Always Best Care, Healing Hands Share Keys to Hospital-at-Home Success for Private-Duty Agencies

When most people hear about hospital-at-home programs, they often picture ICU nurses and doctors running around their living room.

But while hospital-at-home models do rely on physicians and clinical staff, successful programs also leverage the expertise of private-duty home care agencies and their veteran caregivers.

In fact, when hospital-at-home models fail, it’s typically because a caregiver isn’t around to serve as “the eyes and ears” of the home.

“Advanced care in the home requires a complete, interdisciplinary approach,” Summer Napier, CEO and owner of Healing Hands Healthcare LLC, said Tuesday during a virtual event hosted by the National Association for Home Care & Hospice (NAHC). “I think that gets thrown around a lot, but I don’t think that [private-duty home care agencies] always realize they are part of that interdisciplinary team.”

Healing Hands Healthcare is a for-profit in-home care provider that serves nearly two dozen counties in Texas. Its offerings range from skilled nursing care and therapy services, to medical license social working and private-duty home care.

“You should have a seat at the table on every discussion,” Napier said, specifically speaking at the 2021 Winter Leadership Summit hosted by NAHC’s private-duty home care affiliate. 

Led by the likes of Johns Hopkins, Mount Sinai and others, active hospital-at-home programs have been around for years in the U.S. Logistical and reimbursement challenges meant they remained relatively few and far between until last year, however.

In 2020, more hospitals began launching such models in response to the COVID-19 pandemic and a need to increase in-patient bed capacity. In November, the U.S. Centers for Medicare & Medicaid Services (CMS) even launched a dedicated “Acute Hospital Care at Home” waiver to temporarily eliminate certain payment barriers.

As of Feb. 19, there were at least 44 health systems and 103 hospitals in 28 states participating in the CMS program, federal data shows. At least six participants have secured a waiver in February alone.

Those who follow health care trends shouldn’t be overly surprised by the waiver program’s popularity, Sheila Davis, vice president of area operations for Always Best Care Senior Services, suggested during the NAHC event.

Always Best Care is a home care franchise company that operates across 209 territories in 30 states.

“We saw a significant shift after the 90s with assisted living and skilled nursing facilities,” Davis said. “But now amidst the pandemic, we’re seeing the opposite effect, where [patients] are really choosing to age in place in their own home. And the patient care model of the future is that of hospital-at-home.”

Among their many benefits, hospital-at-home models have been found to achieve cost savings of 19% to 30% compared to traditional in-patient stays. Additionally, models often have shorter lengths of stay compared to normal trips to the hospital, plus higher patient satisfaction and functional outcomes. 

“Compared to similar hospitalized patients, hospital-at-home patients experience better clinical outcomes and have lower rates of mortality,” Davis said. “They also have a better mindset and medication usage.”

Both Always Best Care and Healing Hands Healthcare have carved out roles in hospital-at-home programs in their markets, Davis and Napier said at the NAHC event.

Despite a lack of immediate opportunities, Healing Hands Healthcare had actually been putting together the framework to enable hospital-at-home programs long before COVID-19, Napier noted.

“I’ve been talking about our hospital-at-home program before it was a real thing for home health agencies — and people laughed at me,” she recalled. “It was never the right time, it was never the right time. And then guess what? The right time came — and guess who [hospital partners] reached out to?”

Having its ready-to-go program and priorities in place has helped Healing Hands Healthcare serve more than 300 hospital-at-home patients since the pandemic began.

Overall, the organization has been able to keep 96% of those individuals at home and out of the brick-and-mortar hospital setting.

Broadly, private-duty home care agencies looking to take part in hospital-at-home models need to invest in building an on-call workforce capable of responding to a range of medical emergencies, Napier and Davis advised.

To be successful, agencies must likewise double down on caregiver training and education. A good place to start is by developing programs for specific complex conditions, such as congestive heart failure (CHF), COPD, dementia and more.

“Sometimes we get overwhelmed with the details,” Napier said. “A hospital-at-home program can be the same as a CHF program, though you may call it different things at different times for marketing purposes. The fact of the matter is, you need to be able to take care of sick patients.”

