontline work, including medication
management and involving patients in chronic disease self-management.
These staff are working effectively with the rest of the team. “They are
communicating with each other all the time,” and it is not high-tech.
Technology and Services

Kathryn H. Bowles, Visiting Nurse Service of New York Research
Center and the University of Pennsylvania School of Nursing, asked about
the key features that make the VA telehealth program work while others
across the nation struggle with making it cost- and clinically effective. Edes
said that although he is not responsible for the VA telehealth programs, his
department does integrate with those efforts, which serve about 15 percent
of veterans receiving home-based primary care. Telehealth appears to work
well, he said, when the home care team and telehealth team meet regularly
and solve problems together. This kind of effective integration boils down
to good communication. Bowles asked if having one electronic health re-
cord across the entire VA system helps. Edes responded that in any kind of
emergency situation, like Hurricane Katrina or even when veterans travel
from one part of a state to another, it is tremendously valuable.
Judith Stein, Center for Medicare Advocacy, asked what can be done
to close the divide between the people who need home care services and
the people who provide them. Claypool believes that the home care worker
minimum wage and overtime protection rules recently put on hold by the
U.S. Department of Labor will “live to see another day,” in part out of
growing recognition of how much home-based LTSS depends on these
workers. Finally, Stein noted that many of the services that have been dis-
cussed at the workshop are vitally important but are being inappropriately
denied coverage under Medicare.

Models of Care and

Approaches to Payment
No single model of care will be able to meet the needs of all individu-
als who receive (or want to receive) home health care. As a variety of ap-
proaches are needed to deliver a range of services in the home, different
approaches to payment also need to be considered. At the workshop, an
overview of the current range of models and approaches to payment was
provided, and then six speakers described their individual experiences (in-
cluding both successes and challenges) in trying new models of care and us-
ing new approaches to payment. Together, these presentations consider how
to facilitate the development of the models and payment approaches that
will be needed to achieve a vision for the future role of home health care.
Overview of the Range of Models

and Approaches to Payment
Peter Boling
Virginia Commonwealth University
Boling began his presentation by describing the scenes that he encoun-

ters when he takes his medical students to his patients’ homes, an aspect of
clinical training that students rarely experience. Recent visits provided an
opportunity for the students to see the deep connections that can develop
between clinician and patient, he said. These stories, presented in Box 6-1,
gave the students—and the workshop participants—a sense of the con-
tinuum of care and the diverse realities of patients’ worlds.
65

BOX 6-1
Two Virginia Men
Boling took his medical students to the home of a Virginia man, age 53
years, who has lost the use of his limbs and torso. He has been Boling’s patient
for 20 years. He spends his days mostly in the prone position because that gives
him the most maneuverability, given his limited use of his hands. As a result, he
developed pressure ulcers on his elbows. He has had multiple hospitalizations
because of urinary tract infections. On one occasion, he was placed in a nursing
home, after which he said he is never going back. He is heavily dependent on
medical technology, specifically, his bed and wheelchair.
This man runs a consumer-directed care model for himself. According to him,
the three women assigned to comanage his care with him are not very competent,
and he has had to teach them what to do. In fact, he has trained a number of
different individuals to be his aides and how to properly care for a quadriplegic,
“which is not easy,” Boling said.
The second patient Boling described is a man who was accidentally shot in
the neck at age 16 years while walking with his sisters on Coney Island. He com-
pleted his college education, obtained a master’s degree, and became an effective
teacher. One of his students is the sister of the woman who is now his personal
care aide (again, a consumer-directed care arrangement), and she—along with
her baby and husband—live in the front part of the house where he stays. She
smokes a lot. Although it is not an ideal situation, he has been homeless in the
past, so it is much better than what he has experienced at some other times in
his life.
He has a laptop and is waiting for Internet service. Boling wants to help him
reconnect with his teaching. In the past, this man also trained some of his aides,
who at night worked in strip tease clubs. He says that was a very interesting period
for him and that they actually did a pretty good job.
SOURCE: As presented by Peter Boling on September 30, 2014.
Measuring the Value of Home Health Care

The diversity of home health care experiences makes the components
of care as well as their effects hard to measure in a reliable, consistent man-
ner, “so that you can say structure, process, [and] outcome and be able to
categorize them in a way relevant to federal health policy,” Boling said.
Nevertheless, it is necessary to define the population of care recipients and
their needs in some manner. The really complicated patients—analogous to
Thomas E. Edes’s 5 percent—simply do not fit into the usual care systems.
“We need to carve these patients out,” Boling said, and provide them care
by use of a different model in which care is paid for differently and out-
comes are measured differently.

MODELS OF CARE AND APPROACHES TO PAYMENT 67
Boling said that a strong medical component is often left out of home
health care and that it needs to be combined with social supports into a
service that is truly patient-centered and affordable and that aligns funding
with the care model. When quality is measured and value is estimated, it is
important to adjust the cost estimates according to the risks for the popula-
tion being served and to select quality measures specific to that population,
as well as the care setting. These measures must be simultaneously accurate
and not too burdensome to collect, he said.
Patient Needs
Home health care users fit into a variety of subtypes, Boling said (see
Table 6-1). The most complicated, challenging, and expensive patients
receiving home health care, Boling said, are those with a high comorbidity
and illness burden who may need acute care at home, post-acute transi-
tional care, or long-term health care. His estimates are that some 3 million
to 4 million Americans are chronically limited to their homes and have
three or more problems with activities of daily living (ADLs). Most but
not all of them are elderly, he said, and although they may have a reduced
life expectancy, they are not necessarily eligible for hospice. Some are
dependent on medical technology, such as ventilators. A group of very ill
patients—another 2 million to 3 million—also requires large amounts of
medical care, but only for a relatively short time, because of an acute illness
or injury or because of an advanced life-limiting condition.
TABLE 6-1 Home Health Care User Categories

Category Description of Home Health Care User
A The user has no illness (acute or chronic) and uses self-help sources
B The user is ambulatory, independent, and not “sick”; some chronic health
conditions exist
C The user is younger, and functions (ADLs) are limited by one condition;
the user is not “sick” often but needs continuous ADL support
D The user is older with chronic cognitive or functional impairment; the user is
infrequently acutely ill (low cost) and needs support with ADLs
E The user requires post-acute care at the end of a discrete illness episode but
has a rapid return to stable condition and home health care ends
F The user has a high comorbidity and illness burden and is sick, and the cost
of care is high
NOTE: ADLs = activities of daily living.
SOURCE: Reprinted with permission from Peter Boling, Virginia Commonwealth University.

Although the medical needs of these patients may be considerable,

Boling said, they also need a matrix of social services, including, as other
presenters have said, paid personal care, transportation, nutrition and home
safety services, communication assistance, and legal and financial plan-
ning. The care system needs to make the services that cannot be provided
by friends and family accessible, comprehensive, and coordinated and to
make sure that these services are aligned with the patient’s goals and needs,
he said.
Medicaid recipients needing home health care encounter a program
that, Boling said, offers discontinuous skilled care, a weak medical model,
a slow response to urgent problems (resulting in unnecessary hospital-
izations), and inconsistent attention to needs for help with ADLs and
a system that is not aligned with other programs and payers, notably,
Medicare.
Models of Home-Based Care

As evidence that substantial improvements are possible, even for acutely
ill individuals, Boling pointed to a number of programs, in addition to the
programs previously described by Edes sponsored by the U.S. Department
of Veterans Affairs (VA) (see Chapter 5). Boling reviewed evaluations of
three models of care that have proved successful according to patient out-
comes and cost reductions but that have not been adequately replicated or
scaled up:
• An evaluation of Outcome-Based Quality Improvement, a 1990s

performance improvement methodology that reduced hospitaliza-
tions by about one-quarter (Shaughnessy et al., 2002);
• A randomized trial of Hospital at Home, which provided hospital-
level care at home and that resulted in fewer medical complications
and lower costs (Leff et al., 2005); and
• A randomized trial of the effects of assignment of an experienced
nurse practitioner (NP) to at-risk older adults while they were still
in the hospital; the NP followed up with these adults once they
were home, managed their care, and ensured that the care plan was
followed; this approach resulted in reduced hospital readmissions
and a 50 percent cost savings (Naylor et al., 1999).
Concerns that have limited the spread of these highly targeted programs
are that they are not considered scalable, which is not necessarily true,
Boling said. A key question is who benefits from the savings from such
programs? Although they are good for the Medicare program, participat-

ing hospitals experience reduced reimbursements. Boling tells his hospital

and the subspecialists who practice there, “You will not miss these patients
if we carve them out. You lose money on them. They clog up the works
and slow down the clinics.” Finally, not all patients in the NP-centered
program described above could function without additional help after the
NP visits end. “That’s a limitation of this new silo—the transitional care
silo—that we are starting to create,” he said. Stimulated by this problem, a
less expensive, less intensive intervention was tested on a slightly less sick
group of patients and also proved effective, but it provided lower cost sav-
ings (Coleman et al., 2006). This model involved patient empowerment,
improved communication and records transfer, and had “a lighter clinical
touch,” Boling said. Although it may be more easily scalable, the problem
of who will pay for it remains.
Boling then reviewed a number of other innovative programs.
Community-Based Care Transitions Program

The Community-Based Care Transitions Program,1 created under Sec-
tion 3026 of the Patient Protection and Affordable Care Act of 2010
(ACA),2 has devoted up to $500 million to tests of new transitional care
models at more than 100 participating sites so far. Again, this program
provides short-term assistance for patients, Boling said, but the program
“starts to reorient people’s thinking in the community and involves a lot
more people in the process of improving health care.”
Geriatric Resources for Assessment and Care of Elders

The Geriatric Resources for Assessment and Care of Elders (GRACE)
model was tested in a randomized trial and showed considerable improve-
ment in clinical care processes (Counsell et al., 2007). Selected patients
were discharged home, where they received quarterly visits from an NP
for 2 years. The NPs reported back to clinic-based geriatricians and made
recommendations. Analysis showed an approximately 30 percent reduction
in overall costs, attributable to fewer hospitalizations and emergency room
visits in the highest-risk subgroup, Boling said.
1 See
http://innovation.cms.gov/initiatives/CCTP (accessed December 24, 2014).
2 Patient

Program of All-Inclusive Care for the Elderly

The Program of All-Inclusive Care for the Elderly (PACE)3 is an es-
tablished benefit for individuals dually eligible for Medicare and Medicaid
that has been used by only a small number of participants (Wieland et al.,
2010). It requires people to give up their traditional Medicare and Medicaid
and enter a structured, high-overhead, mostly center-based program pro-
viding comprehensive health and social services. Although the savings that
it achieves are modest, Boling said, the quality of services for those who
like the model is high, and it decreases the cost burden for government
programs by accepting the full risk for enrollees.
Home-Centered Primary Care

Boling noted a non-VA home-centered primary care program tested in
a case-control study that used an interdisciplinary team model to provide
medical care and hospice services in the home (De Jonge et al., 2014). This
model achieved better care and reduced costs 17 percent over 2 years and
reduced costs 31 percent for the most complex, sickest patients through
reductions in hospitalizations and nursing home use. It requires an experi-
enced care team, and traditional fee-for-service payments do not cover its
costs.
Independence at Home
Independence at Home,4 funded by Section 3024 of the ACA, is tar-
geted to post-acute care patients with several serious chronic conditions and
disabilities. The participating sites, which are using various organizational
models, may be able to share in program savings. This is a key, Boling
said, to creating incentives for medical care providers to become involved
in longitudinal home-based care for a high-cost population and to fund
the program longer term. If the model works, legislation will be needed to
expand it.
Boling responded to a question from James Pyles of Powers Pyles Sutter
& Verville PC about how Independence at Home works for seriously chron-
ically or terminally ill individuals who may need help on a 24-hour-per-day
basis. Realistically, Boling said, the only people in the home 24 hours per
day are patients and their family members. Then, depending on what they
can afford, an aide may be present for 8 hours or more. If someone truly
3 See http://www.npaonline.org/website/article.asp?id=12&title=Who,_What_and_Where_
Is_PACE (accessed December 5, 2014).
4 See http://innovation.cms.gov/initiatives/independence-at-home (accessed December 5,
2014).

needs care 24 hours per day, whether they are in hospice or getting to that
point, the care process is often supported by a constellation of friends and
family, neighbors, and paid aides under existing financial models, Boling
said.
Further Considerations
Overall, Boling noted the following lessons from these models:
• Significant cost savings are achievable.

• Targeting of the highest-risk patients is the key to achieving savings.
• Transitional care models need to transition to longer-term care for
many patients.
• To continue, successful models need stable sources of funding.
This litany of successful and promising programs also suggests the

need to look at some models that have not worked. Lessons from these
approaches, Boling said, include
• The coordination of care through a call center or the like does not
work unless good integration with primary care is achieved.
• Patient-centered medical homes are not sufficiently patient centered
for the sickest people who are homebound, although they may be
effective for the majority of patients.
• Accountable care and managed care models need some kind of a
carve out for the frailest population.
Standards of care that recognize that some of the treatments that

make sense in younger, healthier populations may not be relevant to frail
individuals who are in their 80s and 90s are needed, Boling said. In some
cases, these treatments do not save lives or improve outcomes and instead
create troubling side effects and increase risk. Low-value services are too
expensive at almost any price point, he concluded.
Teresa L. Lee, Alliance for Home Health Quality and Innovation, asked
how the system can navigate toward new delivery models that make more
optimal use of comprehensive home health care without setting up more
silos. Boling advocated for carving out this population from the hospitals
and clinics and bringing in a well-trained home health care workforce to
deliver team-based care using an integrated medical-social model.

Experience of Sutter Health

Jeffrey Burnich
Sutter Health
Sutter Health is a large, not-for-profit integrated delivery system in

Northern California. Like other providers, Sutter faces the urgent need to
transform its care delivery practices across the health care continuum to
better serve very frail, very sick, very-high-cost patients, particularly in the
last few months of life, Burnich said. Many, but not all, of these patients
are Medicare beneficiaries. In doing so, one of Sutter’s greatest challenges,
Burnich said, has been system fragmentation.
In 2009, Sutter Health developed the Advanced Illness Management
(AIM)5 program by bringing together a cross-disciplinary group (including
doctors, nurses, home health care and hospice professionals, and data ana-
lysts) to try to develop a new approach to integrating services for its home
health care population. Burnich said that it built on Sutter’s managed care
experience and a strengthened telesupport system. The result was the cre-
ation of transition teams in the home-based care program and the capacity
to respond to emergencies, such as acute exacerbations of illness, pain cri-
ses, and family anxiety for patients receiving either end-of-life care or other
services. The integrated care system is organized around patients’ goals
and is targeted to people who are both frail and the sickest. Referrals can
come from a hospital, a doctor’s office, or a skilled nursing facility. Burnich
noted that about 40 percent of the referrals come directly from physician
practices, and “without the doctors’ support, this program wouldn’t be
where it is today.” The combination of AIM and integrated care manage-
ment expertise in the home is yielding person-centered, evidence-based,
coordinated care, he said.
The Sutter system uses a single electronic health record to record most
of the services that it provides, although the home health care nurses use
a separate database. The record system that Sutter uses also does not have
a hospice platform, but Burnich believes that it will be adopted when it is
developed.
About 2,100 patients are in this system at present, with the number
increasing by about 5 percent per month, but the number of patients in-
cluded is limited by the need to find trained home health care providers. The
program leaders attribute this growth to the strong demand from physi-
cians: “We can’t keep up,” Burnich said. Program staff make sure that they
5 See
http://www.sutterhealth.org/quality/focus/advanced-illness-management.html (accessed
December 5, 2014).

communicate with referring physicians to assure them that their patients are
receiving good care but do not inundate them with data.
According to Burnich, the following are essential parts of the program
for each patient:
• An advance care plan,

• A self-management plan for patients of symptoms that raise a red
flag,
• Medication management,
• Ongoing follow-up visits, and
• Engagement and self-management support.
All of this, he said, rests on a curative plus palliative care foundation.

The Sutter project received a health care innovation grant from the
Centers for Medicare & Medicaid Services (CMS), and at the time of the
workshop, Burnich was preparing to present its preliminary results to that
agency. These include a 59 percent reduction in hospitalizations for patients
enrolled in the AIM program for 90 days, a 19 percent reduction in emer-
gency department use, and a 67 percent reduction in high-cost days in in-
tensive care units. Significant cost savings attach to each of these reductions.
Initially, Burnich said, hospital administrators thought that they did not
want to lose these patients because they contribute to the hospital’s fixed
costs (“contribution margin”), but in fact, after day 9 or 10, they cost the
hospital more than the reimbursement covers, creating negative income.
By keeping these high-cost patients at home, hospitals actually make more
money by losing less. When the staff in the finance department understand
that, they are more comfortable with a program that does not fill beds,
Burnich said.
Sutter has analyzed the profit and loss implications of the program
for hospitals, for doctors’ practices (because they might lose revenue), and
for home hospice, Burnich said. The doctors actually benefit financially
from it, because there is no other way to cover the high cost of caring for
these patients and providing the lengthy consultations that they need. The
savings amount to $11,000 per beneficiary per year, and over the 3 years
of the CMS grant, Burnich said, Sutter plans to serve 10,800 patients. It
committed to save $29 million on these patients but is on track to actually
save $118 million. The impetus for pursuing a program of this type arises
because of the extent of capitation within Sutter, which means “we are on
the hook for managing these patients,” Burnich said.

Experience of Atrius Health

Richard Lopez
Atrius Health
Atrius Health is a nonprofit alliance of six leading independent medical

groups in eastern Massachusetts that has created an integrated delivery sys-
tem that includes both home health care agency and hospice services. Atrius
Health provides care for 1 million adult and pediatric patients. The Visiting
Nurse Association Care Network and Hospice (VNACNH), which has been
part of the system for the past few years, is a wholly owned subsidiary,
and Lopez said that its integration with the rest of Atrius’s providers is an
ongoing process. This acquisition was deemed necessary to take care of the
alliance’s capitated patients through Medicare Advantage, its accountable
care organization (ACO) patients through the CMS Pioneer program, and,
ultimately, Lopez said, its commercially insured patients. About 35,000
Atrius patients are involved with its Pioneer ACO, and some 25,000 are
enrolled in Medicare Advantage. Together, they account for a half billion
dollars in risk. The demographic trends and illness projections mentioned
by previous workshop speakers are very relevant to Atrius’s strategic plan-
ning, Lopez said.
One strong point in acquiring VNACNH, Lopez said, was that its
geographical coverage area was relatively congruent with that of Atrius.
The availability of both physician services and services from VNACNH
allowed Atrius managers to plan effectively and be financially aligned to
serve a large, high-risk population. To do that, Lopez said, Atrius has cre-
ated interfaces that
• Improve communication between home health care providers and

physician offices;
• Foster teamwork across providers and disciplines;
• Facilitate the development of a collaborative program designed to
meet patient-centered care goals, regardless of payment source; and
• Provide metrics for accountability.
Communication and Teamwork

Although the visiting nurses complete the usual lengthy intake forms
that assess patients for everything from the risk of falls to the medications
that they take and the presence of depression, these records are often not
well incorporated into the patients’ records, Lopez said. Atrius’s electronic
health records system ensures that current assessments appear where they
are convenient for physicians to access. Practice care managers receive a

weekly email report on clinical data for active patients. The report includes
progress toward goals, response to teaching, discharge planning, and any
hospice team meeting notes. The report is then distributed to physicians.
(Lopez noted that the Atrius system uses encrypted email for communica-
tion among providers.)
Atrius has instituted an automated referral system through the elec-
tronic health records, so that when a referral is made it goes to VNACNH
intake staff, who can then access the patient’s record to set up the case for
VNACNH. At present, VNACNH uses an end-of-life information system,
and Lopez said that Atrius is considering adopting a home health care mod-
ule in the next year or two to make records more fully integrated.
A steering committee comprising senior staff oversees the development
of the Atrius-VNACNH relationship and clarifies policies and procedures to
ensure care coordination and collaboration, Lopez said. In addition, many
specific activities have been undertaken to transform VNACNH’s relation-
ship with Atrius Health from one in which VNACNH is a vendor to one
in which VNACNH and Atrius have a true partnership.
In primary care practices, Lopez noted that an effort has been made
to integrate members of the patient-centered team with VNACNH staff in
relevant places along the continuum of care. In particular, work has con-
centrated on educating practice staff about palliative care and end-of-life
challenges, he said. Another specific team-building strategy is “geriatric
roster reviews,” which are regular team meetings in the doctor’s office in
which case reviews are done for patients identified to be at high risk.
Program Design and Metrics

VNACNH has developed a palliative care consult team that works with
the primary care practice and the home health care staff to better manage
patients near the end of life, and it also has a robust advance care plan-
ning program. According to Lopez, one goal of the end-of-life efforts is to
encourage earlier hospice enrollment, contrary to current practice patterns in
Massachusetts, which overall has one of the nation’s shortest hospice lengths
of stay. “A lot of low-hanging fruit is there,” Lopez said, as Atrius attempts
to improve quality and reduce costs of care.
The system has developed a one-time-visit home assessment system
paid for not through Medicare but by the physician groups. They assess
patients’ homes for safety and adequacy as a care environment. Atrius’s
total joint program, also paid for by the physician groups, enables patients
to undergo rehabilitation at home rather than in a skilled nursing facility
or inpatient rehabilitation facility. Those who can go home with help after
knee or hip replacement incur about $3,500 less in care costs and have the
same or better outcomes, Lopez said.

