It’s not uncommon for patients referred to home health care following a hospital discharge to never start services. In fact, a recent study based on 2016 claims data found that just 54% of patients referred to home health actually utilized it.

But a new report from analytics and metrics firm Trella Health suggests that figure is improving.

To identify the latest post-acute care (PAC) discharge, admissions and utilization trends, Trella researchers analyzed Medicare fee-for-service claims data from Q2 2019 through Q1 of this year. During that time frame, more than 70% of patients with home health instructions adhered to those orders — a significant leap compared to four years ago.

Specifically, 71.7% of patients adhered to home health instructions in Q1 2020, while 70.3% did so in Q3 2019, according to the Trella report. Trella defines home health adherence as the percentage of home health episodes started or resumed within 30 days of discharge as instructed, divided by the total number of discharges with home health instructions.

That definition is slightly different than what the recent study used, but it still reflects improvement, Trella’s Kirsten Reed, author of the report, told Home Health Care News.

There are numerous factors that play into the improved home health adherence rate, but likely none more important than patient education. Many home health providers have worked to establish stronger relationships with their patients over the past few years, educating them on the value of skilled home health care often while they’re still in the hospital.

“Within the first week of receiving a referral, we try to make at least four points of contact with a patient and/or an emergency contact within their profile,” Cleamon Moorer, Jr., president of American Advantage Home Care Inc., previously told HHCN. “Some of that conversation is about educating on what to expect from a skilled care provider.”

A shift in referring patients undergoing certain procedures — such as joint replacements — to home health may also play a role, Reed added.

The same holds true for programs like the Hospital Readmission Reduction Program (HRRP). Under HRRP, hospitals could get penalized financially for certain negative health outcomes.

“Providers and discharge planners might therefore be more likely to highlight the importance of home health instructions than they were previously, as these programs have been a greater focus over the past few years,” Reed said. “For non-emergent procedures that typically result in home health referrals, the care team may proactively work with a patient before admission to create a discharge plan and discuss home health options.”

Looking ahead

Home health adherence rates may have been up from Q3 2019 through the first quarter of this year, but it’s difficult to predict whether that trend will continue throughout the rest of 2020.

With the onset of the COVID-19 pandemic, many prospective home health patients ultimately declined services due to exposure fears, especially in March and April. Anxieties lessened over the summer, but some believe patients will once again become concerned about having individuals enter their homes during a fall or winter resurgence.

“The biggest concern — and opportunity — we have as an organization is the continued uncertainty, unrest and anxiety facing our communities, our patients, their families and our front-line ‘heroes’ in the field,” Dan Dietz, president and CEO of CommonSpirit Health at Home, told HHCN earlier this month. “Adding fuel to ‘COVID-fatigue’ is the unknown impact of the flu season aligning with a possible resurgence of the coronavirus.”

Trella similarly highlighted that uncertainty in its report.

“We are curious to see how COVID-19 affects adherence rates, as patients had to balance a desire to receive care at home, if possible, with the fear of caretakers potentially spreading the virus,” the report stated “Especially early in the pandemic, when personal protective equipment was scarce and testing was limited, patients were forced to make difficult decisions and tradeoffs.”

Adherence may remain high, however, if hospitals, discharge planners and patients continue to understand the value of home health care.

“COVID-19 has underscored the importance of post-acute care and why underinvesting in the space is simply not an option,” Reed told HHCN. “As acute care hospitals faced capacity concerns, home health agencies quickly pivoted to alleviate the strain on their inpatient partners. Whether that meant picking up the phone daily to keep referring facilities up to date on their ability to accept patients, offering no-contact telehealth options when possible, or assuaging concerns around sanitation and PPE, the home health sector has proven to be an invaluable part of the health care continuum.”

Discharge destinations

Apart from home health adherence, Trella’s new report also flagged patterns in overall PAC discharges from Q2 2019 through Q1 2020. Over that time, 50.6% of in-patient discharges were coded for a PAC stay, a slight decrease from 52.2% over the previous four quarters.

For patients who received PAC orders upon discharge, 21.3% went to skilled nursing facilities (SNFs). That was slightly higher than the 21.1% coded for home health services, according to Trella.

Those figures are a reverse of what Trella found in its Q1 2019 trends report, which had home health as the most common post-acute care referral destination.

Due to the COVID-19 virus and the devastating impact it has had on the SNF space, it’s likely that home health will again become the No. 1 PAC destination moving forward.

“SNF admissions and utilization will decline at an even greater rate than before the pandemic due to the devastating toll COVID-19 has taken on them financially and how quickly the virus can spread within the care setting amongst patients who are high risk for serious illness or death if infected,” Reed said. “Concerns persist about how well SNFs can successfully cohort patients with known or probable exposure from the rest of their patient population, especially as they seek to implement cost-effective testing regimens.”

There is also a potential for the share of home health referrals to increase in the future due to more dedicated SNF-diversion efforts.

“Our analysis of Medicare claims for the Q1 2020 reporting period uncovered some noteworthy data points, though post-acute care trends remained fairly stable,” the Trella report continued. “As the first quarter of COVID-19 impacted data becomes available, we anticipate greater shifts and disruptions to established patterns will emerge.”

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