As far as finding hospital-at-home opportunities, private-duty agencies need to first determine the appetite for services in their markets. A good starting point is connecting with existing hospital partners, Davis said.

Partly due to its size and established partnerships, Always Best Care had hospitals reach out first. 

“From the perspective of a large-scale agency, if you do have many different locations, sometimes it’s approaching the local hospitals or the bigger hospitals and saying, ‘Do you already have a hospital-at-home program in place?’” Davis said. “‘Do you need ancillary services to be a part of that program?’” 

With the hospital-at-home programs they enable, Always Best Care and Healing Hands usually receive payment directly from patients and families.

“In Texas, we don’t have a ton of shared-risk models yet,” Napier said. “About 90% of it is the family saying, ‘I want [my loved one] home. I know they’re going to do better at home.’”

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Top Home Care Trends for 2021

Despite continued staffing challenges, home care is on the rise. Several emerging trends will define that ascent in the year ahead.

Some of those trends will revolve around home care’s role in new care delivery models designed to treat higher-acuity patients. Others will have to do with shifts in the home care market itself and the broader U.S. economy, which is still recovering from the impact of the COVID-19 virus.

To remain competitive in 2021 and after, home care operators must identify the key trends that will help or hurt their businesses. To help them out, Home Health Care News offers its top home care predictions for the coming 12 months below.

HHCN previously published its separate predictions for the home health industry in January.

The home care scales will tip toward franchising.

Generally speaking, the extremely fragmented home care market is mostly made up of independent operators, corporate affiliates and franchise-backed offices. The scales will start to tip more heavily toward franchising in 2021, however, for a variety of reasons.

During economic downturns when unemployment is high, jobless individuals often look to pivot careers, with many prioritizing personal satisfaction and a sense of giving back to their communities. With 10,000 baby boomers turning 65 each day and more Americans living with chronic illnesses than ever, there’s arguably no better combination of “business upside” and “service” than home care.

But with constantly changing legal requirements, a difficult labor landscape and a long list of coronavirus-related operational challenges, such would-be home care operators will need experienced guides. That’s where franchise models have a possible leg up compared to their peers.

“There’s something attractive about franchising in that you don’t have to come up with your own concept,” Suzanne Beall, vice president of government relations at the International Franchise Association (IFA), told HHCN in May. “You’re buying into a brand and community. You have all of that community support to get your business up and running.”

Many in-home care franchise companies are already touting the growth they’ve seen over the past several months.

Synergy HomeCare, for example, recently announced it sold 35% more territories in 2020 compared to 2019. Best Life Brands, a family of companies that operates throughout the senior care continuum, awarded 71 new franchise agreements across its brands last year.

Always Best Care also recently announced it launched eight new territories in untapped markets in 2020.

“We started off [2020] with no franchises sold in January and February,” Always Best Care CEO Jake Brown told HHCN last summer. “All of a sudden, we started selling in March and April. We have a fair amount of high-quality candidates in the pipeline, so we think it may uptick even faster.”

Others have touted similar growth.

Home care franchise growth isn’t just going to come from new owners entering the market. There will also likely be more independent-to-franchise conversions, with owners across the country needing backup with the new, COVID-19 world and all of its challenges, from sourcing personal protective equipment (PPE) to navigating Paycheck Protection Program (PP) loans.

While HHCN foresees strong franchising tailwinds in 2021, that doesn’t mean independent home care operators will disappear entirely. In fact, if they can successfully manage all of the coronavirus-related disruption alone, independent home care providers will likely see their businesses boom.

Some may even look to cash in on an uptick in home care M&A action.

Care management will be a hot topic.

On-demand companionship services. Physician-led house calls. Transportation assistance. Remote patient monitoring. Nutritional support.

In 2021, seniors have access to a seemingly infinite list of services to help with activities of daily living (ADLs) and their overall well-being. That’s especially true when it comes to aging-in-place hardware and software.

To fill communication gaps and improve outcomes, more seniors, payers and providers are turning to care management services. Home care leaders are starting to think more seriously about care management, too, including Right at Home CEO Brian Petranick.