Lopez also noted that by using the programmatic flexibility allowed

under the Pioneer ACO program, Atrius’s VNACNH staff help patients
who end up in the emergency department go home with support rather
than experience an unnecessary hospital admission or referral to a skilled
nursing facility.
According to Lopez, other program initiatives in some stage of planning
or initial implementation include the following:
• Expansion of telehealth care for congestive heart failure patients

beyond the Medicare episode;
• Implementation of physician/VNACNH visits by video and through
the use of remote diagnostic technology; and
• Expansion of home-based primary care, which entails streamlined
communication and scheduling as a team.
The philosophy underlying all these programs is one of care management

and not medical management, Lopez said, and home visits are based on
need, not insurance coverage.
The results of this integration of home health care and Atrius Health’s
physician practices are being assessed monthly through the use of measures
examining cost and utilization, quality, and the patient experience. Lopez
said that the data collected for the Pioneer ACO and Medicare Advantage
patients receiving VNACNH home health care services indicate that in
comparison with the outcomes in previous years,
• Hospital readmission rates are down;

• VNACNH is providing an increasing proportion of home health
care;
• Eighty-five percent of patients admitted to VNACNH are screened
for the risk of falls and for depression (with the outcome of the
screening being documented in the electronic record); and
• Ninety percent of patients have had a discussion about medicines,
pain management, and home safety.
According to Lopez, work still needs to be done to increase the proportion

of patients with advance care planning discussions and documentation and
to improve patient satisfaction (84 percent of patients give the VNACNH
a rating of 9 or 10).
In the future, Atrius Health is considering developing an internal bun-
dled payment system, providing clinical pharmacy management in the
home, and more fully integrating home health care and hospice services
with the system’s existing medical record system. The system will continue

to work on its major challenge, Lopez said, of “bridging that communica-

tion gap between the doctor’s office and the home.”
Experience of the Visiting Nurse Service of New York

Rose Madden-Baer
Visiting Nurse Service of New York
The Visiting Nurse Service of New York (VNSNY) is the nation’s

largest not-for-profit home health care organization, Madden-Baer said.
It offers home health, hospice, and palliative care; Medicare Advantage; a
managed long-term care plan; paraprofessional and private duty nursing;
and aide services. On any given day, she said, approximately 66,000 people
are under the agency’s direct or coordinated care, and in 2013, its staff
made some 2.3 million clinical visits for patients of all ages.
VNSNY is involved in a number of acute, post-acute, and community-
based care models for population health, and according to Madden-Baer,
the agency has a dual imperative to transform itself from not only providing
excellent home health services to also using its expertise to develop centers
of excellence around care coordination and to provide new models of care
as alternative payment structures develop. “We use our care coordination
expertise as a laboratory for development and testing of new community-
based health care models,” Madden-Baer said. The vision is to be the
region’s best-in-class not-for-profit community-based integrated delivery
system so that it may play a role well beyond that of a traditional home
health care agency.
VNSNY Platform
The platform that VNSNY has developed is used for the coordination
of population care, management of delegated care, and population health,
depending on the needs of particular programs or clients. The platform
covers the following:
• Evidence-based tools;
• Person-centered goals and care plans;
• Nurse-conducted assessment and care coordination;
• Health coaching and support;
• Collaboration with primary care and other providers;
• Financial and clinical outcomes measurement and reporting; and
• Predictive analytics and risk stratification.

At the center of all these activities is the individual patient and his or
her family, Madden-Baer said, whom VNSNY staff interact with in multiple
ways: face-to-face, by telephone, and electronically. These interactions are
based on a person-centered goal and care plan that includes opportunities,
goals, and interventions.
A set of predictive analytics has been developed with the agency’s re-
search center. These tools allow the stratification of patients into low-risk,
rising risk, and high-risk categories. The type of risk may vary, she said,
from risk for hospitalization to risk for care management, for example. The
agency uses a care management documentation system (not a home health
care documentation system) that includes a comprehensive health risk as-
sessment and also has the New York State–mandated uniform assessment
tool embedded in the system. Data from the risk assessments contribute to
the calculation of the risk score. Madden-Baer said that once a person is
appropriately categorized, the agency uses a “dosed mix” of interventions
and evidence-based tools to improve patient activation, depression symp-
toms (as applicable), and medication adherence.
Workforce
Madden-Baer noted that patient assessments are performed by regis-
tered nurses (RNs) who are trained in a 12-week intensive program at the
Duke University School of Nursing to be population care coordinators.
Their training modules cover topics such as care transitions, evidence-based
practices, social determinants of health, health literacy, sociodemograph-
ics, and biopsychosocial issues. The RN population care coordinators lead
teams that include NPs, psychiatric NPs, pharmacists, hospital-based RN
liaisons (who, in some cases, serve as transitional care coordinators), social
workers, and health coaches. In addition, they work with a wide range of
other health care providers and organizations as needed.
The health coaches, who are trained in Eric Coleman’s Care Transitions
Model, not only provide health coaching and patient navigation but may
also accompany high-risk patients to their first primary care appointment
and ensure that patients understand the medical terminology and patient-
provider discussion. The health coaches can help address health literacy
barriers, Madden-Baer said, because they often come from the same com-
munity as the patient or speak the same foreign language.
New Projects
VNSNY is engaged in two CMS demonstration projects on bundled
payments, Madden-Baer said, and is embarking on a hospital-at-home proj-
ect with a large academic medical center. Some health plans have delegated

their disease management services to VNSNY, for example, for diabetic and
prediabetic enrollees. The agency is working with ACOs and health plans to
provide posthospitalization transitional care. It has two projects under way
to provide health and wellness services with behavioral health support for
posttraumatic stress disorder and reconnections to primary care services for
people affected by Hurricane Sandy. VNSNY also provides care coordina-
tion for the largest managed long-term care plan in the state.
New York State has sponsored a major initiative, the Delivery System
Reform Incentive Payment Program, to encourage care coordination, atten-
tion to social determinants of health, behavioral health, and better man-
agement of services for Medicaid recipients and recipients dually eligible
for Medicare and Medicaid. Madden-Baer said that at present VNSNY is
partnering on at least 11 different projects, drawing on the agency’s exper-
tise in population health and the coordination of care.
Successes and Challenges

According to Madden-Baer, factors that have been important to the
success of the agency are the use of evidence-based tools, commitment to
staff training at all levels, a partnership with a leading academic institution
to conduct training, the use of standardized approaches across service lines,
and the use of interventions tailored to the specific needs of patients.
The agency’s challenges, said Madden-Baer, are the current reimburse-
ment model, the need to change the perception of VNSNY—internally and
externally—to recognize that it is more than a home health care agency, and
the need to capture data for program monitoring and evaluation.
Experience of Humana at Home

Eric C. Rackow
Humana At Home
According to Rackow, Humana is pivoting from a health plan to a

health care company, creating an integrated care model to support its
members. Humana At Home manages a suite of programs intended to
provide care for older adults with multiple chronic conditions and func-
tional, behavioral, or cognitive limitations. It has 60 home health care
clinical offices in 13 states and almost 15,000 employed and contracted
field care managers in its nationwide network. It has developed a national
database that care managers can use to link members to local organizations
that provide a range of supports, from Meals on Wheels to audio books
for the blind and an online portal to support family caregivers. Rackow
said that the program currently manages 600,000 Humana members who

are in Medicare Advantage programs, Medicare Advantage special needs

programs, or Medicare Advantage programs for individuals who are dually
eligible for Medicare and Medicaid.
Pyramid of Services
The organization provides programs for managing individuals with an
escalating intensity, depending on their functional and activity limitations
as well as the number and severity of their illnesses (see Figure 6-1). Patient
management starts with a telephonic program that offers in-home support
when needed. About 25 percent of the population served by the telephonic
program has an in-home visit to assess the home and the patient’s circum-
stances, and about 10 percent has ongoing, in-home care management.
Hospital at Home
MD/NP Home Visits
Home Health (Skilled Services)
Care Coordinaon and Management (RN/SW)
Telehealth and Remote Monitoring (Virtual Connecvity)
FIGURE 6-1 Humana At Home’s goal for a range of home-based services.

NOTE: MD = medical doctor; NP = nurse practitioner; RN = registered nurse; SW
= social worker.
SOURCE: Reprinted with permission from Eric Rackow, Humana At Home.

As other workshop presenters have emphasized, Rackow said that

Humana At Home focuses its services on care coordination and manage-
ment for the sickest 25 percent of members who drive almost 80 percent
of the program’s costs. “We are not going to solve this in the hospital,”
Rackow said. They target this population through the Humana At Home
Chronic Care Program, which is an ongoing care management program for
this population with critical needs, complex illnesses, and multiple chronic
conditions. To identify the members most at risk for future severe illness,
Rackow said, the organization looks at both the presence of chronic ill-
nesses and functional limitations affecting ADLs. In Humana’s experience,
impairment of functionality “drives health care utilization and cost in the
chronically ill, especially in seniors,” Rackow said.
Humana’s home health care pyramid begins on a base of telephone
counseling, Rackow said, and then the middle levels of care use licensed
home health aides to provide personal health care support. Furthermore,
Humana is developing a program that provides skilled services that will be
certified by Medicare. Care managers and members involved in the in-home
personal and skilled care program have the additional support of com-
munity health educators, social service providers, behavioral management
professionals, and an interdisciplinary care team of consultant nutritionists,
pharmacists, and physicians.
At present, the top of the pyramid is the home delivery of physician ser-
vices. This represents a distinct evolution from care coordination to direct
clinical care. Ultimately, the organization sees developing these increasingly
intense services all the way up to a hospital-at-home model. Humana At
Home also offers a 30-day transitions program with three visits—one in the
hospital before discharge, one within 48 hours of arriving home and before
the primary care appointment, and a follow-up visit after that appointment.
According to Rackow, at the time of his presentation at the workshop, some
30,000 Humana members had been served by that program.
Results
According to Rackow, 2013 data for the 116,000 members newly
involved in care management showed a 42 percent decrease in hospital
admissions, and the data for 2014 available to the time of his presentation
showed a similar reduction. Among the 16,000 members participating in
the posthospitalization transition program, 2013 data showed a 39 percent
reduction in hospital readmissions, a decline that, again, was replicated in
2014, he said.
“But is keeping people out of the hospital the right thing to do?”
Rackow asked. Humana data show that management at home not only is
decreasing hospitalizations and readmissions but also is having a beneficial

effect on patient mortality. Compared with the survival of matched control

patients, those members involved in the chronic care program had a 2.8
percent absolute improvement in survival.
The country is in the middle of a paradigm shift, Rackow concluded,
from a situation in which care is provided for acute conditions to one in
which care is provided on a chronic basis, from a situation in which medical
events trigger care to one in which medical events trigger holistic support,
from a mind set in which health care is oriented toward a cure to one in
which it is provided to enhance the patient’s function, from fragmented care
to integrated care, from a situation in which payment is provided per care
episode to one in which payment is provided for a continuum of care, and
from a situation in which care is provided in person to one in which it is
provided virtually. A key element in this shift, he said, is the movement of
the site of care from a hospital to the home.
Experience of Optum Complex

Population Management
Ronald J. Shumacher
Optum Complex Population Management
Optum Complex Population Management is part of the UnitedHealth

Group family of companies and a direct care delivery and care management
business. (Other lines of business of Optum include data analytics, phar-
macy benefits management, health care financial services, and consulting.)
Like the other organizations that were described at the workshop, Shum-
acher said that Optum also serves a high-risk, vulnerable population that
has high health care costs because of its utilization of hospital and emer-
gency care. This population is poorly served by fragmented care and the
lack of coordination of care for multiple chronic conditions and receives in-
adequate care at the end of life, he said. Typical Optum clients are managed
care plans and, increasingly, programs for dually eligible individuals that
delegate the delivery of services for their high-risk populations to Optum.
Although Optum has a range of programs for people who are in
transition, have long-term service and support needs, or need palliative or
end-of-life care, Shumacher focused his comments on Optum’s Care Plus
community program, a longitudinal home health care delivery model pro-
vided largely by NPs but with some services provided by physicians. Like
the other programs described at the workshop, Optum uses data analytics
to stratify patients on the basis of the risk of future service utilization and
costs. “Essentially,” Shumacher said, “we are providing a house call pro-
gram with home-visiting providers that is paired with a care management
and technology company to serve high-risk individuals.”

The traditional approach within managed care for members with medi-
cally complex, multiple chronic conditions, Shumacher said, “really under-
performs in a lot of ways.” It entails numerous providers, patients receive
many different medications, care is disjointed and confusing, and some-
times, elements of care plans are contraindicated or conflicting. Usually,
he said, in-office medical care is insufficient both in time and in quality for
these patients. Doctors do not receive the right insights, and patients do
not develop the relationships with their clinicians required for the care of
medically complex conditions.
In contrast, Shumacher said, Care Plus is a system that delivers clini-
cal care and that is adaptable to all types of payers. It provides proactive,
preventive maintenance and disease education services to teach people how
to manage their care better. It uses care providers—NPs who work with
the patients’ primary care physicians—who can manage care in the home
and write orders for laboratory tests and medications. They engage in ad-
vanced discussions with the patient about the patient’s illness and explain
different care options. A centralized care management team provides back
office support.
The NPs specialize in having patients avoid unnecessary hospitaliza-
tions and emergency department visits. Similar to other models in vari-
ous markets, Shumacher said, the baseline hospitalization rates for its
population of patients are high but the use of in-home care services has
helped achieve a reduction in hospital admissions of more than 60 percent.
Furthermore, Care Plus can reduce overall health care costs for members
with medically complex conditions by 42 to 52 percent compared with
the costs for members whose care is not managed. In addition, as these
extremely ill individuals approach the end of life, their rates of health care
service utilization and costs are much lower than those for all Medicare
patients, especially high-risk Medicare patients. In the last 6 months of
life, Shumacher said, Care Plus can reduce costs by 61 percent. In addition,
when they are asked to rate their satisfaction with the services of Care Plus,
patients and families give Care Plus high scores.
In the future, in addition to working with managed care organizations,
Care Plus could work with delegated provider groups, ACOs, and state
and federal government programs, instead of only through health plans,
Shumacher said. Care Plus is typically paid on a case rate per engaged
member per month. However, it can be paid on a capitated basis, through
a gain-sharing program with quality goals, and through a system in which
some customers assume the full risk and take a percentage of the premium.

Experience of the CAPABLE Model

Sarah L. Szanton
Johns Hopkins University School of Nursing
Szanton discussed the challenges faced by people with functional limita-

tions that affect ADLs and how a project at the Johns Hopkins University
School of Nursing works to improve function for many clients. (See Box 6-2
for a story related by Szanton.)
Szanton said that the Community Aging in Place—Advancing Better
Living for Elders (CAPABLE) model6 was developed with foundation and
federal support and is now being tested under a Center for Medicare &
Medicaid Innovation (CMMI) grant and through a randomized controlled
trial funded by the National Institutes of Health. If these tests are success-
ful, she said, the program may be implemented nationwide. “CAPABLE
focuses directly on people’s own functional goals, with the idea that if we
address those, then they can take care of their medical issues,” she said.
It is client directed and not just client centered, and the clients’ goals are
exemplified by the following: “I want to be able to get up my stairs, so I
can sleep in my bed instead of on my couch.” Or, “I want to be able to
stand long enough to be able to eat some foods, so I don’t have to go back
to the hospital.”
Program Approach
By and large, program participants are low-income, dually eligible
individuals recruited from community centers and mailings, but they are at
high risk for functional limitations. CAPABLE provides clients with a team
member who can make household repairs, a nurse, and an occupational
therapist over 4 months. The initial visit is with the occupational therapist.
In traditional home health care, occupational therapists cannot start a case,
but in this model, function is the driver, and that is what occupational
therapists address best, she said. They assess client needs for every ADL and
instrumental activity of daily living (IADL), and then the clients prioritize
those needs that they want to be addressed.
On the second visit, the occupational therapist goes through the whole
house, examining all the areas that the client uses and assessing the causes
of the client’s limitations. The assumption is that “a limitation is a combina-
tion of what a person’s qualities are and what the environment throws at
them,” Szanton said. “If you can give them grab bars or if you can fill in
6 See http://nursing.jhu.edu/faculty_research/research/projects/capable (accessed December

24, 2014).

BOX 6-2
Mrs. B’s Story
Baltimore, Maryland, resident Mrs. B has hypertension, congestive heart

failure, diabetes, and arthritis. She was recently hospitalized for an exacerbation
of her heart failure and just finished an episode of post-acute care in a skilled
nursing facility. Like a cascade of dominoes, the precipitating heart failure problem
occurred partly because she cannot stand up long enough to cook and cannot get
groceries in the house. Therefore, she often eats some kind of prepackaged food,
which tends to be a high-salt food, that she can just grab.
She keeps her clothes in her dining room, because that is where she lives.
She can no longer climb the stairs to her bedroom. She cannot even really get
dressed, because this “closet” is a sweater bag that is held together with safety
pins, and her arthritic hands cannot undo the pins, Szanton said.
When first contacted by the CAPABLE program, Mrs. B was spending most
of the day, every day, sitting in a chair. Holes in her floor made it dangerous to
walk on. The Astroturf covering of the steps from the sidewalk to her front porch
was ripped and hazardous. “None of us should walk up those front stairs,” Szanton
said, and certainly not someone with a shuffle, gait problems, and bad balance.
Older adults who have lived in the same place for a long time and who do not have
money to fix problems often similarly have houses that are starting to fall apart.
Although the expense associated with functional limitations is well-known,
the impact of the home environment on people’s function and how environmental
improvements can reduce limitations in activities of daily living receive less atten-
tion. Mrs. B—and people like her—want to be more functional and often can be.
CAPABLE program case management considered questions like the following: can
she get her foot over the side of the bathtub, can she stand long enough to cook,
and can she get dressed? These are often the issues that older adults care about
more than their diseases, and these needs are mostly unaddressed.
What Mrs. B most wanted was to be able to stand long enough to make her
meals. The CAPABLE program team tackled the problem: the nurse worked on
her arthritis pain and her leg strength; the occupational therapist worked with her
on the use of different cooking tools and ways to conserve energy; and the team
member who made household repairs lowered the kitchen shelves, put in a mi-
crowave, and gave her a crock pot. These are simple steps, and all were related
to achieving her goals.
SOURCE: As presented by Sarah Szanton on September 30, 2014.
the holes in their chair seats, sometimes they no longer have limitations.”
Together, the therapist and client fill out a work order for the person who
will make household repairs, who tackles jobs in the client’s priority order
within a budget of $1,300. (Installation of a second banister is one of the
most common requests, Szanton noted.)

