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Home Care Group Seeks D-H Linkup

West Lebanon — An Upper Valley home care agency believes it has a role to play in an experimental model of care being led by Dartmouth-Hitchcock that is aimed at improving quality, lowering costs and expanding access for patients.

Officials with Visiting Nurse & Hospice of Vermont and New Hampshire are talking with the Twin States’ largest health care provider about partnering on a pilot program involving Medicare patients in New Hampshire.

If successful, the partnership could help Dartmouth-Hitchcock meet certain goals for its Pioneer accountable care organization, or “ACO,” a key provision of federal health reform aimed at improving coordination between health care providers and lowering the cost of care for Medicare patients.

The West Lebanon-based VNA won’t join the Pioneer ACO as a formal member just yet, but the agency believes it can nevertheless relieve Dartmouth-Hitchcock’s burden as patients return to their homes.

VNA officials say the organization has the staff, training and resources to attend to patients with increasingly complex and high acuity conditions, such as congestive heart failure, and can take on many of the responsibilities that Dartmouth-Hitchcock nurses are attending to now. The partnership could allow Dartmouth-Hitchcock to concentrate its resources in those parts of the hospital where they are most needed, and lead to lower costs while maintaining or even improving access and the quality of care for patients.

“We are interested (in partnering with Dartmouth-Hitchcock) because we feel we have value to add,” said Jeanne McLaughlin, president and CEO of the VNA of Vermont and New Hampshire.

The pilot project, expected to start in June, would be similar to one Dartmouth-Hitchcock organized with the VNA in Concord last year, said Dartmouth-Hitchcock Clinical Director Sheila Johnson. In that effort, VNA nurses worked with Dartmouth-Hitchcock to make sure patients were taking the proper medication after they were discharged from the hospital. The pilot involved 171 Medicare beneficiaries.

The benefit for Dartmouth-Hitchcock was being able to keep its staff working at the hospital in Lebanon rather than driving an hour away to treat patients in their homes. Instead, the VNA nurse could tend to those home care needs and address medication issues that might have resulted in the patient needing to be readmitted to the hospital.

Meanwhile, VNA nurses were picking up new clients and doing the work they were trained to do, Johnson said. The arrangement was not only more efficient for Dartmouth-Hitchcock, but it reduced the number of patients readmitted to the hospital after they were discharged, going from a readmission rate of 30 percent when the year-long pilot started to 16 percent when it finished.

“I believe (VNA nurses) have to be more and more our eyes and ears in the home,” Johnson said.

Readmissions have been of particular concern for hospitals lately. Under a provision of the Affordable Care Act, hospitals with high numbers of patients coming back too soon are now being penalized through lower Medicare reimbursements.

VNA officials believe they can help keep patients from having to go back to the hospital by stepping up care in the home.

The West Lebanon VNA has organized smaller pilot studies with Gifford Medical Center in Randolph and Alice Peck Day Memorial Hospital in Lebanon. Both of those efforts led to lower readmission rates, according to hospital officials. It has also recently begun a pilot with Springfield (Vt.) Hospital.

In these pilot studies, the VNA has worked closely with hospitals to coordinate the transition home and then “front-loaded” the care given to that patient in the first week after they leave the hospital.

In the first few days at home, the patient will be visited by a registered nurse, physical therapist, occupational therapist, social worker and, if necessary, a speech therapist. This team is there not only to check on the patient’s well being and help him or her recover, but also make sure the home surroundings are safe to reduce the risk of accidents.

Although the Gifford and APD pilots were small, involving a total of only nine patients, the results were promising, leading to a 40 percent reduction in rehospitalizations and 93 percent reduction in medication errors.

Teresa Voci, vice president of Gifford’s division of medicine, said involving the VNA in transitioning patients back home simply made sense for hospitals.

“Like Hillary Clinton said, it takes a village,” she said. “It takes a community (to care for patients) and, for us, the VNA is part of that community.”

Voci has worked with the VNA not only as a Gifford hospital administrator, but also as a patient. This winter, Voci broke both of her legs in a snowmobile crash, an incident from which she continues to heal. VNA staff worked with her as she recovered at home. VNA caregivers aided Voci’s recovery in more ways than one, giving her emotional support and a personal connection that she missed when she was home alone.

“From an emotional standpoint, I couldn’t wait for my (physical therapist) to come in,” she said. “When someone came to my home, it was amazing.”

This spring, the VNA expects to be working on five separate pilot projects in Vermont and New Hampshire to look at how it can help more patients get out of the hospital and receive the care they need in the home. Those pilots will focus on reducing the need for urgent care and hospitalization, on cutting medication errors and improving quality of life.

These projects are aimed at demonstrating the value that the VNA brings to accountable care models.

“Our effort in doing these pilots are to remind (hospitals) that we have a huge role to play in working into their ACO concept,” McLaughlin said.

The ACO model was developed at Dartmouth College and included in the Affordable Care Act. The central aim is to encourage doctors and hospitals to lower costs while maintaining high quality care. In return, providers are rewarded through splitting the savings with Medicare.

Because it is not a member of the Pioneer ACO, the VNA would not share in those savings. That may change down the road, Johnson said, if Dartmouth-Hitchcock invites the VNA to join. But there are multiple VNA organizations serving the Twin States, and Johnson said it would be difficult to pick one with which to work, particularly because patients have different preferences for which VNA they prefer.

Dartmouth-Hitchcock has two ACOs. Last year, it was one of 32 “Pioneer” ACOs launched nationwide, an initiative the federal government hopes will save $1.1 billion over five years. The Pioneer ACO includes about 26,000 Medicare patients in New Hampshire. And this year, Dartmouth-Hitchcock formed a new ACO called “OneCare Vermont” with Fletcher Allen Health Care in Burlington. In addition to those two large hospital systems, OneCare encompasses around 280 primary care physicians and nearly every hospital in Vermont. Only Porter Medical Center in Middlebury has chosen not to join. The effort involves around 43,000 Medicare recipients in Vermont.

Home care is generally a less intensive, and therefore less expensive, option than treating patients in a hospital setting, but there is no guarantee that these pilot projects will lower the cost of care. The VNA is using more resources as it assumes responsibility for patients with increasingly complex diseases.

The VNA may end up absorbing financial losses if a patient’s recovery is more difficult than expected, said Bob Ellis, director of business development for the VNA.

The hospitals refer patients they believe could benefit from the pilot studies, regardless of whether or not the patients have insurance, he said. The VNA then figures out how to recoup costs.

The amount hospitals spend on patient care will go down as the VNA takes on more of the burden for care, but the overall costs to treat patients will not necessarily go down.

If the VNA ends up providing services that go above and beyond what the contract with the insurer originally called for, then the VNA has to absorb those additional costs, Ellis said.

Those kinds of issues are what these pilot projects will reveal, McLaughlin said.

“If we find we’re losing a ton of money, we may re-evaluate how we’re approaching the pilot,” she said. “But it’s another opportunity to have a discussion with the ACO.”

Chris Fleisher can be reached at 603-727-3229 or cfleisher@vnews.com.