“If you think about it, there’s probably 5,000 different pieces of technology that somebody can bring into the home to help with the aging process,” Petranick told HHCN in January. “Well, who in their right mind has time to research 5,000 pieces of technology, from a consumer perspective? Or 50 home care companies? Or 20 transportation companies? I think there is an opportunity for somebody that can come in and help people manage the broader aging process, not just one aspect of it.”

Another home care organization gaining ground in care management is 24 Hour Home Care, which acquired Grace Care Management in November.

In August, Caring People similarly completed a handful of deals, driven by a focus on care management.

“[Aging Care and AMR Care Group] had a core competency in providing care management services,” Caring People CEO Steven East told HHCN at the time. “That’s a revenue vertical and a service line that we’re very interested in adding to our existing platform.”

A lot of home care agencies actually do care management already. Some just don’t charge for it — or recognize it as a dedicated service line. That’s going to change in 2021, particularly if operators can use care management as another value-add in Medicare Advantage (MA) discussions.

The demand for companionship services will continue to rise.

Home care operators will continue to launch new service lines in 2021, including care management offerings and more. But home care’s bread-and-butter service — companionship — has never been more important.

Even before the coronavirus, older adults in the U.S. faced a loneliness epidemic. Yes, some data suggests a trend in recent years of adult children moving back in with their aging parents due to economic hardship, but a large portion of today’s seniors are disconnected from the world around them.

One-third of adults aged 45 and older feel lonely, according to a 2020 report from the National Academies of Sciences, Engineering and Medicine (NASEM). Nearly one-fourth of adults aged 65 and older are considered to be socially isolated, with the problem frequently exacerbated by transportation barriers, hearing loss and other challenges.

The ongoing pandemic has worsened loneliness and social isolation risks, the latter of which is associated with 50% increased risk of dementia.

“This is a very real public health crisis,” Lisa Marsh Ryerson, president of AARP Foundation, said in October. “Decades of research on prolonged social isolation and loneliness … [shows that it is] worse for health than obesity and as damaging to health as smoking 15 cigarettes a day.”

With these considerations in mind, home care agencies will double down on companionship services, pumping new money into old offerings. Clients, their families and potential referral sources will seek out those agencies that do companionship well.

There are some skeptics who see companionship services more as an afterthought than a lucrative business line. But the rapid growth of companionship-focused social determinants of health companies like Papa is quickly changing those views.

Founded in 2017, the “family-on-demand” startup Papa is now active in all 50 states, often made available to consumers through health plan providers such as Aetna, AvMed, Florida Blue Medicare, Humana, Priority Health, Regence Blue Shield and others.

“Just imagine an 80-year-old woman living by herself,” Papa founder and CEO Andrew Parker told HHCN in January. “She doesn’t really know how to use technology, doesn’t have that many family members, doesn’t have a car — a lot can go wrong in this situation. Pairing her with a Pal that calls her, video chats and, when appropriate, shows up to be a friend and provide companionship … is life-altering for these older adults.”

Home care will become ‘the glue’ that holds new models, communities together.

Nursing home occupancy was at 80% or below in all 48 of the continental United States at the start of 2021, professional services firm CliftonLarsonAllen reported at the end of January. Meanwhile, in the acute care setting, nearly three out of every four hospital beds were occupied as of Feb. 4.

In addition to ushering in a new age of telehealth, the COVID-19 pandemic has changed how, when and where care is being delivered. Hospitals and skilled nursing facilities (SNFs) are two of the biggest examples.

In the SNF space, operators are seeing a renewed interest in SNF-to-home diversion, with referral sources now more likely to direct a “jump-ball” post-acute care patient to a home health agency. To position themselves for referrals that may have traditionally gone to a SNF, innovative home health companies are building targeted SNF-at-home programs that bring all sorts of high-acuity services into the home.

But successful SNF-at-home models, industry leaders are learning, require the kind of high-touch, low-acuity services that home care agencies deliver. April Anthony — who leads the home health and hospice segment of Encompass Health Corp. (NYSE: EHC) — touched on that requirement during a Jan. 27 earnings call.

“We are … collaborating with two home care organizations that provide personal care support [for] a SNF-at-home program in order to meet a growing need for these services in our markets,” Anthony noted.