At the end of the first month, the nurse starts. The nurse does not do
anything about medication adherence, diet, or exercise unless it is the cli-
ent’s goal. The visits—six in total for the occupational therapist and four
in total for the nurse—continue, with the occupational therapist and nurse
working on a different goal at each visit. If a client has fewer goals, the
program stops.
Results
The program has been pilot tested and may be ready to be scaled up,
Szanton said. According to Szanton, the pilot tests showed that the one-time
cost of the 10 professional visits averages $3,300 per enrollee, including
travel, clinical care coordination, and home repair and modification. In
contrast, nursing home care costs about $75,000 per year. If CAPABLE
prevents even 3 weeks of nursing home care, she said, it has saved money;
if it can avert hospitalization for one client in every five, it has saved money.
“As you can imagine,” Szanton said, “the clients love it.” One of the
best program outcomes is decreased depression. Depression lifts because
people can do what they want to be able to do, she said. For example,
they can bathe themselves, they are cooking, and they are getting out of
the house to go to church. “It’s depressing to sit in a chair all day long.”
For most participants, the level of depression decreased or at least did not
increase.
Rates of occurrence of functional limitations also followed a downward
trend, Szanton said, with the number of functional limitations decreasing
from an average of about four to about two, with almost 80 percent of
clients seeing improvements in functional limitations and only 7 percent
seeing declines. Szanton expects that stronger results would emerge with a
post-acute care population.
In closing, Szanton described the following example. One client was
taking 26 medications when she started the program. On the occupational
therapist’s first visit, it took 30 minutes for the client to walk the short dis-
tance from the bathroom to her bedroom, yet her goal was to go downstairs
and wash her hair in the kitchen sink. “This shows the power of asking
people what they want to be able to do,” Szanton said.


Policy and Payment

Lee asked the panelists what kinds of health policy changes are needed,
particularly in Medicare, to facilitate the more appropriate use of home
health care. For example, she asked, for those who received CMMI grants,
were any Medicare rules waived? Rackow said that CMS needs to recog-
nize functionality as an important component of keeping people healthy.
At present, he said, Medicare does not reimburse for home health aide
services that support beneficiaries’ functional needs; it reimburses only for
medical care, yet much health care utilization and cost are driven by those
problems with function. Madden-Baer noted that for a congestive heart
failure project that VNSNY is running with 50 hospitals, beneficiaries
are not required to be homebound after the initial episode of care from
a certified home health agency, as is usually required for subsequent care
under the 90-day bundled payment. Also, the home health agency has the
flexibility to engage a pharmacist consultant to simplify dosing schedules
and to deploy NPs to the home when an appointment with a primary care
physician is unavailable.
Boling suggested that the framework that focuses on chronic condi-
tions be abandoned, because almost all elderly people have at least two
chronic conditions. Instead, he said, the focus should be on function-
limiting chronic conditions. He also advised that the expansion of the
scope of various projects be managed, because if it is not, a project soon
becomes unaffordable. The monitoring present under the CMMI grant
helped B urnich’s project avoid this tendency to expand. He said further
that projects should not expand faster than the speed with which they can
hire staff with the competence and skills to produce high-quality, reliable
services. Rackow said that Humana has best practices and protocols that
precisely define the amount of services, the time to be spent on those ser-
vices, and the costs that the health plan pay per member per month, which,
again, establishes boundaries.
Lee further asked what approaches to payment might be critical for
future reforms. Capitated payments allow organizations to make the best
decisions to support the health of their members, Rackow said. At present,
access to a program like Humana’s is limited to people enrolled in particu-
lar health plans and using particular provider groups. Shumacher said that
programs that have strong results could be made more available to broader
groups of people under a payment-for-value rubric.
Medicare Advantage is growing rapidly but under the ACA has built in
some payment cuts that will discourage plans and providers from partici-
pating, Burnich said. Despite the advantages of capitation, not every senior
will join Medicare Advantage, he said, and his organization is experiment-
ing with other types of chronic care management programs.

Consolidation and Integration

A workshop participant asked if additional consolidation and integra-
tion of home, community, and post-acute care services will drive value.
The participant further asked about the importance of integration in and
of itself.
The company acquired by Humana that is now Humana At Home
would never have been able to scale up its home health care program
without being under the Humana umbrella, Rackow said, according to
either its national coverage or the number of clients. Because of Humana’s
support, the Humana At Home program has expanded its horizons, seeing
home health care as “the glue in the system” for keeping people as healthy
as possible.
Lopez said that integration has been important to Atrius Health on
multiple levels: alignment of mission and care delivery goals, provision of
a financial bottom line, communication, and medical information sharing.
Although Atrius could have worked with several visiting nurse associations
in eastern and central Massachusetts instead of just one, he said, the align-
ment, goals, and financial and communications issues would have to have
been worked out with each one of the associations and would have been
burdensome.
The blurring of distinctions between providers and health plans,
Burnich said, creates some risks. In the 1990s, plans that began serving
as providers failed. The renewed trend “could be good,” he said, “but we
will have to see.”
UnitedHealth Group’s acquisition of INSPIRIS gave Optum increased
ability to implement a successful delivery model that could reach many
more payers and their members, Shumacher said. The bringing together of
disparate businesses and the creation of a common platform take time, so it
may be a while before the full value of integration can be realized, he said.
Madden-Baer said that VNSNY, being both a provider and a health
plan, is learning to be “a lot less transactional and more care management
focused” over the longer term. An example is the shift in the call center’s
approach: it supports the management of care when a patient calls, instead
of instinctively advising patients to call 911 after hours.
Operating at a Smaller Scale

Terrence O’Malley, Massachusetts General Hospital, asked the panel-
ists what lessons from their organizations can be applied to organizations
that operate on a much smaller scale.
Telephone and telehealth care coordination, supported in various ways,

can be scaled down, said Rackow. Humana is testing interactive voice re-
sponse systems with patients with congestive heart failure.
Madden-Baer said that VNSNY’s home health care program started
small and thought of itself as a laboratory for testing models of care,
which have been added over time and which have allowed the evolution of
VNSNY into a much larger organization.
Technology is not the be-all and end-all, because “the warm touch is
still a critical component,” said Burnich, but there are ways to scale down
through the use of technology, including through the use of sensory devices
and video visits, for example.
A good first step for smaller agencies is to start tracking their data,
Shumacher said. If they can show that they are providing better care, that
quality is improving, and that costs are going down, they can grow from
there. “A lot of what I talked about,” Szanton said, “you can do for free.”
Just rephrasing the questions about function and asking the person about
his or her goals are free. Home repair is going to provide such a strong
return on investment that even with low levels of capitation, it can easily
be provided. She suggested the mobilization of healthy older people who
have skills, who have some time, and who may be eager to help fix up other
people’s homes.


Innovations in Technology
Technology is currently critical to home health care. Future advances

in home health care technologies have the potential not only to facilitate
the role of home health care within the overall health care system but also
to help foster community-based independence for individuals. In one panel
at the workshop, three speakers spoke about a wide range of technologies,
including the existing base of evidence on the impact of technologies, the
challenges facing the development and use of technologies for home health
care, and how to facilitate the use of technology to achieve an ideal state
of home health care in the future. Chapter 8 touches further on the role of
information technology and the use of electronic health records.
Evidence Base for Home Health care Technologies

George Demiris
University of Washington
Computing is pervasive and ubiquitous, it is wearable, and it is used in

every aspect of our lives, said Demiris. Advances in computing and informa-
tion technology are also affecting home health care. Although information
technology has been used in health care for a long time to bridge geo-
graphic distances and give people access to expert opinions without having
to travel, ultimately, computing and information technology may actually
be used to improve the quality of home health care services and enable
their redesign, said Demiris. For example, Demiris noted that a Medline
search for papers on the use of technology in home health care published
91

in 2003 found 556 papers; a decade later, the number was 1,390. Finally,
not just the field of technology for home health care but also the evidence
that goes with it have continued to grow, he said.
Active Versus Passive Technologies

One distinction that can be made among types of technologies is
whether they are active or passive. Someone must operate an active tech-
nology, Demiris said, whether it is hardware or software. Active and passive
technology can also be distinguished according to whether the user needs
training. Passive technologies are, for example, cameras, sensors, or other
devices embedded in the residential infrastructure that allow an individual
to be monitored without requiring that individual or another person to
operate them. As described in the literature, both types of technology have
a variety of functions, Demiris noted, including monitoring and the provi-
sion of assistance in the various areas described in the following sections.
Physiological Monitoring
Active home telemonitoring devices can capture vital signs, weight, or
symptoms and report them to a remote provider or a home health agency.
Passive telemonitoring technologies include bed sensors that capture rest-
lessness, sleep interruptions, or pulse and respiration during sleep.
Monitoring of Patient Function and Detection of Emergencies

Active technologies include devices that can detect falls and that people
can wear. They also include personal emergency response systems that a
person can also wear and that allow the person to press a button to sum-
mon help when he or she falls. Passive systems may be embedded in the
carpet and can detect falls or near falls.
Safety
Alarm systems can actively detect fires or floods; passive systems can
use motion and heat sensors, for example, to distinguish between heat that
occurs during meal preparation and heat that builds up when a person turns
on the stove and forgets about it.

INNOVATIONS IN TECHNOLOGY 93
Security
Camera systems allow the remote monitoring of residential spaces and
visitors; passive systems use sensors to capture the level of activity and
whether unusual patterns of activity are occurring.
Social Interactions
Social interactions can be made through the active use of social net-
works, and software can assess self-perceived social connectedness. Passive
sensor-based systems track the number of visitors, the amount of time spent
inside and outside the home, and sedentary behavior.
Cognitive and Sensory Activity

Active technologies can generate alerts and reminders, aid with the lo-
cation of lost objects, or dispense medications. Passive automated features
operate in the background and trigger warnings, alerts, and reminders or
turn on lights.
The Evidence Base

Although both the amount and kind of evidence on home health care
technologies are increasing—from evidence from pilot studies to evidence
from some longitudinal research and randomized controlled trials—“it is
still not really clear what seems to work and what doesn’t work,” Demiris
said, especially because the findings are sometimes contradictory. The pace
of technological advance is faster than traditional research grant cycles, so
that by the time a study has been planned and funding has been acquired,
the technology to be studied may be outdated. Furthermore, research
projects rarely enable the tailoring of technologies on the basis of the situ-
ation in the home or the needs of the individual patient, because everyone
in the study needs to receive the same intervention.
Technology interventions do not always have to be complex and so-
phisticated, Demiris said. Simple tools can sometimes be effective. For ex-
ample, when the members of his group looked at ways to support informal
hospice caregivers (e.g., family members, friends, neighbors), they used
video conferencing technology to solve the caregivers’ problems. This tech-
nology is being tested in a three-arm clinical trial with groups that receive
(1) friendly visits and usual care (the controls), (2) standard care plus the
problem-solving therapy in person, and (3) standard care plus the problem-
solving therapy by video. If the results for Groups 2 and 3 are equivalent,
the video intervention might be a cost-saving alternative. Although the cost

results are not yet available, Demiris said that families are embracing the
technology and “finding it [to be] a convenient and effective way to com-
municate” with the hospice teams.
Simple, low-cost technologies can allow health care workers to capture
information more efficiently, and sometimes new technologies let them
obtain new data, Demiris said. For example, traditional telehealth allows
the capture of a person’s blood pressure or weight, and some of the new
technologies provide information about a person’s lifestyle or behavior,
eliminating the need to rely on self-reports.
One example of research on smart home technologies for people living
in retirement communities involves the use of stove sensors, motion sen-
sors, and sensors that detect water and electricity consumption, Demiris
said. The last two are being used in an ongoing study to assess the overall
mobility of people in their own homes. Now researchers also have data
on sleep quality, restlessness, sedentary behavior, hygiene patterns, meal
preparation, and so on. Again, these data should be much more accurate
than those obtained from self-reports. Sophisticated algorithms may detect
patterns of an individual’s normal routine and deviations from those pat-
terns, and clinicians can be presented with these summative data.
Usability and interface design are important considerations, especially
for older adults, and technology designs need to be tested with these popu-
lations, Demiris said. For example, a multiuser kiosk used by people who
wanted their vital signs assessed also asked them some questions, and re-
searchers were challenged to create a system that could continuously tailor
the interface to accommodate the functional, hearing, visual, or cognitive
limitations of the users. Focus groups revealed that many older adults had
visualization needs very different from those of their family members and
clinicians, not only according to the type of information and level of detail
desired but also according to the use of colors or features that one group
found distracting and another group found helpful.
Studies that survey users about the acceptability of technologies may
produce high levels of satisfaction, but Demiris believes that acceptance
is more complex than that. For example, obtrusiveness is a broader con-
cept than whether a system is active or passive. A technology may have
undesirable features that are too psychologically or physically prominent.
“Privacy is a huge issue, but it’s not the only one,” he said. The challenge
of obtrusiveness is not only people’s perceptions about what may happen to
information about them but also the issue of function and how the equip-
ment works, that is, whether it makes annoying noises or requires a lot of
maintenance.
According to Demiris, other home technology issues need to be re-
solved, including

• Whether a technology will reduce the number of face-to-face visits;

• The technology’s effects on the client’s self-concept and the poten-
tial stigma of having it in the home (“turning the home into an ICU
[intensive care unit],” one patient said);
• The technology’s effects on people’s daily routines;
• Whether any positive behavior changes are sustainable; and
• Affordability (in research studies, the technology is usually free).
In sum, although technology has a lot of potential and some evidence

suggests that it can actually improve home health care services, “it’s really
about finding technology as a tool to meet clinical needs,” Demiris said,
rather than having it be “viewed as a solution to any of the problems we
are facing.”
Role of telehealth
Raj Kaushal
Almost Family, Inc.
According to Kaushal, Almost Family, Inc., which was founded in 1976

and which operates in rural areas, is the fourth largest home health care
provider in the United States, operating in 14 states and serving between
25,000 and 30,000 patients daily. Because of Almost Family’s size, it can
pilot test a variety of ways to improve care in its provider-based environ-
ment, and it works strategically with physicians, accountable care organiza-
tions, and hospitals.
A common denominator in the workshop so far, said Kaushal, is that
in home health care technologies can be value-added services that aid
with patient centeredness, sustainability, and reimbursement. Telehealth
can have a wide range of complexity, from the simplicity of the telephone
all the way to the extreme complexity of smart homes. Providers, however,
do not know the best way to provide evidence-based telemedicine, he said.
From the patient perspective, telehealth can range from being as simple
as a telephone call, joining an online support group, or obtaining health
information and self-management tools online to having email and online
communication with health care providers. From the provider perspective,
telehealth can range from the use of electronic health records and remote
monitoring of vital signs and symptoms all the way to doing consultations
and patient visits by video.
Technology can be helpful to teams of caregivers—physicians, nurses,
therapists, social workers, and others, all of whom are delivering some
aspect of care—by creating vital links that facilitate communication, coor-
dination, and improved collaboration. Kaushal’s organization tries to create

those links within the company, as well as outside the company with the
families, payers, external clinicians, and referral sources that it deals with
every day.
Almost Family’s goal, he said, is to keep patients independent in their
homes, while reducing emergency care and hospitalizations and improv-
ing quality of life and perceived patient satisfaction, along with reducing
the total cost of care. Almost Family does this not only by following an
evidence-based medical care plan but also by paying attention to functional
issues—ambulation, bathing, transfer, and so on—in what is a highly regu-
lated industry.
Meanwhile, home health care takes care of people with complex and
multiple chronic conditions (e.g., heart failure, chronic obstructive pul-
monary disease, diabetes). Telehealth applications can enhance the man-
agement of this high-risk population, Kaushal said, by providing daily
monitoring (between in-person visits), timely intervention as the patient’s
condition warrants, triage of clinical needs, and reinforcement of the treat-
ment and discharge plan. The collaboration benefits include, for example,
the ability to target visits and interventions to the patients and at times
when they are the most needed and to tailor self-management training and
health education for both patients and caregivers.
These patient management improvements assist physicians with both
the coordination of care and the communication of health care problems
and in the long run can save clinicians’ time through improved coordination
and collaboration, Kaushal said. For hospitals, they can reinforce the dis-
charge plan, allow the hospital to recognize key indicators for readmission,
contribute to the stabilization of patients after hospitalization, and gener-
ally support care transitions. The communication component encourages
good communication and relationships with discharge planners.
For the system as a whole, telecommunications applications have the
potential to gather and compile useful data so that health care systems can
learn more about what home health care applications produce the most de-
sired outcomes, Kaushal said. To test the impact of telehealth, his company
worked with two of its partners, Medtronic and Cardiocom, on a 12-month
study of some 566 patients with congestive heart failure. The intervention
involved post-acute care and post-episode calls, used an interdisciplinary
team approach, and created some champions in every study market. The
study demonstrated the positive effects of telehealth on hospitalization rates
and patient satisfaction and reduced 30-day hospital readmission rates to
about half the national average (12.6 percent versus 24 percent nationally).
What Almost Family learned from this study, Kaushal said, was that it
was not only technology or communication, coordination, and collabora-
tion that made the difference but also the need to align staff, standardize
care processes around clinical best practices, and then conduct focused

training for clinicians around those processes. “Technology became a tool

instead of a focus,” he said. These best practices involved patient educa-
tion as well.
According to Kaushal, positive outcomes like these can lead to orga-
nizational growth in several ways: by providing a competitive advantage,
by enabling expansion of service coverage to other disease entities, and by
creating opportunities for new business and new partnerships. Kaushal
noted several lessons from the experience, including the following:
• Sites that had strong clinical care champions had the best outcomes.
• An integrated hospital–physician–home health care approach to the
delivery of care produced the highest number of enrollees.
• Operational planning (program design; incorporation of new pro-
grams into ongoing operations; leadership support; broad stake-
holder involvement; and definition of clear goals, timelines, and
deliverables) is important.
• Vendor systems must be scalable.
• Monitoring of the communication between the members of the
team and clinicians in the field directly improved patient care.
• A focus needs to be placed on communication that takes into ac-
count the situation, background, assessment, and recommendation
(the SBAR approach).
• Success is different for different people, including different patients.
In the future, Kaushal believes that when standardization begins to oc-

cur and reimbursement is aligned with value, innovation will be accelerated
if telehealth applications show that they can improve the quality of health
care and not just save costs so that systems do not have to rely solely on
local execution. “Because we live in the environment of reimbursement, if
reimbursement is not there, sometimes good ideas fail,” he said.
Use and Development of Assistive Technology

Wendy J. Nilsen
National Institutes of Health
Nilsen reported on a workshop1 held on September 9 and 10, 2014, at

the National Institutes of Health (NIH) in collaboration with the Computer
Community Consortium that explored technologies for aging in place and
the gaps in products, policies, and research. The meeting was not about
1 See
http://www.cra.org/ccc/visioning/visioning-activities/aging-in-place/411-aging-in-place-
workshop (accessed December 8, 2014).

“technology for technology’s sake,” Nilsen said; “technology is a reality.”

She pointed to Eric Dishman’s visionary conception of health and the need
to be thinking about the research that will point the way to that future. The
workshop brought together health care researchers, technology research-
ers, industry, and government to discuss a series of questions around four
topics:
1. How should technologies be designed for the aging population

that wants to age at home? People who want to age in place are
a diverse population, so should technologies be designed for the
entire aging population or the 5 percent?
2. What kind of sensing innovations are needed? The design of sen-
sors and the development of algorithms and precise timing to make
them useful are tough, so what information should sensors be
conveying?
3. How can people be helped to use technology to identify potential
transition periods, and how can they be helped through health care
transitions?
4. How can non–health care technologies be used to support health?
Nilsen noted that the workshop started from the assumption that tech-
nology could enhance health outside of hospitals and nursing homes by im-
proving and sustaining health and increasing the quality of life; by allowing
people to live at home longer; by reducing health care costs, especially the
cost of unnecessary hospitalizations and rehospitalizations; and by reducing
the strain on the health care workforce and on family caregivers. Further,
the participants looked for ways to use technology’s strengths to facilitate
communication and data collection.
The workshop participants found that it was hard to talk to each other,
Nilsen said. The people involved with technology wanted to see more
investment in basic science, the people involved with health care wanted
better technology now, and participants in general tended to focus on the
technologies relevant to their own particular area of expertise. The tech-
nologists tend to think that all health care professionals are clinicians, she
said, and the clinicians tend to think that all people involved with technol-
ogy are programmers, but many partitions exist in both fields. “We really
need to think about each other as complementary disciplines that work
together for a common goal,” she said.
Nilsen said that it will be necessary to transform thinking about home
health care from an approach that it is “health care at home” to one in
which it is “smart homes where people can be healthy.” Technology in the
home needs to be seen as an alternative form of care, she said, and not just
an add-on to current systems. Such a rethinking implies a balance between

personalization and universal design, as well as stronger human factors

research to support that balance. She gave as an example the glucose moni-
tor, saying that glucose monitors are often not designed for people who
have diabetes because they have tiny buttons and even smaller type. “If
you have problems with your vision from long-term diabetes, you can’t see
eight-point type,” she said. The new technologies developed must be useful
to the patient, the caregiver, and the care team by giving them actionable
data useful to them, Nilsen said.
Other technologies that can serve everyone include, for example, tablet
computers that have very simple operating systems for people who have
never used computers. Furthermore, although users can take advantage
of the health care applications that operate on tablet computers, they also
can use the tablets for email and social networking. In other words, Nilsen
said, the technology is designed so that people can use the technology in
the way in which they intend to use it, with health care woven in. Ideally,
integrated technologies free up time for conversation. For example, if home
health aides did not have to take a blood pressure, she said, they might have
time to find out what is going on in their patients’ lives that may be having
a greater impact on their health and well-being than their blood pressure.
For the long term, the health care system will need both more person-
alized technology and evidence-based, generalizable solutions that can be
adapted to individual needs, Nilsen said. Other long-term considerations
are the need to “future-proof” the technology—that is, the need to antici-
pate the rapid pace of technological change and not become stuck in what
is possible today—and avoid the creation of new digital divides, in which
only some people—for example, wealthier or better-educated individuals—
can benefit, she said.
Another difficult question applies to monitoring technologies and, espe-
cially, cameras. Nilsen asked whether those technologies are there to keep
an eye on the person so that the family knows what the individuals is doing
and whether they are safe, or whether they are there to help the person be
independent longer. This is one of the facets of obtrusiveness that George
Demiris raised earlier.
Assessment of the usefulness of various technologies may require new
research methods, such as “continuously evolving evaluations where tech-
nology can be evaluated on the fly,” Nilsen said. Randomized clinical trials
may still have a place for the evaluation of specific outcomes and the devel-
opment of best practices. According to Nilsen, the following developments
are needed to evaluate the evidence:
• New robust methods of analysis and sensor-driven decision analy-

sis to create predictive, personalized models of health;

• Methods for rapidly generating evidence that will allow validation

of the effectiveness and reliability of technologies, including addi-
tion of technology into existing trials or cohort studies;
• Test beds that will enable the efficient, economical, and systematic
exploration of the use of technologies and that will involve the
community in research;
• Development of a generalized matrix for cost analysis that uses,
for example, the amount of the caregiver’s time that is saved as
one of a set of standard measures of a technology’s cost-saving
performance; and
• A mind set that thinks about technologies broadly, including their
integration into other health care services and embedding of health
care tools and data collection into the “Internet of things.”
Again, she said, what is needed is a balance between the information

needed now and the data that need to be collected to move home health
care into the future.

participants were able to make comments and ask questions of the panel-
ists. The following sections summarize the discussion session.
Design and Use of Technologies

Mary Brady, U.S. Food and Drug Administration (FDA), echoed the
suggestion that one factor affecting whether technologies are actually used
by people is how well they can be incorporated into the patient’s life. Tech-
nologies that are too obtrusive are less acceptable, she said. One of the ways
to find this out, she suggested, is through better human factors engineering
and testing of the usability of a technology throughout the development
process. Brady further noted that FDA has a guidance for industry related
to premarket concerns.2 She said that many types of technology that were
not designed for nonclinical and home use are being used outside the clini-
cal environment (where care is needed 24 hours per day, 7 days per week).
The guidance asks industry to consider the design, the users, and the physi-
cal environment in which a device will be used.
Cindy Krafft, American Physical Therapy Association, said that some
of the technologies in development have great potential to support patient
2 See http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/
ucm331675.htm (accessed December 8, 2014).

functionality and activities of daily living. Still, she said, home health care
agencies cannot make assumptions about their patients’ ability to use the
technology. Krafft gave the example of a case in which telehealth was used
to report weight on a daily basis. However, she noted, home health care
nurses need to be sure that patients can get on and off the scale by them-
selves; often, they cannot, which can lead to inaccurate data reporting.
Rehabilitation has been a great beneficiary of technological advances,
Nilsen said, in part because technology can provide data between in-person
visits. She gave as an example a program funded by the National Science
Foundation in which physical therapists remotely gathered data from a Wii
Balance Board.
Peter Boling, Virginia Commonwealth University, warned against the
creation of technology silos, as has been done “with every other component
of health care.” He noted examples of the problems that silos engender,
including delays in receiving monitoring data because of the way an infor-
mation routing system is set up. He described a paraplegic patient who lay
in bed for 3 days without food or water because he could not reach the
phone and could not afford the $30 per month needed for a wearable alert
device. Although Boling was confident that technologies can work, he said
that they often fail because they are implemented to serve the developer’s
business model and not the needs of the population that could benefit. “The
vision is out there, but the application is far behind,” he said.
Incentives
Krafft noted that a tremendous opportunity exists to expand rehabilita-
tion therapies to prevent patient decline and keep patients out of higher-cost
care. Unfortunately, she said, the current payment methods discourage the
widespread use of rehabilitation methods that might replace a reimbursable
therapy visit. Demiris agreed that telehealth and similar technologies raise a
concern that they will be used to replace actual visits. They could be a great
convenience for patients and families, or they could result in a diminution
of services. In the early days of telehealth, he said, advocates emphasized
that these services would be an add-on (they would not replace visits), but
later it became clear that, if that were true, they would not be cost-effective.
Rather than visits lost or visits added, it is important to think about the
effective coordination of the services needed to achieve agreed-upon out-
comes. Technology is only one tool among many in service redesign, he
said. Nilsen agreed, saying that rehabilitation technologies are often useful
in providing data between in-person visits. At Almost Family, Inc., Kaushal
said, physicians, nurses, and therapists focus on a plan of care instead of
visits or technology. Each patient needs a plan of care that is integrated
across clinical disciplines, that includes the appropriate technology, and

that each discipline is following. “That is the biggest challenge we face in

everyday life,” he said.
Thomas E. Edes, U.S. Department of Veterans Affairs (VA), noted that
in the VA’s home-based primary care program, patients who receive 10
or more visits are recognized as having more complex conditions and are
moved into a higher cost category. Of the 10 visits, half can be telehealth
visits. To measure productivity within Almost Family, Inc., Kashaul said
that the organization has developed an equivalency measure, in which
some number of telehealth visits has been equated to one in-person visit.
With this system (which is still being tested), staff who are paid per patient
visit do not feel penalized for telehealth visits, he said. Kathryn H. Bowles,
Visiting Nurse Service of New York Research Center and the University of
Pennsylvania School of Nursing, said a further step would be to think about
ways to reward clinicians who become more efficient. She described a ran-
domized trial that she led in which the nurses were asked to replace some
in-person visits with visits via the use of video technology. The trial found
that nurses who were efficient could save time. They were then assigned
additional patients, however, and so got more work. She said that one way
to overcome that disincentive might be to base rewards on patient outcomes
and counting telehealth encounters into the productivity standards rather
than just the number of patient visits per day.
Evaluating New Technologies

Bruce Leff, Johns Hopkins University, questioned whether randomized
controlled trials are really a robust method for evaluating these technolo-
gies. Technologies are not used in isolation, he said, but are used in the con-
text of people, processes, and the planning of care. They are implemented
in a very specific setting with a specific clinical team and social milieu.
Moreover, trials take a long time and are very expensive. Leff noted that
at present, Sarah Szanton is evaluating the CAPABLE program that she de-
scribed (see Chapter 6) in two different ways: one way is through a classic
trial funded by NIH in which she cannot change any of the protocol, and
the other way is through the use of a challenge grant from the Center for
Medicare & Medicaid Innovation, in which the evaluation is constantly
being reinvented as it goes along.
Demiris acknowledged these challenges, adding that the technology
itself may become outdated, given how long it takes to plan and carry out a
randomized trial. Furthermore, technology does not operate independently
of everything else. “So when you introduce, let’s say, access to the Internet
for a specific educational intervention,” he said, “you can’t prohibit patients
from browsing other websites” that also may affect their behavior and
you cannot prevent a wearable device that is being tested from being used

for additional purposes. For these reasons, the use of “pragmatic clinical
trials” or greater flexibility in the research protocol may be useful and al-
low the inevitable evolution of technology over the period of the research
(Demiris, 2011).
Nilsen listed other kinds of trials—optimization trials, adaptive trials,
and continuously evolving trials—that can be considered for the evaluation
of technology. Moreover, ways to shorten the amount of time required for
traditional randomized trials may exist. NIH is working on speeding up
subject recruitment, for example, as well as shortening the time needed to
obtain outcomes.


Making Connections
Earlier chapters addressed gaps and barriers in specific sectors of home

health care (e.g., workforce, payment, models of care, technology). How-
ever, beyond these challenges, home health care sits within a larger system
of care that needs to be considered. In one panel at the workshop, three
speakers spoke about different connections that are needed to integrate
home health care into the broader health care environment: connecting to
the overall health care system, connecting to social services, and connect-
ing data.
Connecting to the LargeR Health Care Ecosystem

Barbara Gage
The Brookings Institution
Changes in the broader health ecosystem affect home health signifi-

cantly, said Gage, especially as organizations focus on the triple aim of the
Patient Protection and Affordable Care Act of 2010 (ACA)1: improving the
patient experience of care (including quality and satisfaction), improving
the health of populations, and reducing the per capita cost of health care.
“These initiatives were always under way, but nobody had pulled them
together into one related effort.”
Gage reviewed a number of significant changes in the health care envi-
1 Patient
105

ronment that are in progress. She noted that the U.S. Congress has required
that all Medicare-funded services have quality reporting programs in place,
whereas in the past, only hospitals and nursing facilities had them. Innova-
tive payment methods are focusing not only on the costs of care but also
on outcomes, thus focusing the conversation—and payment—on value and
not just ongoing payment for additional services. Shared savings from the
achievement of quality goals are available to several categories of providers,
and incentives to coordinate care are in place, she said. Finally, she said, ac-
countable care organizations (ACOs) must integrate care across the health
care system because they are financially responsible for patient outcomes.
Gage noted that additional new programs target specific populations,
programs, and services, such as people who are eligible for both Medicare
and Medicaid, programs of long-term services and supports (LTSS), and
Medicaid efforts to serve more recipients in the community (rather than
in nursing homes). The high-cost Medicare population and the population
receiving LTSS tend to be the same people: those living in the community
who have many medical and social support needs. “That’s where home
health really comes into the picture,” she said. In addition, innovations,
such as carve-out initiatives for high-risk populations, are occurring in the
private payer sector.
Role of Home Health in the Medicare Program

Home health can play a number of central roles in this changing
marketplace. Gage said that it can—and often does—provide the desired
coordination across providers, whether it occurs at times of transition (e.g.,
from hospital to home) or between medical and social supports, and for
patients and family caregivers it is often an educational resource describ-
ing care options and resources. Gage provided some data (MedPAC, 2013)
about the people served in the Medicare home health program, showing
that
• Sixty-six percent of patients enter a home health program from the

community and not the hospital.
• Patients admitted from the community have an average of 3.8
chronic conditions, and 29 percent have Alzheimer’s disease or
dementia.
• Post-acute care patients have an average of 4.2 chronic condi-
tions, and 21 percent of these patients have Alzheimer’s disease or
dementia.
• Forty-two percent of patients admitted from the community qualify
for both Medicare and Medicaid, compared to 24 percent of post-
acute care patients.

MAKING CONNECTIONS 107
• Home health aide services represented the majority of services

provided in 11 percent of the episodes for people admitted from
the community, whereas they represented 4 percent of the services
for post-acute care patients.
Every year, one in five Medicare beneficiaries is hospitalized, and about

35 percent of hospitalized individuals are discharged to post-acute care
(Gage et al., 2009). Among the individuals in the population discharged
to post-acute care, 38 percent use more than one post-acute care provider.
About one-quarter of those who go to home health care are readmitted to
the hospital. Some of these cases are medically complex and some are not,
Gage said; some readmissions are avoidable and some are not.
Patients follow different paths after acute care, Gage noted. About 23
percent of those who go into a formal service program go directly to home
health care and receive all the care that they need there (Gage et al., 2009).
More complex patterns involve transitions from the hospital to a skilled
nursing facility and then to home health care. About 8 percent follow this
pattern, she said. Tracking these diverse pathways demonstrates that “when
we talk about a person’s services, it’s really an episode,” she said. “It isn’t
just one unique service.”
Although some home health care patients have complex care needs,
they probably do not need 24-hour nursing or they would have been dis-
charged to a long-term care hospital, a rehabilitation hospital, or a skilled
nursing facility, Gage said. On a scale from 1 to 100, home health patients
have the highest mean self-care score, about 60, when they start home
health care, she said, which is some 15 points higher than that for patients
in skilled nursing facilities (Gage et al., 2012). Home health agencies also
provide a large amount of therapy that is paid for by Medicare, but the
level of care is much lower as compared to the level of therapy services pro-
vided to individuals in inpatient settings. Even so, Gage said, these therapy
services may be keeping people mobile or able to carry out their activities
of daily living (ADLs).
For outcomes, Gage’s research shows that home health care is able to
achieve a 10-point gain (about 15 percent) in patients’ self-care functional-
ity, which she calls “pretty impressive.” If similar analyses comparing gains
in self-care ability for similar groups of patients are done, home health care
patients again have larger improvements than patients in other settings
(Gage et al., 2012). Some of the accomplishments of home health care arise
from the fact that it treats a somewhat different patient population, Gage
said. It is especially helpful for patients with musculoskeletal problems,
for example, but does not provide an advantage for patients with nervous
system problems or strokes.

Role of Home Health in the Changing Health Care Marketplace

The nurse case managers who do initial home health assessments are
automatically doing case management of the type endorsed in the newer
models of the organization of care, Gage said. As health care reform reem-
phasizes person centeredness and focuses on care coordination, outcomes,
and cost-effectiveness, home health gains in importance. Clinicians now
need to follow patients “past their front door and into the community,”
Gage said, because now they are responsible for them 30, 60, or 90 days
after hospital discharge, so what happens in the community is vitally
important.
Home health agencies serve both the Medicare post-acute care and the
LTSS populations. To the extent that hospitals are only just now learning
about the need to take this longer-term, episode-based view, she said, they
may not be as well integrated as desirable with the home health agencies in
the community. In some locales, the home health agencies work closely with
the agency on aging for that area, which can fill in additional pieces of the
comprehensive care needs of a given patient. However, Gage said, there is
a need for greater coordination, communication, and data standardization
among service-providing agencies.
New legislation has directed the Centers for Medicare & Medicaid
Services (CMS) to improve Medicare’s post-acute care services and the re-
porting on them.2 It will require home health agencies and other providers
to submit data on quality measures, resource use, and standardized patient
assessments. (It also includes a provision to study the effect of Medicare
beneficiaries’ “socioeconomic status on quality, resource use, and other mea-
sures” and the impact of specified risk factors on such measures.) This will
result in a more national approach to quality measurement and to thinking
about patients “in a consistent way,” Gage said. Meanwhile, she said, there
is consensus on how to measure key aspects of long-term care, like pressure
ulcers, in ways that are reliable. Under the coordinated quality strategies
of the U.S. Department of Health and Human Services, CMS is developing
the infrastructure that will allow the electronic exchange of c onsensus-based
quality measures that can be folded into bundled payments, for example. In
many areas, she said, “standardized information is being moved into either
the quality programs or the payment programs, or both.”
The strengths of home health that Gage believes will help shape its
future are the proven programs that home health agencies often provide,
including both home health care and hospice; the broad array of services
that they provide, including nursing, therapy, social work, and aide services;
2 Improving
Medicare Post-Acute Care Transformation (IMPACT) Act of 2014, Public Law
113-185, 113th Cong., 2nd sess. (October 6, 2014).

their placement in the community, where they know the local providers and
often know the residents with more complex medical conditions; and the
training of their staff in the coordination of services, such as medication
reconciliation and social support, “which all of those different payment
policy initiatives and quality metrics come back to: coordination and com-
munication across the system.” Gage believes that home health care is an
underutilized resource, particularly as the health care environment moves
toward managing patients across a continuum of care.
MEDICARING accountable care communities:

CONNECTING HEALTH CARE AND SOCIAL SERVICES
Anne Montgomery, Altarum Institute
Kyle Allen, Riverside Health Systems
The ultimate goal for the continuum of care, Montgomery said, would
be “to connect acute care, post-acute care, community agencies, and LTSS.”
Although the U.S. Congress tried to establish such a program through the
ACA, it was unsuccessful.3 Because of this failure, she believes that this
arena may not be revisited legislatively for “quite a while.” Meanwhile,
research and modeling that may reveal more viable approaches to making
these connections “with existing programs, existing financing, and existing
services” can continue.
Currently, because most health care policy is driven by budgetary and
political considerations, policy skews strongly toward the status quo at
a time when a lot of innovation and creativity is required, Montgomery
said. At the Altarum Institute’s Center for Elder Care and Advanced Ill-
ness, Joanne Lynn has continued to develop a locally anchored, compre-
hensive model called MediCaring accountable care communities (ACCs),
which would create some of the needed connections, she said. The model,
which would deliver both health care and LTSS, is tailored to address the
needs of the rapidly growing population needing a broad spectrum of
services, primarily people over age 65 years with two or more problems
with ADLs, those with cognitive impairment needing constant supervi-
sion, and the oldest old (those age 85 years and older) who are medically
frail and do not have much reserve. According to Montgomery, features
of ACCs include
3 TheACA included a Community Living Assistance Services and Supports (CLASS) Act,
which would have instituted a voluntary, national, federally administered long-term care in-
surance program, but concerns about the program’s projected high costs and likely difficulties
with implementation and sustainability caused it to be repealed in 2013.

• Comprehensive longitudinal care plans that cover all settings where

a person receives care, including the home, and that are grounded
in patient preferences for treatment and quality-of-life goals;
• More efficient and appropriate medical care tailored to the often
unique needs of frail elders that are not addressed by the current
“sick care and episodic” model and made more readily accessible
at home, including 24-hour on-call arrangements;
• The full range of health, social, and supportive services, including
assessment of the adequacy of housing;
• Use of core funding derived from shared savings in a commu-
nity ACO structure modified to serve the frail elderly population
(MediCaring ACCs); and
• Ongoing monitoring and improvement guided locally by a com-
munity board that comprises providers, professional managers,
community agencies, and stakeholders (e.g., employers, because
of the net negative impact of caregiving on employee productiv-
ity, and health and local leaders), which anchors the project in the
community and works toward achieving sustainability.
Building such care plans and convincing policy makers of their value
would enable the kinds of documents that health and social service provid-
ers could more easily follow on the basis of an understanding of “which
services work, which are cost-effective, which are timely, and when they
need to be adjusted,” Montgomery said. “The longitudinal care plan is sort
of like the trunk of a tree, where all the treating providers are branches off
of it.” Such plans are likely to be more administratively efficient as well, she
said, because they would constitute a single plan and not the cumbersome
and time-consuming multiple plans developed by different providers today
in a “sick care/episodic care” delivery model. In aggregate, such care plans
could aid with estimations of the need for services and workforce capacity
in a given locale and whether too many or too few workers are available
for the number of elders needing services.
Allen has been working on a project funded through the ACA’s
Community-Based Care Transitions Program4 in two communities across
the country and has been struck by the infrastructure built through the Ad-
ministration on Aging Services in these communities. One of these projects
worked with five local area agencies on aging as part of the Eastern Vir-
ginia Care Transitions Partnership, which covers about 7,500 square miles
and both rural and urban areas. The partnership involves 11 hospitals in
5 different health care systems and is enrolling 900 people per month in a
community-based care transitions model. In addition, Allen worked with
4 See http://innovation.cms.gov/initiatives/CCTP (accessed December 30, 2014).

Altarum to design a Center for Medicare & Medicaid Innovation grant

proposal tailored to four communities: Akron, Ohio; Milwaukie, Oregon;
Queens, New York; and Williamsburg, Virginia.
These MediCaring ACCs, which are still in the development phase,
would coordinate funding from multiple payers—Medicare and Medicaid,
the Older Americans Act, state and local programs, and private sources—
and in the process wring out current waste and inappropriate services and
then reinvest and redeploy some of that funding for social services or to
improve housing. The United States is quite different from the rest of the
developed nations in the share of aggregate social services spending that
goes to these health-related supports, which is very low, she said.
A package of waivers of existing Medicare rules would be necessary to
pilot test the MediCaring ACC program, Montgomery said, among which
are
• Waiving the Medicare rule limiting skilled nursing or therapy ser-

vices delivery in the home to those who are homebound,
• Allowing nurse practitioners to authorize home health care or hos-
pice services in states where that is permitted, and
• Allowing ACOs or other entities to enroll only frail elders and al-
low the geographic concentration of services.
The most important waiver is the last one, she said, which would allow
shared savings across the bundle of services for this population.
Allen said that he is confident that this model could be funded through
the projected savings that it will generate. A detailed financial model has
been developed for four communities with extremely varied health care
systems.
Connecting the Data

Terrence O’Malley
Massachusetts General Hospital
O’Malley harked back to the story related by James Martinez (see

Chapter 1, Box 1-2), saying that individuals and their caregivers are the
heart of the system. Swirling around them are all the other services that
they need, he said, including health and wellness services, medical care,
social services, LTSS, and home health care. Creating a new care model
will depend on increasing the connections among them. “In health care,
we’re a bunch of silos,” he said. “We only connect around the exchange of
information around a patient, but the issue is what happens between the
silos. It’s the white space.”