Leslie Palmer, administrator and clinical director at Josephine at Home, has similarly described the importance of home care in SNF-at-home models.

“If you’re an expert in home health but not home care, then maybe look at partnering with an existing home care agency,” Palmer told HHCN in August. “It’s the same thing with home care — either look into forming a partnership with a home health provider or having someone who’s an expert help launch your own home health service lines.”

With support from the U.S. Centers for Medicare & Medicaid Services (CMS), hospitals and health systems are likewise shifting acute care into the home to strategically boost capacity during the public health emergency. As of Jan. 29, there were at least 35 health systems and more than 90 hospitals operating in CMS’s Acute Hospital Care at Home initiative.

Like a strong SNF-at-home program, successful hospital-at-home models also sometimes depend on home care support.

As new types of home-focused care delivery concepts emerge in 2021 and beyond, home care agencies will be seen as the glue that holds those models together.

New labor battles will emerge.

As 2021 begins, a slew of factors are forcing labor disputes to come to a head.

For one, the public health emergency has made the perceived risk of home care jobs much higher. It has also highlighted caregiving careers in general.

A new administration has taken over, too, meaning new policies and provisions will trickle down to alter the home care landscape.

President Joe Biden has already laid the groundwork for a higher minimum wage and the “Fight for $15” movement. In some geographic areas, that would represent a modest increase in hourly pay for caregivers. In others, it would be a more sizable one.

Either way, a federal minimum wage of $15 an hour would force agencies to get creative with their staffing structure and pay in order to keep providing care and still make money on the margins. While the $15 minimum wage is far from a certainty, it will definitely continue to be a theme throughout the next four years.

Agencies have already implemented hazard pay in many cases during the COVID-19 crisis, often using Paycheck Protection Program (PPP) loans from the government to do so. Some states are considering mandating hazard pay, but it is likely that more governmental assistance would be needed to make that viable.

There is also risk — both at the state and federal level — that caregivers will be able to opt out of work and receive unemployment benefits if they feel unsafe at their jobs. Because unemployment includes weekly add-ons as of now, not working could pay more, which would be a significant issue for employers.

Home care demand is increasing, but without logical solutions to the labor disputes that will take place over the next year, there may not be the workforce to meet that need.

Disruptors, aggregators will look to capitalize on the pandemic.

Since 2017, there have been more than a few venture capital-backed startups to pop up promising to “disrupt” the home care industry. Many have failed, plagued by state-level employment challenges, consumer skepticism and other hurdles.

As more attention is paid to the home due to the coronavirus, VC groups will ramp up their interest in the setting. Chris Booker, a partner at Frist Cressey Ventures, confirmed that was a trend his firm was already seeing when he spoke at HHCN’s Capital+Strategy event in December.

“From [an in-home care] perspective, the market connects with COVID, because now everything is moving into the home,” Booker said at the event. “Really, health care is just moving into the home, [in general]. And so that’s what we’re seeing, in particular on the venture side.”

VC investors will mostly look to back providers of care in the home in 2021, but they’ll also back technology startups dedicated to enabling home-based care and making it more efficient.

“Aggregators” will look to disrupt the home care market in different ways.

Because home care is fragmented and filled with mom-and-pop agencies, it’s relatively difficult to build businesses with scale. There are some large home care assets that come to market, but buyers often have to take a buy-and-build approach, following one acquisition with a second, third and fourth.

Buyers of this nature will be very active in 2021, looking to get into the home care game before it becomes too hot. Many already started at the end of last year, reflected in the 15 or so home care transactions that took place in the fourth quarter, according to M&A advisory firm Mertz Taggart.

Scale in home care is becoming increasingly important as national payers embrace social determinants of health and non-medical services.’

“We’ll continue to see deals for home care,” Mertz Taggart Managing Partner Cory Mertz wrote in a Q4 M&A report. “Payers really saw firsthand the value of home care during the public health emergency. It was a vital resource in managing chronic conditions, especially with individuals avoiding in-person trips to the doctor.”

Aggregators aren’t always direct buyers. Aggregators in 2021 will also include more entities that take the approach of partnering with existing home care operations in Honor-like arrangements.

Additional reporting by Andrew Donlan.

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