O’Malley reflected on previous presentations, noting that home health

care alone offers a wide range of services, from hospital-in-the-home types
of practices to the services of a person who can make home repairs. New
standards and processes are critical to managing the array of services
needed by people with multiple chronic conditions, disabilities, and frailty,
he said. Innovative care models are having dramatic results in targeting
high-risk patients, and O’Malley believes that these models are scalable.
To bridge the gap between the current service delivery silos, O’Malley said
that it will be necessary to add more social services to the medical model or
more medical services to the social services model or develop ways to inte-
grate them. Additional challenges include the need to make the transitions
between sites of care or between different teams that provide care safe, close
the open loops in referral management, and coordinate care across an entire
episode (longitudinally), and engage providers so that they are working off
the same patient care plan. Home health agencies could potentially be the
manager or integrator of all these services, he said.
Although communication is vitally important in the creation of a co-
ordinated system, home health and LTSS programs are unlikely to be able
to afford costly electronic health records systems, O’Malley said. Numer-
ous workshop participants pointed out that their home health agency used
a data system different from the ones used by other providers in their
networks. According to O’Malley, the creation of a shared information
platform is therefore a significant challenge that will require the following:
• A compelling business case,

• The use of health information exchanges or other exchange mecha-
nisms to connect with others,
• Low-cost ways to access the exchanges,
• Adoption of common data management standards to transmit data
reliably,
• Standardized information that is meaningful to providers and oth-
ers who can use it to monitor system performance, and
• Effective channels for two-way communication between service
providers and patients and families.
O’Malley said that the information platform for home health needs
to be inexpensive, easy to use, and reliable—“standardized and interoper-
able,” in the words of the Office of the National Coordinator for Health
Information Technology (ONCHIT). ONCHIT has selected a standard
for patient information exchange called the consolidated data architecture
(CDA), and a library of reusable data templates that can be combined to
form CDA documents exists. These documents can be of any size but use
a specific syntax. “It’s just like Legos,” he said, noting that the different

pieces can come in many varieties but that they all work together and can
be packaged in different ways.
As an example, O’Malley cited a project in Worcester, Massachusetts,
in which the electronic record begins being built when the patient enters
the emergency room and continues to be built through admission, is added
to during the hospital stay, and upon discharge is sent to the skilled nurs-
ing facility (via low-cost, Web-based software called a surrogate electronic
environment [SEE]). The information that the nursing facility collects for
the Long-Term Care Minimum Data Set (MDS)5 is added to the CDA file
and reconsolidated by SEE. Upon discharge from the nursing facility, an
updated document is sent to home health and the primary care physician.
What they learned in working on this project, O’Malley said, was not that
they needed hundreds of different data sets, as was initially feared, but that
by using the CDA system, they needed only five:
1. The test or procedure report—what the clinician needs to get back

when ordering a test;
2. The test or procedure request—what the clinician needs to send
when ordering the test;
3. The shared care encounter summary—what the clinician needs to
get back from a consultant (whether it is a specialist physician or
the emergency department);
4. The consultation request clinical summary—what the clinician
needs to send to a consultant; and
5. The transfer of care summary—what the institution needs to send
when there is a permanent transfer of care (a discharge to any other
site).
Every care site that receives a patient needs surprisingly similar in-
formation, O’Malley said. The data sets (described above) are nested,
and many of the data elements in the smaller sets are reused in the larger
sets. This is possible because the data elements are all interoperable and
standardized.
The home health and longitudinal plans of care include many data ele-
ments that would already exist in these transitions of care data sets, plus
some additional elements, O’Malley said. The plans of care are based on
medical, surgical, nursing, behavioral, cognitive, and psychological issues,
as well as information about function and the environment (e.g., housing,
5 TheMDS “is a standardized, primary screening and assessment tool of health status that
forms the foundation of the comprehensive assessment for all residents in a Medicare and/
or Medicaid-certified long-term care facility. The MDS contains items that measure physical,
psychological and psychosocial functioning” (CMS, 2012).

supports, transportation). These can be mapped to the data sets. Specific

medical conditions or medication-based expansions can be included. “If you
can exchange not so much the care plan but the interoperable, critical parts
of a plan—concerns, interventions, goals, and assigned team members—the
receivers can reuse those components in their own care planning process,”
he said. According to O’Malley, the components of a CDA document can
include the following, among many other elements:
• Patient history and physical notes,

• Progress notes,
• Diagnostic imaging reports,
• Operative notes,
• Procedure notes,
• A discharge summary,
• A continuity-of-care document,
• Consultation notes,
• Referral notes,
• A transfer summary, and
• A care plan.
Each of these sections can be broken down into multiple fields of information.
Again, he said, building this will require shared mechanisms to ex-
change health information and the acquisition and use of low-cost software.
Once the CDAs are created, they can be used for additional purposes, such
as reporting on quality and management of population health. This model
represents a solution to the challenge of sharing essential health information
across different sites to facilitate the level of care coordination needed by
patients with complex medical conditions, O’Malley said.
If home health agencies participate in this shared information exchange
between health care and community-based service providers, it provides
them with the opportunity to play a number of new roles, in addition to
the role of service provider, O’Malley said. “This gets home care away from
merely selling the commodity of home care visits.” Home health agencies
can become aggregators, integrators, managers, and guarantors of the
range of services needed by individuals with complex health care needs. In
so doing, he said, they can sell value, which comes with the integration of
services and with the establishment of these services as reliable, consistent,
and scalable. “The reason home care can do this,” O’Malley said, “is that
no one else in the health sector does—or can do—what home care does,
by bringing services to the individual, not the other way around, by pro-
viding services in geographically dispersed areas, not a fixed location, and

by being the bridge between traditional health care and community-based

service providers.”

A brief open discussion followed the panelists’ presentations. Work-
shop participants were able to give comments and ask questions of the
panelists. The following sections summarize the discussion session.
Montgomery noted that the Improving Medicare Post-Acute Care
Transformation (IMPACT) Act of 20146 will require reporting on stan-
dardized measures that will give a much closer look at patient function
and a broader view of service provider capabilities, as well as greater ac-
countability across post-acute care settings.7 Gage said that the act’s quality
metrics are all basic information that home health agencies already monitor
and collect.
Even with more standardized post-acute care metrics, coordination of
these services with hospitals is likely to continue to pose challenges. Peter
Boling, Virginia Commonwealth University, related a story about one of his
patients and said that even having an electronic health record that notes the
identity of a patient’s primary care physician does not prevent assignment to
another doctor for follow-up if the patient ends up in the hospital of a dif-
ferent health care system. Patients need a greater say in which hospital and
system that they are taken to, O’Malley said. In addition, basic rules of the
road will have to be worked out between health care providers and shared
savings plans, which are accountable for the full care of a patient, whether
that is delivered in network or by others, he said. Obviously, plans would
prefer to have their patients under their supervision and care. Allen added
that patient education in advance about the importance of staying in the
correct managed care model (or, in his experience, Program of All-Inclusive
Care for the Elderly [PACE]) to avoid out-of-pocket costs may be a partial
approach. In addition, O’Malley said, the emergency medical technicians
who take the patient to the out-of-network hospital also should be part of
6 Improving Medicare Post Acute Care Transformation Act of 2014, Public Law 113-185,
113th Cong., 2nd sess. (October 6, 2014).

7 According to Montgomery, under the IMPACT Act, the new quality measures that all
post-acute care providers will be required to report are “functional status, cognitive function,
and special services; treatments and interventions, such as the need for ventilator use, dialysis,
chemotherapy, central line placement, and total parenteral nutrition; medical conditions and
comorbidities, such as diabetes, congestive heart failure, and pressure ulcers; impairments such
as incontinence and impaired ability to hear, see, or swallow; and other categories deemed
necessary and appropriate by the Secretary.”

the information exchange. They should be able to download all the infor-
mation that they need about the patient, including hospital preference, he
said. Part of the organization around MediCaring ACCs involves bringing
the emergency medical service providers to the table, Allen noted. Just by
working more closely together locally, improvements in how services are
linked can be made. On the West Coast, an increasing number of emergency
services programs are actually functioning like case managers, because they
know the patients who return often to the hospitals, Gage said. “They
know the home; they know where the patient needs to go.”

Reflections and Reactions
At the beginning of the second day of the workshop, two of the moder-
ators for panels presented on the first day of the workshop reflected on the
key messages they heard regarding what it will take to get to the ideal state
of home health care. These included the panels that addressed workforce
considerations and new organizational and payment models.1 Then, in the
final session of the workshop, three individuals presented their reactions
to the workshop overall. Some of the recurrent topics identified by these
individuals are highlighted in Box 9-1.
The following sections are the reflections and reactions of the members
of these two panels.
REFLECTIONS ON DAY ONE

This section summarizes the reflections of moderators for panels on
workforce (see Chapter 5) and models of care and approaches to payment
(see Chapter 6) presented on the first day of the workshop.
1
For personal reasons, Barbara B. Citarella was unable to present her reflections for the
panel on key issues and trends (see Chapter 4).
117

BOX 9-1
Highlights from Individual Speakers
The following are topics identified by individual reactors as being recurrent

topics from the workshop’s presentations:
• A focus on the sickest, highest-cost patients (Bowles, Lee)

• The need for quality and outcomes measurement (Labson, Lee)
• The potential for cost savings (Bowles, Lee)
• The need for better transitions of care and better coordination of care
(Bowles, Labson, Lee, Stein)
• The appropriate use of technology, including information technology and
telehealth (Bowles, Labson, Lee, Stein, Taler)
• Support for family caregivers (Bowles, Labson)
• Improved training for and use of the home health care workforce (Bowles,
Labson, Taler)
• The need to focus on an individual’s level of function (Bowles, Labson,
Lee, Taler)
• The need for flexible payment approaches (Bowles, Lee)
• The need for patient-centered goal setting (Lee, Stein)
• The need for better connections between health care and social services
(Stein, Taler)
Workforce
Margherita C. Labson
Among the points emphasized in the workforce panel, Labson said, was
the compelling need for robust methods of analysis of workforce topics.
Thomas E. Edes, in particular, she said, demonstrated how helpful infor-
mation can be in program development. Targeting of high-risk, high-cost,
and vulnerable populations for home-based primary care unquestionably
requires a more diverse and skilled workforce, and his data showed “how
much better it is to approach these clients at the primary care phase rather
than waiting until they need restorative care,” Labson said. In addition
to targeting, which all panelists emphasized, Edes discussed the needs for
strong transition programs. Labson pointed out that these junctures in the
health care continuum are places where the risk of error is highest.
The U.S. Department of Veterans Affairs (VA) has the advantage of
having a system-wide electronic record system, a capacity that is “woe-
fully lacking in the industry at large,” Labson said. However, several other

REFLECTIONS AND REACTIONS 119
presenters during the day mentioned that although many of the delivery
systems may have a single record, their hospice or home health care services
do not, at least not yet.
As noted by Gail Hunt, the willingness as well as the ability of family
caregivers to provide home health care is important to a successful home
care situation, Labson said. Caregiving responsibilities change people’s
lives, and some of these changes lead to better organization. This is perhaps
a lesson implicit in health professionals’ training of family members for
more specific caregiving tasks. Like Edes, Hunt pointed to the appropri-
ate use of technology in the home, Labson noted, and she emphasized the
importance of using patient-reported outcomes as one of the measures of
effectiveness of a program.
Robyn I. Stone described some of the different types of health work-
ers in the direct care workforce, with each one having somewhat different,
but sometimes overlapping, responsibilities and capacities. According to
Labson, Stone provided a realistic appraisal of the future of the direct care
worker, which will be affected by the
• shrinking availability of family caregivers,

• changing demographics of direct care workers and their patients,
• availability of career lattices that allow ongoing career development,
• low wages and scant benefits, and
• overall health of the U.S. economy.
Improvements in the performance of this workforce will require im-

provements in competency-based training, supervision, worker empow-
erment, wages and benefits, and the potential for career advancement in
specialty areas, such as comorbidity care or dementia care, Labson said.
According to Labson, the independence at home and consumer-directed
care movements were touchstones for the remarks of Henry Claypool. He
emphasized the value of promotora-type care, as opposed to rehabilitative
care, for people in their homes and the need for those with clinical training
to empower their clients. Rather than a narrow focus on clinical issues, he
supported the broader attention to functional issues. With respect to direct
care workers, the skilled/unskilled dichotomy is pejorative and may inhibit
direct care workers from taking their appropriate place on the interdisci-
plinary team, Labson said.

Models of Care and Approaches to Payment

Teresa L. Lee
Alliance for Home Health Quality and Innovation
Key themes from the panel, which included the overview by Peter Boling
and descriptions of six diverse programs, were presented by Teresa L. Lee.
She noted that most of the discussion focused on the very sickest, highest-
cost patients, defined by the use of different definitions for classifying such
individuals by different programs. These patients were described as having
multiple chronic conditions and functional limitations; being treated with
multiple (sometimes conflicting) medications for multiple conditions; and
being frequent users of hospitals, emergency departments, and nursing
homes. To identify these patients, Lee noted, most of the models use vari-
ous types of risk stratification, which requires health information systems
sufficient to perform such stratifications, adequate patient assessment pro-
tocols, and data analytics.
Lee said the diverse care delivery and payment models described en-
compassed everything from advanced illness management to bundled pay-
ment arrangements, accountable care organizations, home-based primary
care, and hospital at home, all with home health or home-based care com-
ponents. Despite this variation, Lee noted a number of common elements
among the home health care models discussed:
• Home health care services are integrated with primary care, specifi-
cally physicians and advanced practice nurses, and palliative and
end-of-life care programs.
• Home health care services focus on care coordination, care man-
agement, and care transitions.
• Most models include post-acute care, and all models are working
toward proactive, preventive maintenance care.
• Nursing care and physical or occupational therapy play critical
roles, and in some models, the role of home health aides is being
strengthened.
• The models use telehealth and remote monitoring (even low-tech
approaches) to engage patients and increase program efficiency.
Person-centered goal setting and the integration of family caregivers into

care teams were also important themes raised by panelists, Lee said. In par-
ticular, the Community Aging in Place—Advancing Better Living for Elders
(CAPABLE) model presented by Sarah L. Szanton emphasized the use of the
priorities of each individual receiving care to establish goals for that person.
These goals may not be related to health or medical goals or needs, Lee said.

Lee further noted that although a number of the models that were
described are emerging, some already have data on their impact on qual-
ity and cost outcomes over different time frames, although they include
different populations and use different evaluation methods. Nevertheless,
the patterns in the data were similar, showing dramatic reductions in hos-
pitalization rates; the numbers of rehospitalizations, emergency department
visits, and days in intensive care units (ICUs); and total costs per enrollee.
According to Lee, the policy and payment reforms that would strengthen
these models and allow their expansion included the following: appropriate
reimbursement for services geared to the stabilization or improvement of
patients’ functional status; approaches to the use of bundled payments for
post-acute care that allow more flexibility in the delivery of care through
the use of a waiver of the Medicare requirement that patients be home-
bound and improved coordination with primary care; encouragement of
the use of capitation, which also facilitates flexible payment approaches;
and the use of value-based purchasing.
The vertical integration of a number of the models has led to the
alignment of incentives by payers and providers, enabled a consensus on
a financial bottom line, and improved communication among payers and
providers, Lee said. For programs operating on a smaller scale, panelists
recommended that a focus be placed on best practices, protocols for the
tracking of quality and costs metrics, and the avoidance of expansion faster
than the program can deliver positive results.
Finally, Lee raised the unasked question about the extent to which
the new models are able to improve rates of diagnosis of certain specific
diseases or conditions (e.g., dementia) and ultimately reduce preventable
hospitalizations.
Final REACTORS PANEL

This section presents the remarks of three individuals who reflected on
the workshop presentations overall, including their individual thoughts on
themes that they heard throughout the 2 days of the workshop. In addition,
after these formal remarks were provided, several workshop participants
contributed some final thoughts.
Kathryn H. Bowles
Visiting Nurse Service of New York Research Center and University of
Pennsylvania School of Nursing
In summarizing what she considered to be the main themes during the

2 days of the workshop, Bowles began by emphasizing the opportunity to
shift care from costly acute and institutional care to the home and com-

munity. She noted many examples showing that home health care costs less.
She found the frequent emphasis on patient function to be well received,
including the need for exercise, physical therapy, and other interventions
attempting to support patient function.
Bowles thought that Steven Landers’s key ingredients needed repetition:
the use of physician- and nurse practitioner (NP)-led holistic care plans, an
enhanced capacity for an acute care response, thoughtful use of information
technology to fill gaps and to communicate, and enhanced support during
transitions. She also reiterated his message that home health “must rise to
the occasion and embrace value creation.”
Bowles indicated that speakers also emphasized the importance of the
provision of care by interdisciplinary teams and occasionally mentioned
the importance of including the patient and family caregiver as part of the
team. Bowles noted that it is important to consider the home health and
personal aide workforce to be members of the team, especially in their role
as the eyes and ears for other team members.
The movement toward team-based care suggests the need for some-
what different training in medical and nursing schools and in other health
professions schools, she said. “We need to be in class together, in the
clinic together; we need to be problem solving together from the begin-
ning.” Training programs need to add content about the role of home- and
community-based care and the excitement that can come from that type of
care, she said. Home health care providers also need continuing education
and updating of their training and tools. Bowles also noted the need to
improve the efficiency of the processes within home health care, including
intake procedures, prioritization of new cases, and the frequency of home
visits.
Further, Bowles said, care should appear to be seamless to patients and
providers, but hard work will be required to make that happen. Informa-
tion technology can increase opportunities to communicate, share informa-
tion, monitor patients, teach, support the work, and evaluate outcomes.
These information systems need patient portals that allow information
gathering and sharing and that improve self-care. The VA’s information
system can be examined for lessons, she added.
Standards facilitate the ability to share information across systems.
Bowles noted that the American Nurses Association recognized a stan-
dardized, point-of-care terminology, the Omaha System for documenting
in-home care and other care in four domains: environmental, psychosocial,
physiological, and health-related behavior.2 Multidisciplinary clinicians use
that system to document problems, record signs and symptoms related to
2 Formore information, see http://www.omahasystem.org/overview.html (accessed Decem-

ber 9, 2014).

those problems and their interventions, and rate outcomes, she said. In
2014, Minnesota approved a statewide electronic health record and data
exchange initiative and recommended that the Omaha System be one of
the standards used. Such standardized data will help with the identification
of best practices and the development of evidence-based protocols, Bowles
suggested.
According to Bowles, a number of barriers to the greater use of tech-
nology needs attention. The lack of multistate professional licensure and
restrictions on NPs inhibit their ability to practice at the top of their license;
another is the integration of telehealth and other technologies into daily
work. For such integration to happen, Bowles said, technologies must be
easy to use and produce timelier results, and telehome alerts need to be
smarter and produce fewer false alarms. Technologies are needed that sup-
port medication administration, reconciliation, and reminders; that send
information to clinicians, including decision support, at the point of care;
that can take on some of the inefficient, repetitive teaching in home health
care; and that can provide support through the use of social networks.
Although telehealth may be a useful tool for the field, she said, much more
needs to be learned about it so that it may be used effectively and efficiently.
Identification of the right levels of care for patients coming out of
the acute care setting is still not easy, Bowles said, particularly because
discharge planning is not standardized. Patients not infrequently refuse
post-acute care services because they do not understand their importance.
Another need is to increase support for people to age in place and to help
them focus on their goals and the care outcomes important to them.
“Our greatest barrier,” Bowles said, “remains the payment models.”
The following were some of the ideas from the workshop that she noted
were more thought-provoking:
• The emphasis on the most costly 5 (or 10) percent (What about
everyone else, she asked?);
• The suggestion that the number of chronic illnesses is less impor-
tant than the effects of the chronic illnesses on patient function;
• Reconceptualization of community care as pre-acute care and a
focus on keeping people healthy and out of the hospital rather than
the reverse; and
• The VA’s medical foster home program as an innovative concept.
Judith Stein
Center for Medicare Advocacy
Stein, as an advocate for Medicare beneficiaries having difficulties with

the current health care system, pointed to several presenters’ emphasis on

patient priorities, agreeing that people want to set their own goals and
priorities and that “priorities” may be a better word for this than “goals.”
She said, “I don’t think I’ve ever heard, when I’ve spoken with the people
I was trying to get services from, ‘Well, what does the patient want?’” She
went on to emphasize a number of themes.
Many workshop presenters discussed the provision of as much patient
support as possible in the community, she said, which means that the lo-
cation for the provision of care is not limited to the patient’s home. She
believes that more discussion of collateral issues like transportation and
housing is needed. The intervention from individuals who can help make
repairs around the home was welcome, she said, because in her experience,
simple issues prevent people from being able to stay in their homes, for
example, needing a safety bar for the bathtub or a ramp to get up to the
porch.
Coordinated care was another theme that Stein identified. Coordina-
tion of all aspects of an individual’s care, including skilled, medical, and
nonskilled services, is key to successful outcomes, she said. She expressed
concern, however, that although Medicare Advantage strives to manage the
costs of care, it has not proven to be able to coordinate care. Coordination
of care means to “coordinate the services, the transportation, the housing,
the physicians,” she said. “[It] does not mean to ‘manage the dollars, save
the dollars.’”
Although the need for a willing and available caregiver received atten-
tion, “a willing and available patient” is also needed, Stein said. People
sometimes refuse services because they do not understand them or the
need for them, as was mentioned regarding post-acute care. “How you
communicate is incredibly important,” she said, and there also needs to be
sensitivity to what individuals are comfortable with. For example, mothers
do not necessarily want their daughters or sons to tend to their bathroom
needs, she explained.
The workshop participants were rightfully focused on what technology
can mean, she believes. However, she noted that at the Center for Medicare
Advocacy, staff members have encountered denial after denial of Medicare
claims for durable medical equipment, prosthetic devices, and speech-gen-
erating devices. The implication, she said, is that creative uses of technology
that are most useful to beneficiaries may run afoul of coverage rules. This
is short-sighted and counterproductive for beneficiaries, providers, and the
Medicare program, Stein said.
The interpretation of Medicare rules that limits home health care to
post-acute care situations remains a serious problem, despite the Jimmo v.
Sebelius decision, Stein said. For these and other reasons, she said, “we need
a 21st century Medicare program” that addresses contemporary patient and
caregiver needs and considers medical and technological advances.

George Taler
MedStar Washington Hospital Center and
Georgetown University School of Medicine
All aspects of the U.S. health care system have been based on the medi-
cal model, focused on the illnesses and disabilities of the individual, and
“we need to move it much more towards an emphasis on healthy com-
munities,” said Taler. He cited the conceptual shift, suggested by speaker
Wendy J. Nilsen, from the consideration of home health care as health care
in the home to consideration of the home as a place to be healthy and safe
and was the central locus of care.
He sees care in the home to be a proverbial three-legged stool, supported
by health care, social services, and function. In his model, health care is not
about a set of consultative clinicians and supporting professionals; it is about
an interdisciplinary team working for a population “to whom they are re-
sponsible personally and accountable to society.” The social work leg of the
stool should involve not just the brokering and pulling together of services,
as they are now mostly used, but also counseling of patients and family
caregivers and provision of a community organization function, he said, en-
joining family, friends, and local agencies, such as the neighborhood village
movement. Housing and function work together, are intimately related, and
either limit or facilitate what can be accomplished in the home. By enlist-
ing the help of neighbors and volunteers and with the aid of small grants
and donations, older adults can age in place, which promotes age-related
diversity in the community and maintains property values that benefit all.
Taler then suggested that the workshop participants conduct a thought
experiment. He asked them to envision a matrix. Down the left margin,
they should list functions (activities of daily living, instrumental activities of
daily living, patient goals, and so on). The next columns are used to answer
a series of questions from left to right:
• What is the patient’s current status? Which of those activities and

goals are they able to accomplish (determined by the use of what-
ever assessment scale is convenient)?
• Where is the patient likely to go, relative to those activities and
goals, with the help of medical care, devices, rehabilitation services,
and so on, including patient motivation?
• What is the caregiver willing and able do to fill in the gaps?
• What can the formal care system do to train the caregiver, provide
additional assistance, or provide devices to fill in the gaps a little
better?
• What can secondary caregivers—neighbors, friends, relatives, or
paid assistance—contribute?

This exercise begins to create a care plan that focuses squarely on function
and sets priorities, he suggested.
Taler endorsed speaker Robyn I. Stone’s emphasis on the importance
of direct care workers as part of the home health care team. They need
adequate training and a care plan that helps them know what they need to
do, how to be effective eyes and ears for the team, and how to be account-
able not only to the team but also for their contribution to the outcomes
of their patients, he said.
Meanwhile, he noted, the country faces a dearth of geriatricians. The
geriatric NPs have been folded in with the adult NPs, and only a handful
of physical therapists with geriatric expertise exist. The future workforce,
Taler said, is a serious concern. The chronic care management field needs
primary care physicians who are truly engaged in “the intellectual chal-
lenges of managing the complexity of [the medical conditions of] these
patients, not only because of the joys of working in an interdisciplinary
team but also for the emotional satisfaction of dealing with people at this
time in their lives.” Remunerative positions will be needed to attract these
physicians, and the funds will likely come from shared savings programs
under development through Medicare.
Taler also noted that much attention was given to technology issues,
including monitoring technologies. Not discussed, he said, were practice
management technologies that optimize clinicians’ time, facilitate commu-
nication, and utilize point-of-service diagnostic technologies that permit
informed decisions to be made on the fly, in patients’ homes. “With about
20 pounds of equipment costing perhaps $20,000, it is possible to do in
the home anything that an urgent care center can do,” he said. Going
further, he said that with the right financial incentives, within 4 hours it
is possible to create a nursing home, hospital, or intensive care unit in a
patient’s bedroom. “There’s no need to go to a hospital for the vast major-
ity of problems, except major surgery, invasive procedures, and complex
imaging.” Preoperative and postoperative care can be done at home with
ICU-level monitoring devices wirelessly connecting to a central telemetry
unit. Taler also noted the lack of discussion about the specific technologies
that can facilitate home-delivered medications and treatments.
Taler stated that neither hospitals nor primary care (as it is currently
structured) can handle the wave of older patients requiring care for chronic
conditions. He also said that current home health care organizations are
unsustainable, but no one wants to be in a nursing home. For that reason,
Taler challenged innovative home health care leaders to stop thinking about
themselves as small fish in a large pond and instead “think about us as oxy-
gen in the tank. If we don’t succeed, our health care system dies.”

Final Thoughts from Workshop Participants

Amy Berman, The John A. Hartford Foundation, said the current sys-
tem has many incentives to move in directions that would preclude home
health care. When the future is considered, the health care system has a
tremendous regulatory burden with respect to what is accomplished in that
first home health visit. As a result, she said, home health providers are not
necessarily focused on accomplishing what is of the greatest importance to
patients until the second, third, or fourth visit. This includes the provision
of assistance to the family to help them understand how to handle different
aspects of care.
Berman also noted that for many people, caregiving is managed at a
distance; that is, children do not necessarily live close to their parents any
longer. Information sharing—and the Health Insurance Portability and
Accountability Act3—should not be a barrier to this, even though, at pres-
ent, it often is cited as being a barrier to team-based dialog.
Karen Marshall, Kadamba Tree Foundation, noted that people often
come to the issue of care at home in a moment of crisis. People need a
bridge between the present and future, she said, so that they have realistic
expectations of what it means to have a long-term illness and to age. Some
education could take place in the long period of time that exists before a
crisis.
Michael Johnson, BAYADA Home Health Care, said that professionals
should be interested not in what they are teaching patients and caregivers
but in what they are learning. “We continue to talk about teaching, he said,
and I just want to be sure that we’re talking about learning, and how we
measure that.”
For the delivery of high-level, high-quality care at home, Anthony Sung
described a pioneering project at Duke University: home-based bone mar-
row transplantation. Although this is one of the most advanced technical
medical procedures, the Duke team has successfully treated seven patients
in home-based settings. Sung argued that it is better for patients in terms
of improved quality of life and decreased exposures to infection, and the
clinicians believe that it also will improve other outcomes. Home health
care preserves patients’ normal microflora, he said, and in that way can
improve homeostasis and health.
The workshop concluded with a final comment from Judith Stein: “I
just want to say, we should unite. We have nothing to lose but our silos.”
3 Health
Insurance Portability and Accountability Act of 1996, Public Law 104-191, 104th
Cong., 2nd sess. (August 21, 1996).


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Appendix A
Workshop Agenda
The Future of Home Health Care: A Workshop
September 30–October 1, 2014
The Keck Center of the National Academies

500 Fifth Street, NW, Room 100
Washington, DC 20001
Sponsored by:
American Academy of Home Care Medicine
American Nurses Association
American Physical Therapy Association
Axxess
Community Health Accreditation Program
Home Instead Senior Care
National Alliance for Caregiving
Unity Point at Home
Workshop Objectives
• Provide an overview of the current state of home health care.
• Examine the particular role of Medicare-certified home health
agencies in achieving the triple aim: to improve the quality of pa-
tient care, improve population health, and reduce costs.
• Explore how to integrate home health care into the future health
care marketplace.
• Discuss how to facilitate the future role of home health care (e.g.,
workforce, technology, infrastructure, policy reform).
• Highlight research priorities to help clarify the value of home
health care.
131

DAY ONE: September 30, 2014

8:45 a.m. Welcome and Remarks on the Ecosystem of Home
Health
Bruce Leff, Workshop Co-Chair
Johns Hopkins University School of Medicine
Elizabeth Madigan, Workshop Co-Chair

Case Western Reserve University
CONSUMER PERSPECTIVE
9:15 a.m. James Martinez
KEYNOTE: HOME HEALTH CARE—THE CURRENT STATE

9:30 a.m. Robert J. Rosati
Visiting Nurse Association (VNA) Health Group
9:55 a.m. BREAK
pANEL I: KEY ISSUES AND TRENDS TO CONSIDER IN PLANNING

FOR THE FUTURE IDEAL STATE OF HOME HEALTH CARE
10:15 a.m. Introductions
Barbara B. Citarella (Moderator)
RBC Limited
10:20 a.m. Series of Presentations
Trends in Population Health

Tricia Neuman, Kaiser Family Foundation
Trends in Public Policy

Douglas Holtz-Eakin, American Action Forum
Trends in the “Real World”

Barbara A. McCann, Interim HealthCare
11:20 a.m. Discussion with Speakers and Audience

APPENDIX A 133
kEYNOTE: hOME hEALTH cARE 2024—THE IDEAL STATE

11:45 a.m. Steven Landers
VNA Health Group
12:10 p.m. Lunch
pANEL ii: WHAT WILL IT TAKE TO GET TO THE IDEAL STATE?:

wORKFORCE
1:10 p.m. Introductions
Margherita C. Labson (Moderator)
1:15 p.m. Series of Presentations
The Value of Team-Based Care

Thomas E. Edes, U.S. Department of Veterans Affairs
Supporting Families
Gail Hunt, National Alliance for Caregiving
Direct-Care Workers
Robyn I. Stone, LeadingAge
Care Coordination and the Consumer Voice

Henry Claypool, The American Association of People
with Disabilities
2:15 p.m. Discussion with Speakers and Audience
2:40 p.m. BREAK
pANEL iii: WHAT WILL IT TAKE TO GET TO THE IDEAL STATE?:

NEW MODELS OF CARE AND APPROACHES TO PAYMENT
Teresa L. Lee (Moderator)

3:05 p.m. Overview of the Range of Models and Approaches to

Payment
Peter Boling
Virginia Commonwealth University
3:35 p.m. Specific Examples

Jeff Burnich, Sutter Health
Richard Lopez, Atrius Health
Rose Madden-Baer, Visiting Nurse Service of
New York
Eric Rackow, Humana At Home
Ronald J. Shumacher, Optum Complex Population
Management
5:00 p.m. Adjourn Day 1
DAY TWO: October 1, 2014

8:45 a.m. Overview of Day

rEFLECTIONS ON dAY ONE

8:50 a.m. Reflections by Day One Panel Moderators
Barbara B. Citarella, RBC Limited1
Margherita C. Labson, The Joint Commission
Teresa L. Lee, Alliance for Home Health Quality and
Innovation
CONSUMER PERSPECTIVE
9:05 a.m. Karen Marshall
Kadamba Tree Foundation
1 Due to unforeseen circumstances, Barbara Citarella was unable to join this panel.

APPENDIX A 135
KEYNOTE: TOWARD PERSONAL hEALTH:

GOING HOME AND BEYOND
9:15 a.m. Eric Dishman
Intel
10:30 a.m. break
pANEL IV: WHAT WILL IT TAKE TO GET TO THE IDEAL STATE?:

INNOVATION IN TECHNOLOGY
10:45 a.m. Introductions
Thomas E. Edes (Moderator)
10:50 a.m. Series of Presentations
The Evidence Base for Home Health Technologies

George Demiris, University of Washington
Telehealth
Raj Kaushal, Almost Family, Inc.
Recommendations from the Trans-National Institutes

of Health (NIH)/Interagency Workshop on the Use and
Development of Assistive Technology for the Aging
Population and People with Chronic Disabilities
Wendy J. Nilsen, National Institutes of Health
11:35 a.m. Discussion with Speakers and Audience
12:00 p.m. LUNCH
pANEL V: lINKING hOME hEALTH cARE

TO THE LARGER ECOSYSTEM
Anne Montgomery (Moderator)
Altarum Institute

1:05 p.m. Series of Presentations
Connecting to the Larger Health Care Ecosystem

Barbara Gage, The Brookings Institution
Connecting to the Community2

Joanne Lynn, Altarum Institute
Connecting Data
Terrence O’Malley, Massachusetts General Hospital
REACTORS PANEL

Questions
What does the future look like?
What are the key needs and issues?
How do we communicate the value of home health care?
Reactors
Kathryn H. Bowles, Visiting Nurse Service of New York
and University of Pennsylvania School of Nursing
Judith Stein, Center for Medicare Advocacy
George Taler, MedStar Washington Hospital Center and
Georgetown University School of Medicine
3:15 p.m. Adjourn
2 Due to unforeseen circumstances, Joanne Lynn was unable to make this presentation,
which was given by Anne Montgomery of the Altarum Institute and Kyle Allen of Riverside
Health Systems.

Speaker and Moderator

Biographical Sketches
Kyle Allen, D.O., AGSF, is the vice president for clinical integration and
medical director of geriatric medicine and lifelong health at Riverside
Health System in Newport News, Virginia. He is the former chief of the di-
vision of geriatric medicine and medical director of Summa Health System’s
Institute for Senior’s and Post-Acute Care, Akron, Ohio. Under Dr. Allen’s
leadership, Summa Health System achieved national attention for research,
innovative models of care, and success in demonstrating the value proposi-
tion of geriatric and palliative care to hospitals and the community. In his
new role at Riverside Health System he is continuing this work to evolve a
health systems approach to improving care for older adults and those with
serious and advanced illness. Dr. Allen graduated from the Ohio University
College of Osteopathic Medicine and completed a fellowship in geriatric
medicine at the University of Cincinnati. He is board certified by the Ameri-
can Board of Family Medicine with a Certificate of Added Qualifications
in Geriatric Medicine and is a fellow of the American Geriatrics Society.
Dr. Allen is a researcher, book author, and inventor, has numerous peer
review publications, and speaks to national audiences on health care and
geriatric medicine. He is clinical professor of kinesiology and health sci-
ences at the College of William & Mary, Williamsburg, Virginia. Dr. Allen
recently completed the Practice Change Fellows Program (PCF) (www.
practicechangefellows.org), a national leadership development program for
geriatric leaders and clinicians sponsored by Atlantic Philanthropies and the
John A. Hartford Foundation. He currently serves as a senior advisor for
the Practice Change Leaders Project (http://www.changeleaders.org), phase
two of the PCF project.
137

Peter Boling, M.D., is a professor of geriatric medicine at the Virginia Com-

monwealth University (VCU) Medical Center and an internist in Richmond,
Virginia, and is affiliated with the VCU Health System. He received a medi-
cal degree from University of Rochester School of Medicine and Dentistry
and has been in practice for 33 years. He specializes in internal medicine.
Kathryn H. Bowles, Ph.D., M.S.N., holds a B.S.N. from Edinboro Uni-

versity of Pennsylvania, an M.S.N. from Villanova University, and a Ph.D.
from the University of Pennsylvania. Her program of research examines
decision making supported by information technology to improve care
for older adults. Her ongoing study, funded by the National Institute
of Nursing Research, focuses on the development of decision support to
determine the best site of care for those needing post-acute care. Other
research areas include telehealth technology, home care, and evaluation of
electronic health records. Dr. Bowles has been recognized for her research
achievements. She received the Distinguished Alumni Award in Natural
Science from Edinboro University of Pennsylvania and the Leadership in
Nursing Research Medallion from the Villanova University School of Nurs-
ing Alumni Society. Her work has been continuously funded by federal and
foundation sources for 20 years. She has more than 200 publications and
presentations, she has served on the National Quality Forum Care Coor-
dination Steering Committee and the Centers for Medicare & Medicaid
Services Technical Expert Panel on the development of the Continuity As-
sessment Record and Evaluation tool, and she was a member of the Health
Information Technology Standards Panel Care Coordination Committee
to identify standards for the electronic health record. She was an invited
expert consultant on transitional care, gerontology, information science,
and telehealth for the Ministry of Health in Singapore. She is a fellow of
the American Academy of Nursing and the American College of Medical
Informatics and a member of the American Nurses Association and the
Sigma Theta Tau International Honor Society.
Jeffrey Burnich, M.D., senior vice president and executive officer of the
Sutter Medical Network (SMN), leads a network of nearly 5,000 primary
care and specialty physicians that strives to provide consistently superb
care to patients across Sutter Health in Northern California. Dr. Burnich
works with physician leaders in both medical foundations and independent
practice associations to identify patients’ and doctors’ priorities. Under his
leadership, participating physician organizations have collectively agreed
upon SMN participation standards and made a commitment to reaching
and exceeding standards around clinical quality, patient satisfaction, patient
wait times, online services, and clinical variation reduction. In addition, he
oversees the operations of Sutter Physician Services (SPS), which provides

APPENDIX B 139
health care practice management and administrative services to locations

in California and Utah. The SPS team provides revenue cycle manage-
ment, managed care administration, and practice management solutions.
The Patient Service Center in Murray, Utah, logs 2 million calls per year.
Dr. Burnich serves on the boards of both the Integrated Healthcare Associa-
tion and the California Association of Physician Groups. Prior to joining
Sutter Health in 2008, Dr. Burnich served as chief medical officer and senior
vice president of system care management for the Mount Carmel Health
System in Columbus, Ohio. Dr. Burnich was in private practice as an inter-
nist for more than a decade before joining Mount Carmel. He holds a bach-
elor’s degree in biology from the University of Cincinnati and is a graduate
of the Ohio State University College of Medicine. Dr. Burnich is passionate
about health care delivery around the patient and providing quality and
affordable care when, where, and how patients want to receive it.
Barbara B. Citarella, R.N., B.S.N., M.S., CHCE, CHS-V, is the founder of

the award-winning company RBC Limited, a health care and management
company specializing in disaster preparedness. In addition to consulting in
all areas of health care, RBC Limited has worked extensively with local,
state, and federal government agencies and the private sector on business re-
covery planning, protection of personnel assets, infection prevention, infra-
structure protection, planning for all hazards, and the Incident Command
System. She was a certified instructor at the U.S. Department of Homeland
Security’s (DHS’s) Center for Domestic Preparedness. Ms. Citarella was ap-
pointed to serve as cochair of the National Association for Home Care and
Hospice’s Hurricane Katrina Task Force. She was part of the DHS commit-
tee to rewrite the DHS/Federal Emergency Management Agency Disaster
Preparedness Guidelines for People with Special Needs. She also served as
the conference coordinator for The National Pandemic Flu Conference held
in Washington, DC. Ms. Citarella has also served as an expert on home care
and hospice as a member of a panel on the pandemic flu for the Centers for
Disease Control and Prevention (CDC), the American Medical Association,
and the Agency for Healthcare Research and Quality (AHRQ). She was a
contributing member to the AHRQ document Home Health Care and the
Pandemic Flu, released in 2008. She participated in the CDC Pandemic
Workshop for Primary Practitioners and the workshop for Long-Term
Care. She was a member of the Association of Practitioners in Infection
Control’s (APIC’s) Emergency Disaster Planning Committee. During this
tenure she was a contributing author to Infection Prevention Implications
of Managing Haitian 2010 Earthquake Patients in U.S. Hospitals (Febru-
ary 2010), Infection Prevention and Control for Shelters During Disasters
(APIC, 2007), Reuse of Respiratory Protection in Prevention and Control
of Epidemic and Pandemic Prone Acute Respiratory Diseases in Healthcare

(2008), and Extending the Use and/or Reusing Respiratory Protection in

Healthcare Settings (December 2009). Ms. Citarella is currently the Home
Care Section chair for the APIC. Her presentation at the 2014 annual
conference was titled Health Care Reform and Infection Control. She is
currently working with four state health departments that have received
grants for needlestick safety and is working to involve home health care
and hospice providers across the country.
Henry Claypool, having sustained a spinal cord injury in a snow skiing ac-
cident in college, has been living with a disability for more than 30 years.
This experience has fostered a deep personal commitment to ensuring that
all Americans with disabilities are able to access the services and supports
that they need to lead productive and fulfilling lives, and this has been the
focus of his professional life. In the period of his life immediately following
his injury, Mr. Claypool relied on Medicare, Medicaid, Social Security Dis-
ability Insurance, and Supplemental Security Insurance. Support from these
programs enabled him to finish college and pursue a career of service to oth-
ers. Over his career, Mr. Claypool’s work has spanned from the provision
of direct services at the community level to work on federal policy issues in
his most recent role in public service as a senior adviser to the Secretary of
Health and Human Services. While at the U.S. Department of Health and
Human Services (HHS), Mr. Claypool was a principal architect of the ad-
ministration’s efforts to expand access to community living services, which
culminated in the creation of the Administration for Community Living.
Currently, he is executive vice president of the American Association of Peo-
ple with Disabilities. In these roles, he relies on his unique background of
public service and personal experience to seek pragmatic policy solutions.
George Demiris, Ph.D., is the Alumni Endowed Professor in Nursing at the

School of Nursing and Biomedical and Health Informatics at the School of
Medicine, University of Washington. He is the director of the Biomedical
and Health Informatics Graduate Program at the School of Medicine and
the director of the Clinical Informatics and Patient Centered Technologies
Program at the School of Nursing. He obtained a Ph.D. degree in health
informatics from the University of Minnesota. His research interests include
the design and evaluation of home-based technologies for older adults and
patients with chronic conditions and disabilities, smart homes and ambi-
ent assisted living applications, and the use of telehealth in home care and
hospice. He is a fellow of the American College of Medical Informatics and
a fellow of the Gerontological Society of America (GSA). In the past he has
served as the chair of the International Medical Informatics Association
Working Group on Smart Homes and Ambient Assisted Living and the
lead convener of the Technology and Aging Special Interest Group of GSA.

APPENDIX B 141
Eric Dishman is the Intel fellow and general manager of the Health and Life
Sciences Group at Intel. He is responsible for driving Intel’s cross-business
strategy, research and development and product and policy initiatives for
health and life science solutions. His organization focuses on growth op-
portunities for Intel in health information technology, genomics and per-
sonalized medicine, consumer wellness, and care coordination technologies
in more than a dozen countries. Mr. Dishman founded Intel’s first Health
Research and Innovation Lab in 1999 and in 2005 was a founding mem-
ber of Intel’s Digital Health Group, which recently formed a joint venture
with General Electric called Care Innovations. He is widely recognized as a
global leader in health care innovation with specific expertise in home- and
community-based technologies and services for chronic disease manage-
ment and independent living. He is also known for pioneering innovation
techniques that incorporate anthropology, ethnography, and other social
science methods into the design and development of new technologies. An
internationally renowned speaker, Mr. Dishman has delivered hundreds
of prominent keynotes on health care reform and innovation around the
globe, including the Consumer Electronics Show, TED, the White House
Conference on Aging; and meetings of the World Health Organization.
He has published dozens of articles on personal health technologies and
co-authored many government reports on health information technologies
and reform.
Thomas E. Edes, M.D., M.S., is executive director of geriatrics and ex-

tended care for the U.S. Department of Veterans Affairs (VA). He has na-
tional responsibility for operations and management of the VA’s spectrum
of services, providing care to U.S. veterans with complex, chronic disabling
diseases. Care is provided in all settings: in the hospital, nursing home,
clinic, community, and the veteran’s home. The services include geriatric
clinics, adult day health care, home-based primary care, purchased skilled
home care, veteran-directed home care, homemaker/home health aide, re-
spite care, dementia care, community residential care, medical foster homes,
community nursing homes, the VA community living centers, state veterans
homes, geriatric research education and clinical centers, and hospice and
palliative care in all settings. Under his leadership since 2000, the number of
veterans receiving home-based primary care has tripled, palliative care has
become an established program in every VA medical center, and the Medical
Foster Home has grown from a pilot program to a national program in 42
states and is growing. Through his longstanding interests in home-based
primary care and analyses of its clinical effectiveness and economic advan-
tages, he has been actively involved in the development of independence at
home, a component of the Affordable Care Act that began as a Medicare
Demonstration of Home-Based Primary Care in 2012, providing compre-

hensive, interdisciplinary, longitudinal care in the homes of persons with

serious chronic, disabling disease. Prior to taking this position at the VA
headquarters, he was chief of geriatrics and extended care at the Harry S
Truman Memorial VA Medical Center and associate professor of medicine
at the University of Missouri in Columbia. There he was instrumental in de-
veloping geriatric evaluation and management inpatient and outpatient pro-
grams, subacute care and hospice units, a geriatric fellowship program, and
the Advanced Disease Planning initiative. He was medical director of the
VA Nursing Home Care Unit and the Home-Based Primary Care program.
Dr. Edes served as associate director of the 1995 White House Conference
on Aging Office and served for the Secretary on the Policy Committee for
the 2005 White House Conference on Aging. He was instrumental in the
VA End of Life Care initiative and was a project manager for the Institute
for Healthcare Improvement MediCaring collaborative on improving care
for persons with advanced chronic disease. His research interests included
clinical nutrition, cancer detection and prevention, enhancing outcomes in
home care, end-of-life care, and improving care for persons with chronic
disabling disease. Dr. Edes received an M.D. degree and an M.S. degree in
nutrition from the University of Illinois in 1981. He holds board certifica-
tion in internal medicine and in geriatric medicine and is a fellow of the
American College of Physicians and the American College of Nutrition. In
2010, Dr. Edes was elected president of the American Academy of Home
Care Physicians.
Barbara Gage, Ph.D., M.P.H., is a national expert in Medicare post-acute

care policy issues, including bundled payments, episodes of care, and case-
mix research. She has directed numerous studies analyzing the impact of
Medicare post-acute care payment policy changes, including the congres-
sionally mandated Medicare Post-Acute Care Payment Reform Demon-
stration and the Development and Testing of the Standardized Continuity
Assessment Record and Evaluation (CARE) Item Set. Dr. Gage’s research
has included numerous studies of the relative use of post-acute care before
and after the Balanced Budget Act; case-mix analysis of long-term care
hospital, rehabilitation hospital, skilled nursing facility, home health care,
and outpatient therapy patients; the relative use of inpatient and ambula-
tory rehabilitation services; bundled post-acute care payment demonstra-
tions; and the development of items to monitor the impact of the Medicare
payment systems on access to and quality of care. She earned a Ph.D. in
health policy and administration from Pennsylvania State University and
an M.P.A. in public administration from the University of Maine at Orono.
Douglas Holtz-Eakin, Ph.D., has a distinguished record as an academic,

policy adviser, and strategist. Currently he is the president of the American

APPENDIX B 143
Action Forum and most recently was a commissioner on the congressionally

chartered Financial Crisis Inquiry Commission. He was the sixth direc-
tor of the nonpartisan Congressional Budget Office (CBO) from 2003 to
2005. Following his tenure at CBO, Dr. Holtz-Eakin was the director of
the Maurice R. Greenberg Center for Geoeconomic Studies and the Paul A.
Volcker Chair in International Economics at the Council on Foreign Rela-
tions. During 2007 and 2008 he was director of domestic and economic
policy for the John McCain presidential campaign. Dr. Holtz-Eakin is
codirector of the Partnership for the Future of Medicare and serves on the
Board of the Tax Foundation and on the Research Advisory Board of the
Center for Economic Development.
Gail Hunt is president and chief executive officer of the National Alli-
ance for Caregiving (NAC), a nonprofit coalition dedicated to conducting
research and developing national programs for family caregivers and the
professionals who serve them. Prior to heading NAC, Ms. Hunt was presi-
dent of her own aging services consulting firm for 14 years. She conducted
corporate elder care research for the National Institute on Aging and the
Social Security Administration, developed training for caregivers with the
American Occupational Therapy Association, and designed a corporate
elder care program for employee assistance programs with the Employee
Assistance Professional Association. Prior to having her own firm, she was
senior manager in charge of human services for the Washington, DC, office
of KPMG Peat Marwick. Ms. Hunt attended Vassar College and graduated
from Columbia University. Ms. Hunt has served on the Policy Committee
for the 2005 White House Conference on Aging, as well as on the Advisory
Panel on Medicare Education of the Centers for Medicare & Medicaid
Services. She is also on the Board of Commissioners for the Center for
Aging Services Technology and on the board of the Long-Term Quality
Alliance. She co-chairs the National Quality Forum Measure Applications
Partnership Person- and Family-Centered Care Task Force. Additionally,
Ms. Hunt is on the Governing Board of the Patient-Centered Outcomes
Research Institute.
Raj Kaushal, M.D., is chief clinical officer at Almost Family, where his re-
sponsibilities include oversight of the company’s 240 home health clinical
branches spread over 15 states. Dr. Kaushal’s expertise is as a physician
executive. He is an expert in post-acute care management and has a unique
background in clinical and management leadership, developing companies
built on solid fundamentals and clinical excellence models, resulting in best-
in-class clinical and financial outcomes. He served as chief clinical officer
for home health companies valued at $300 million to $500 million and was

a participant on the Home Health Quality Improvement Committee for the

Alliance for Home Health Quality and Innovation.
Margherita C. Labson, R.N., M.S., is executive director for the Home

Care Program at The Joint Commission. In this role, she is responsible for
coordinating the efforts of the Home Care Business Development team in
identifying new markets, familiarizing organizations with the accreditation
process, and participating in new product development and the strategic
development and tactical operations of the Home Care Accreditation Pro-
gram. Ms. Labson is a veteran health care professional who has specialized
in the provision of home health care services since 1977 from both multi-
operational and academic perspectives. She has extensive knowledge in
the legal, regulatory, and accreditation requirements for the scope of home
health care programs provided in the United States and Puerto Rico. She is
an experienced lecturer and educator, a published author, and functionally
fluent in Spanish. From 1995 until late 2007, Ms. Labson served as a home
care surveyor for The Joint Commission. She has served as both faculty
and preceptor for surveyor education. She was previously the Compliance
Officer for AMS/CMS Corporations in Miami Lakes, Florida. In addition,
Ms. Labson has headed her own consulting firm, held managerial posi-
tions at a variety of home care organizations, and taught at the University
of Akron College of Nursing. Ms. Labson received a bachelor’s degree
in nursing from Duquesne University in Pittsburgh, Pennsylvania, and a
master of science degree in health care administration from Nova South-
eastern University in Davie, Florida. She is a certified professional in health
care quality and a certified case manager and was among the first wave of
the Green Belts certified by The Joint Commission in accordance with its
enterprise-wide program of robust process improvement.
Steven Landers, M.D., is the president and chief executive officer of the
Visiting Nurse Association (VNA) Health Group, Inc., the nation’s second
largest not-for-profit home health care organization. As a certified family
doctor and geriatrician, Dr. Landers places a strong emphasis on house calls
to the vulnerable elderly and has a specialized interest in geriatric medicine,
home health, hospice, and palliative care. Dr. Landers is a graduate of the
Case Western Reserve University School of Medicine and the Johns Hop-
kins University School of Hygiene and Public Health. He currently serves
on the board of directors of the National Association of Home Care and
Hospice and the American Academy of Home Care Physicians. He has
authored several articles on the role of home care in national publications,
including the New England Journal of Medicine and the Journal of the
American Medical Association. In 2009, Dr. Landers was honored as the
National Association of Home Care and Hospice Physician of the Year.

APPENDIX B 145
Before joining VNA Health Group, Dr. Landers served as the director of
the Center for Home Care and Community Rehabilitation and director of
Post-Acute Operations for the world-renowned Cleveland Clinic.
Teresa L. Lee, J.D., M.P.H., is the executive director of the Alliance for
Home Health Quality and Innovation (the Alliance). She joined the Alli-
ance in June 2011. As a graduate of Harvard University’s School of Public
Health and with formal training as an attorney, Ms. Lee is a recognized
professional in the fields of Medicare reimbursement and health law and
policy. She brings to the Alliance a thorough understanding of the critical
intersection between health policy, health care reform, and the law. As
executive director, Ms. Lee hopes to support skilled home health’s critical
and valuable role as the U.S. health care delivery system changes to improve
both the quality and the efficiency of patient-centered care. Ms. Lee has a
strong background in health care policy and association management ex-
perience. Prior to her work for the Alliance, Ms. Lee served as senior vice
president at the Advanced Medical Technology Association (AdvaMed)
in Washington, DC. Her career at AdvaMed included her tenure as vice
president and associate vice president of Payment and Health Care Deliv-
ery Policy. Ms. Lee has also served as a senior counsel in the Office of the
Inspector General at the U.S. Department of Health and Human Services.
A lifelong resident of the Washington, DC, area, Ms. Lee earned an under-
graduate degree from the University of California, Berkeley, a master of
public health degree from the Harvard University School of Public Health,
and a law degree from the George Washington University Law School.
Bruce Leff, M.D. (Workshop Co-Chair), is professor of medicine at the

Johns Hopkins University School of Medicine. He holds joint appointments
in the Department of Health Policy and Management at the Johns Hopkins
Bloomberg School of Public Health and in the Department of Community
and Public Health at the Johns Hopkins University School of Nursing. He
is the director of the Center on Aging and Health Program in Geriatric
Health Services Research and the codirector of the Elder House Call Pro-
gram in the Division of Geriatric Medicine at the Johns Hopkins Univer-
sity School of Medicine. His principal areas of research relate to home
care and the development, evaluation, and dissemination of novel models
of care for older adults, including the Hospital at Home model of care
(www.hospitalathome.org), guided care (www.guidedcare.org), geri atric
service line models (www.med-ic.org), and medical house call practices. In
addition, his research interests extend to issues related to multimorbidity,
guideline development, and case-mix issues. He has served on multiple tech-
nical expert panels for the Centers for Medicare & M edicaid Services on
issues related to geriatrics and home health care. Dr. Leff cares for patients

in the acute, ambulatory, and home settings. He directs the medicine clerk-
ship at the Johns Hopkins University School of Medicine and has received
awards for his teaching and mentorship. He is a former American Political
Science Association Health and Aging Policy Fellow. He is a member of the
Board of Regents of the American College of Physicians, past president of
the American Academy of Home Care Medicine, and an associate fellow
of InterRAI.
Richard Lopez, M.D., a physician at Harvard Vanguard Medical Associ-

ates, was appointed chief medical officer of Atrius Health in January 2009.
In this position, Dr. Lopez works collaboratively with the chief medical of-
ficers and chief executive officers of the six Atrius Health medical groups on
a wide range of clinical and quality initiatives. Specifically, Dr. Lopez’s focus
includes clinical program and regional project development, clinical aspects
of payer/hospital contracting, clinical informatics, medical management,
and safety and quality, as well as collaborating to develop quality standards
and the outcome reporting measures and clinical dashboards that support
the medical groups in meeting those standards. A more than 25-year veteran
of Harvard Vanguard, Dr. Lopez has made many significant contributions
to the organization and is the recipient of Harvard Vanguard’s Lifetime
Achievement Award. He also received the Becker Healthcare Leadership
Award in 2014. Dr. Lopez received a medical degree from the Boston Uni-
versity School of Medicine and completed his residency and internship at
St. Elizabeth’s Hospital. Dr. Lopez received a bachelor of arts degree from
Boston University and is a clinical instructor at Harvard Medical School.
As a board-certified internist, Dr. Lopez has practiced primary care internal
medicine at Harvard Vanguard’s Medford practice since 1982. Dr. Lopez
serves on several committees, including the Massachusetts Medical Society
Committee on Quality of Medical Practice and the Massachusetts Statewide
Advisory Committee on Standard Quality Measure Sets.
Rose Madden-Baer, DNP, R.N., MHSA BC-PHCNS, is the senior vice

president of population health management for the Visiting Nurse Ser-
vice of New York (VNSNY). She has practiced as both a nurse and a
nursing leader in a variety of home health, managed long-term care, and
community-based settings for more than 30 years. Dr. Madden-Baer is
board certified as a public health/community health clinical specialist. She
received a doctorate of nursing practice from the Duke University School
of Nursing in 2012 and holds certifications as a professional in health care
quality, as a home care and hospice executive, as a certified outcome and
assessment information set (OASIS) specialist, and as a population health
care coordinator through a postgraduate program at Duke University.
Dr. Madden-Baer’s responsibilities include creation of clinical operations

APPENDIX B 147
improvement strategies and development of new evidence-based programs,

including the development, implementation, and evaluation of a behavioral
health evidence-based program at VNSNY. Dr. Madden-Baer has devel-
oped and disseminated evidence-based models of care that have informed
community-based service delivery. In ground-breaking work that was also
part of her doctoral research in nursing practice, Dr. Madden-Baer used
predictive analytics to develop VNSNY’s behavioral health program di-
rected at the needs of homebound Medicare beneficiaries. She continues to
build new care models for VNSNY. She has implemented several popula-
tion health models (including two bundle payment models of care) using
population care coordinators trained by the Duke University School of
Nursing. Dr. Madden-Baer worked with other VNSNY leaders to mobilize
teams of nurses and other clinicians and home health aides in community
surveillance and the provision of public and behavioral health services to
residents in the aftermath of Superstorm Sandy. This team was honored as
a 2013 ADVANCE for Nurses’ Best Nursing Team in the Northeast. Ad-
ditionally, the American Red Cross awarded VNSNY an 18-month grant
for $1 million to continue health, wellness, and behavioral health services
to victims of this natural disaster. Dr. Madden-Baer is recognized as an in-
dustry leader with active participation in the Visiting Nurse Associations of
America (VNAA), the National Association for Home Care, and the Home
Care Association of New York. Dr. Madden-Baer’s research has gained
nationwide acceptance, and her work has been disseminated through her
participation in national coalitions, podium presentations, and publication
in mainstream media (including The Huffington Post); in academic journals
and textbooks, including the Journal of Nursing Care Quality (January
2013); and as an exemplar in the textbook The Doctor of Nursing Practice
Scholarly Project: A Framework for Success (Jones & Bartlett Learning,
2013). Dr. Madden-Baer’s innovative work has brought her many honors,
including being a finalist in the innovation category of the 2012 New York
Times Tribute to Nurses, and then more recently, in 2014, she was recog-
nized with a Distinguished Alumna Award by the Duke University School of
Nursing and also received the VNAA Innovative Leader of the Year Award.
Elizabeth Madigan, Ph.D., R.N., F.A.A.N. (Workshop Co-Chair), is asso

ciate professor of nursing at the Frances Payne Bolton School of Nursing
at Case Western Reserve University in Cleveland, Ohio. She has been
involved in home health care as a staff nurse, agency administrator, and
researcher since 1981. Dr. Madigan has also worked with home health care
internationally and with the World Health Organization and Pan American
Health Organization. Dr. Madigan has demonstrated the ability to lead,
inspire, and support others while moving nursing practice and science for-
ward throughout her career. She has a deep commitment to service within

the profession and constantly works to renew the profession of nursing

through her work in home health care, her mentoring capabilities, and her
international work, all of which have advanced the profession and inspired
colleagues around the globe to strive for excellence and improve the quality
of patient care.
Karen Marshall, J.D., has been a family caregiver for both parents and is
currently the executive director of the Kadamba Tree Foundation. She has
helped her parents face a variety of serious illnesses and aging issues. She
has cared for them both in their home and as a working, long-distance
caregiver. These experiences inspired Ms. Marshall to establish the Kad-
amba Tree Foundation, which offers education and support programs to
family caregivers. In addition to developing and facilitating these programs,
she also advises government and community organizations on conducting
outreach to help family caregivers effectively care for their loved ones. She
also volunteers as a support group facilitator and legal expert for a variety
of nonprofit organizations, such as the Alzheimer’s Association.
James Martinez is retired and lives in Northern California. In October

2011, Mr. Martinez’s mother was diagnosed with pancreatic cancer. He
subsequently rented out his home and moved into his parents’ house to help
care for them. After his mother passed away in February 2012, he stayed
on to help care for his father, who suffered from several chronic conditions.
His father passed away in May 2014. Mr. Martinez says his experience with
home health care, including the Advanced Illness Management and hospice
programs, were tremendously helpful to him in caring for his parents.
Barbara A. McCann is the chief industry officer of Interim HealthCare

Inc., supporting agencies in accountable care organizations, demonstration
projects with dually eligible beneficiaries, and other alternative delivery
models. Ms. McCann joined Interim in January 1998 and served as the
chief clinical officer, overseeing the company’s corporate clinical opera-
tions team, which developed policies, procedures, and practice guidelines
for the delivery of patient care as well as compliance with federal laws and
regulations and professional standards of practice. She also directed the
national chronic care and transition programs. Prior to joining Interim,
Ms. McCann was the executive director of accreditation, plan performance,
and clinical management alliances at the national Blue Cross Blue Shield
Association in Chicago, Illinois, where she was responsible for systemwide
strategies for managed care accreditation and health plan performance data.
From 1990 to 1995, Ms. McCann was vice president of outcomes manage-
ment and analytic services at Caremark, where she provided the database
and analytic support to six divisions of the company in the United States

APPENDIX B 149
and abroad. Ms. McCann was also the first director of hospice and home
health accreditation at The Joint Commission on Accreditation of Health-
care Organizations. She serves on several boards, including the Community
Health Accreditation Program (CHAP), and is a Phi Beta Kappa graduate
of the University of California, Berkeley.
Anne Montgomery, M.S., is a senior policy analyst at the Altarum Institute’s

Center for Elder Care and Advanced Illness and a visiting scholar at the Na-
tional Academy of Social Insurance. From 2007 to 2013, Ms. Montgomery
served as senior policy advisor for the U.S. Senate Special Committee on
Aging, where she was responsible for developing hearings and legislation
to improve nursing homes and home- and community-based services in
Medicaid and to address dually eligible beneficiaries, health care workforce
issues, elder abuse, dementia care, and community and social support ser-
vices for older adults. She has also served as a senior health policy associate
with the Alliance for Health Reform in Washington, DC; a senior analyst
in public health at the U.S. Government Accountability Office; and a leg-
islative aide for the Ways and Means Subcommittee on Health in the U.S.
House of Representatives. Based in London as an Atlantic fellow in public
policy in 2001 and 2002, Ms. Montgomery undertook comparative policy
analysis of the role of family caregivers in the development of long-term
care in the United Kingdom and the United States. During the 1990s, she
worked as a health and science journalist covering the National Institutes
of Health and the U.S. Congress. A member of the National Academy of
Social Insurance and Academy Health, Ms. Montgomery has an M.S. in
journalism from Columbia University and a B.A. in English literature from
the University of Virginia and has undertaken gerontology course work at
Johns Hopkins University.
Tricia Neuman, Ph.D., M.S., is a senior vice president of the Henry J.

Kaiser Family Foundation and is director of the Henry J. Kaiser Family
Foundation’s Program on Medicare Policy and Project on Medicare’s
Future. Dr. Neuman’s work at the Foundation focuses on a broad range
of issues pertaining to the Medicare program and the population that
it serves. Dr. Neuman is widely regarded as a Medicare policy expert,
with broad knowledge of issues associated with the health care coverage
and financing for elderly and disabled Americans and the health care of
those individuals. She has published numerous articles on topics related to
health care coverage and financing for the Medicare population, and has
been invited several times to present expert testimony before congressional
committees and other key audiences. She has authored and co-authored
several papers and reports related to Medicare proposals; recent examples
include Raising the Age of Medicare Eligibility: A Fresh Look Following

Implementation of Health Reform, Transforming Medicare into a Premium

Support System: Implications for Beneficiary Premiums, and Policy
Options to Sustain Medicare for the Future. Dr. Neuman has appeared as
an independent expert on NPR, the NBC Nightly News, the CBS Evening
News, the Today Show, the PBS NewsHour, and programs on other major,
national media outlets. Before joining the Foundation in 1995, Dr. Neuman
served on the professional staff of the Ways and Means Subcommittee on
Health in the U.S. House of Representatives and on the staff of the U.S.
Senate Special Committee on Aging, working on health and long-term care
issues. Dr. Neuman received a doctorate of science degree in health policy
and management and a master of science degree in health finance and
management from the Johns Hopkins School of Hygiene and Public Health
in Baltimore, Maryland. She received a bachelor’s degree from Wesleyan
University in Middletown, Connecticut.
Wendy J. Nilsen, Ph.D., is a health scientist administrator at the Office of

Behavioral and Social Sciences Research of the National Institutes of Health
(NIH) and the program director for the Smart and Connected Health pro-
gram at the National Science Foundation (NSF). Dr. Nilsen’s scientific focus
is on the science of human behavior and behavior change, including the
use of technology to better understand and improve health, adherence, the
mechanisms of behavior change, and behavioral interventions in patients
with complex conditions in primary care. More specifically, her efforts in
mobile and wireless health (mHealth) research include serving as the NIH
lead for the NSF/NIH Smart and Connected Health announcement, conven-
ing meetings to address methodologies in mobile technology research, serv-
ing on numerous federal mHealth initiatives, and leading the NIH mHealth
training institutes. Dr. Nilsen Wendy is also the chair of the Adherence
Network, a trans-NIH effort to enhance and develop the science of ad-
herence. She is also a member of the Science of Behavior Change, Health
Economics, and HMO Collaboratory working groups. These projects are
initiatives funded through the Common Fund that target behavioral and
social sciences research to improve health across a wide range of domains.
Dr. Nilsen also chairs the NIH Integrating Health Strategies work group,
which supports the science of behavioral treatments for patients with mul-
tiple chronic conditions in primary care. At NSF, she leads the Smart Health
program, which targets science at the intersection between computer sci-
ence, engineering, medicine, and health, broadly defined.
Terrence O’Malley, M.D., is an internist and geriatrician with an active

nursing home practice at the Massachusetts General Hospital, where he
provides clinical care, supervises trainees, provides network oversight of
post-acute care, and conducts research on improving transitions of care and

APPENDIX B 151
the exchange of clinical information at transitions. Until 2014 he served

as the medical director of Partners HealthCare at Home and the medical
director for Non-Acute Care Services within the Partners HealthCare Sys-
tem and currently sits on the Partners network-level steering committees for
palliative care, readmissions, and quality measurement and is co-chair of
the Transitions of Care Committee. At the state and national levels, he is the
co-principal investigator and evaluation lead on an Office of the National
Coordinator for Health Information Technology (ONC)-funded research
project (Improving Massachusetts Post Acute Care Transfers [IMPACT]),
which measures the effect of the electronic exchange of essential clinical
data at the time of care transitions and its impact on the utilization of
health care services. He also co-chairs the Massachusetts Health Data Con-
sortium Transitions and Care Coordination Information Technology Work
Group and sits on the statewide Care Transitions Steering Committee. At
the national level, he co-chairs the Long-Term and Post-Acute Care Work
Group within the Standards and Interoperability Framework at ONC, and
he is a lead on the Longitudinal Coordination of Care (LCC) Work Group
and the LCC Pilot Work Group. These groups created the data sets required
to exchange a plan for home health care between agencies and the certify-
ing clinician and the components of a longitudinal care plan with exchange
standards for use between all acute care and post-acute care providers. He
is a member of the National Quality Forum Care Coordination Steering
Committee for the Care Coordination Measure Endorsement Maintenance
project and serves on the board of directors of the Long Term Quality
Alliance.
Eric C. Rackow, M.D., is president of Humana At Home. As president of

Humana Cares/SeniorBridge, Dr. Rackow is responsible for the Humana At
Home chronic care management platform. Dr. Rackow is also a professor
of medicine at the New York University School of Medicine. Prior to his
current role, he was president and chief executive officer of SeniorBridge,
where under his leadership the company tripled in size to 44 home health
agencies and a nationwide network of more than 2,000 care managers.
Dr. Rackow joined SeniorBridge following a career in academic medicine,
where he saw firsthand the challenges that frail seniors face in their homes
and the need to provide personalized, ongoing support to prevent unneces-
sary hospitalizations and emergency room visits. Dr. Rackow’s previous
hospital roles include past president of the New York University (NYU)
Hospitals Center, where he was responsible for ensuring the quality of med-
ical services and promoting continued excellence in patient care, medical
education, and clinical research; chief medical officer at the NYU Hospitals
Center; and chair of the Department of Medicine at St. Vincent’s Hospital
and Medical Center of New York. Dr. Rackow is an expert in critical care

and health care delivery. After earning an M.D. at the State University of
New York, Downstate Medical Center, he trained in internal medicine,
served as chief resident in internal medicine, and completed a fellowship in
cardiology at the Downstate Medical Center. Dr. Rackow is the author of
184 articles and 40 chapters on the care of patients with complex medical
problems. He is currently on the Board of Trustees of the Weil Institute of
Critical Care Medicine, which is dedicated to education and research in car-
ing for patients with severe illness or injury. He also serves on the Board of
Trustees of his alma mater, Franklin and Marshall College. Dr. Rackow is a
fellow of the American College of Physicians, American College of Critical
Care Medicine, American College of Cardiology, and American College of
Chest Physicians. Recently, he received the distinguished award of Master-
ship of the American College of Physicians.
Robert J. Rosati, Ph.D., is currently at the Visiting Nurse Association

(VNA) Health Group, where he is working on the development of a con-
nected health institute. Prior to being at the VNA Health Group, Dr. Rosati
held senior management positions at the Visiting Nurse Service of New York
and CenterLight Healthcare. He has more than 20 years of experience in
health care in various research, analytic, quality management, educational,
and administrative roles. Dr. Rosati is currently on the faculty Hofstra
University. He has published more than 40 health care–related articles and
has made numerous presentations at national meetings. Dr. Rosati is also
associate editor of the Journal for Healthcare Quality.
Ronald J. Shumacher, M.D., F.A.C.P., C.M.D., currently serves as chief

medical officer for Optum Complex Population Management, one of the
nation’s largest care delivery and care coordination companies for chroni-
cally ill, medically complex, and post-acute care patients. Dr. Shumacher
previously served as executive director and senior medical director for
Evercare of the Mid-Atlantic and as medical director and vice president
of clinical delivery for UnitedHealthcare Medicare and Retirement, where
he was responsible for the business operations and clinical programs for
Medicare Advantage Special Needs Plans for dually eligible, chronically ill,
and institutionalized Medicare beneficiaries. Prior to his position within
the UnitedHealth Group, Dr. Shumacher practiced internal medicine and
geriatric medicine in Montgomery County, Maryland, and served as the
medical director of the Trinity Senior Living Community in Burtonsville,
Maryland. He has extensive experience as a clinician and medical director
in post-acute care and long-term care. Dr. Shumacher is board certified in
internal medicine and is a fellow of the American College of Physicians, and
a member of the American College of Physician Executives and AMDA—
The Society for Post-Acute and Long-Term Care Medicine. He is a certi-

APPENDIX B 153
fied medical director in long-term care. He received a B.A. from Stanford

University and an M.D. from the George Washington University School of
Medicine and Health Sciences and completed training in internal medicine
at the Georgetown University Hospital in Washington, DC.
Judith Stein, J.D., founded the Center for Medicare Advocacy, Inc., in
1986, where she is currently the executive director. She has focused on
the legal representation of older people since beginning her legal career in
1975. From 1977 to 1986, Ms. Stein was the codirector of legal assistance
to Medicare patients, where she managed the first Medicare advocacy pro-
gram in the country. She has extensive experience in developing and admin-
istering Medicare advocacy projects, representing Medicare beneficiaries,
producing educational materials, teaching, and consulting. She has been
lead counsel or cocounsel in numerous federal class action and individual
cases challenging improper Medicare policies and denials, including, most
recently, Jimmo v. Sebelius, which will dramatically improve coverage and
access to care for people with long-term and chronic conditions. Ms. Stein
graduated cum laude from Williams College in 1972 and received a law
degree with honors from the Catholic University School of Law in 1975.
She is the editor and co-author of books, articles, and other publications on
Medicare and related issues, including the Medicare Handbook (14th edi-
tion, 2013, Aspen Publishers, Inc.), which is updated annually. Ms. Stein is
a board member of the National Care Managers Association, past president
and a fellow of the National Academy of Elder Law Attorneys; a past com-
missioner of the American Bar Association Commission on Law and Ag-
ing; an elected member of the National Academy of Social Insurance; and
a recipient of the Health Care Financing Administration (now the Centers
for Medicare & Medicaid Services) Beneficiary Services Certificate of Merit.
She represented Senator Christopher Dodd as a delegate to the 2005 White
House Conference on Aging, received the Connecticut Commission on Ag-
ing Age-Wise Advocate Award in 2007, and is a member of the Executive
Committee of the Connecticut Elder Action Network. In 2013, Ms. Stein
was appointed to the National Commission on Long Term Care by U.S.
House of Representatives Leader Nancy Pelosi.
Robyn I. Stone, Ph.D., is senior vice president of research at LeadingAge,

and executive director at the LeadingAge Center for Applied Research.
She is a noted researcher and leading international authority on aging and
long-term care policy and joined LeadingAge to establish and oversee the
LeadingAge Center for Applied Research. Dr. Stone came to LeadingAge
from the International Longevity Center–USA in New York, where she
was executive director and chief operating officer. Previously, she worked
for the Federal Agency for Health Care Policy and Research (now known

as the Agency for Healthcare Research and Quality). Dr. Stone also served
the White House as deputy assistant secretary for disability, aging, and
long-term care policy and as acting assistant secretary for aging in the U.S.
Department of Health and Human Services under the Clinton administra-
tion. She was a senior researcher at the National Center for Health Services
as well as at Project Hope’s Center for Health Affairs. Dr. Stone was on the
staff of the 1989 Bipartisan Commission on Comprehensive Health Care
and the 1993 Clinton administration’s Task Force on Health Care Reform.
Stone holds a doctorate in public health from the University of California,
Berkeley.
Sarah L. Szanton, Ph.D., A.N.P., is associate professor and director of

the Ph.D. Program at the Johns Hopkins University School of Nursing. A
number of years ago, while making house calls as a nurse practitioner to
homebound, low-income elderly patients in West Baltimore, Maryland,
Dr. Szanton noticed that their environmental challenges were often as press-
ing as their health challenges. Since then she has developed a program of re-
search at the Johns Hopkins University School of Nursing on the role of the
environment and stressors in health disparities in older adults, particularly
those trying to age in place or stay out of a nursing home. Through a
Robert Wood Johnson Foundation–funded grant, a National Institutes of
Health grant, and a cooperative agreement from the Innovations Office at
the Centers for Medicare & Medicaid Services, she is examining whether a
program that combines home maintenance services with nursing and occu
pational therapy can improve mobility, reduce stress hormone levels, and
decrease health care costs. She is also conducting a study of the Nintendo
Wii program with frail older adults to see whether it can decrease their
risk of falling. As a former health policy advocate, Dr. Szanton hopes that
the outcomes of her research and her growing body of publications in the
literature can have a positive impact on future health policy affecting older
adults.
George Taler, M.D., graduated from the University of Maryland School of

Medicine in 1975 and completed a residency in family medicine in 1978
and a geriatric fellowship at the Jewish Institute for Geriatric Care (now
the Parker Geriatric Institute) in New Hyde Park, New York. Dr. Taler
joined the faculty in family medicine at the University of Maryland School
of Medicine, where he was an associate professor until he left in 1999 to
join the faculty in the Department of Medicine at the Washington Hospital
Center as director of long-term care. He currently holds the rank of profes-
sor of clinical medicine, geriatrics, and long-term care at the Georgetown
University School of Medicine. His responsibilities include being codirec-
tor of the Medical House Call Program, vice president for medical affairs

APPENDIX B 155
of MedStar Home Health–Visiting Nurse Association and MedStar Home

Infusion Services, and medical director of the Capitol Hill Nursing Center,
a 114-bed skilled nursing facility in Washington, DC. Community leader-
ship activities include being past president of the Maryland Gerontological
Association, 1991 to 1992; founding president of the Maryland Geriatrics
Society (the state affiliate of the American Geriatrics Society), 1993; presi-
dent of the American Academy of Home Care Physicians (AAHCP), 1998
to 2000; and chair of the AACHP Public Policy Committee, 2000 to 2014,
where his interests focused on the development and implementation of the
Independence at Home program as part of the national health care reform
initiative. Dr. Taler was a member of the Board of the National Pressure
Ulcer Advisory Panel from 2002 to 2008. In 2012, he was appointed to
be the alternate representative for the American Geriatrics Society to The
Joint Commission’s Professional Technical Advisory Committee for Home
Care and in 2013 was a member of the American Geriatrics Society Public
Policy Committee.


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THE NATIONAL ACADEMIES PRESS

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Copyright © National Academy of Sciences. All rights reserved.

Victoria Weisfeld and Tracy A. Lustig, Rapporteurs

Forum on Aging, Disability, and Independence

Board on Health Sciences Policy

Division of Behavioral and Social Sciences and Education

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International Standard Book Number-13: 978-0-309-36753-0

Copyright 2015 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society

The Institute of Medicine was established in 1970 by the National Academy of

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Copyright National Academy of Sciences. All rights reserved.

PLANNING COMMITTEE FOR A WORKSHOP ON

BRUCE LEFF (Co-Chair), Professor of Medicine, Johns Hopkins

Copyright National Academy of Sciences. All rights reserved.

Copyright National Academy of Sciences. All rights reserved.

IOM-NRC FORUM ON AGING, DISABILITY,

Alan M. Jette (Co-Chair), Boston University School of Public Health,

Copyright National Academy of Sciences. All rights reserved.

IOM and NRC Staff

Copyright National Academy of Sciences. All rights reserved.

This workshop summary has been reviewed in draft form by individu-

AMY BERMAN, The John A. Hartford Foundation

Although the reviewers listed above have provided many constructive

Copyright National Academy of Sciences. All rights reserved.

was overseen by RON ACKERMANN, Indiana University. Appointed by

Copyright National Academy of Sciences. All rights reserved.

2 HOME HEALTH CARE: TODAY AND TOMORROW 11

3 TOWARD PERSONAL HEALTH: GOING HOME AND

4 KEY ISSUES AND TRENDS 35

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5 THE HOME HEALTH CARE WORKFORCE 49

6 MODELS OF CARE AND APPROACHES TO PAYMENT 65

8 MAKING CONNECTIONS 105

9 REFLECTIONS AND REACTIONS 117

A WORKSHOP AGENDA 131

Copyright National Academy of Sciences. All rights reserved.

A 2011 report by the National Research Council (NRC) declared,

Copyright National Academy of Sciences. All rights reserved.

2 THE FUTURE OF HOME HEALTH CARE

2 See www.iom.edu/ADIForum (accessed December 5, 2014).

2nd sess. (March 23, 2010).

Copyright National Academy of Sciences. All rights reserved.

An ad hoc committee will plan a 2-day public workshop, bringing together

1. Provide an overview of the current state of home health care, including

a. The infrastructure needs for home health care, the health care system

Copyright National Academy of Sciences. All rights reserved.

4 THE FUTURE OF HOME HEALTH CARE

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Informal Formal Medicare Home Hospital

Low acuity High acuity

involves physicians, nurse practitioners, or physician assistants providing

3 TOWARD PERSONAL HEALTH: GOING HOME AND

1. Provide an overview of the current state of home health care, including

a. The infrastructure needs for home health care, the health care system