Seeking Value? Add Nonmedical Workers

Investing in community-based services by adding them to payment bundles can reduce readmissions and save significant expense, research suggests.

Hospitals and health systems are under the gun to reduce readmissions. They've been penalized for them since 2012. And that's led many to invest in care management, navigation, and stronger incentives for postacute providers to help keep patients out of hospitals.

It's not enough, says Andrey Ostrovsky, MD.

He says that adding nonmedical personnel into the value equation is critical to bending the cost curve, and he gives two reasons:

1. Medical personnel don't interact with the patient often enough post-discharge,
2. Even if they did, their services are far more expensive than what is needed to help keep patients from needing to come back for an acute stay.

Ostrovsky is, of course, talking his book. As CEO and founder of a company called CareAtHand, which uses predictive modeling to forecast when patients are most at risk for a hospital visit, he and his colleagues offer data-driven predictive analytics to suggest mostly non-medical interventions that should reduce the probability of a particular patient needing a return hospital visit.

'It's Not Just about Doctors and Nurses'
He has a pretty impressive set of statistics to back him up, including a peer-reviewed study in the Annals of Long-Term Care: Clinical Care and Aging, which he co-authored. It shows at least a modest effect from using technology and what he calls an "existing underutilized work force" to reduce medical expense while at the same time improving outcomes.

"Some exciting research is confirming that there is bending of the cost curve by investing in home and community services. Currently, the majority of interventions around bundles are medical interventions," he says. "We're trying to ease the blow on health leaders with the fact that it's not just about doctors and nurses all the time, which is what we've been used to with bundling."

He makes a critical distinction between the interventions he's describing and skilled nursing and home health care sites. Many hospitals are seeking to shore up their performance through incentive contracts and preferred provider lists for those care sites that adhere to treatment protocols and interventions the hospital knows will help prevent some readmissions.

How Postacute Care is Evolving

"It's awesome that these are being applied to [skilled nursing] and home health, but they're still performed by skilled clinicians," Ostrovsky says.

"The notion of moving bundles to home and community-based services beyond skilled care gets at what are the real causes of good health. I'm a physician who has been raised with the biases of doctors. We are the end of the line when someone's going downhill. We know the stuff with diseases, but when it comes to meeting the person or consumer where they are, they're mostly not in the hospital."

In fact, he says, research suggests that among the determinants of health, only 15% to 30% comes from medical care.

The beauty of HCBS (home and community-based services), he says, is that most of the providers already exist, and that hospitals and health systems, or other bundle "conveners," can leverage them relatively easily compared with other investments they may have to make to better manage the bundle, such as spending on information technology as well as labor investments in clinicians.

Coordination is Key
Ostrovsky says "front door entities" such as agencies on aging and centers for independent living can make serious inroads into helping improve patient health. Such agencies can help leverage everything from home care to home-delivered meals, transportation, and behavioral health recommendations.

They do this already, of course, but not in a coordinated way with healthcare providers. That's at least in part because of misplaced or nonexistent incentives.

With exceptions, these organizations have not traditionally worked together with hospitals—or any other entity, for that matter—on specific interventions to reduce the probability of a hospital visit. But the potential is there for them to have big impacts on preventing an admission or readmission.

Nursing oversight of such efforts is critical, but Ostrovsky argues that no matter the convener, nonmedical care team members have to be involved to really start to reduce healthcare costs.

He argues that by better leveraging these agencies and groups, and by coordinating care with them, health systems can get many patients out of expensive long term skilled nursing environments and into the home setting.

This would significantly decrease the cost burden to a Medicaid managed care organization, for example, as well as to the patients and families themselves.

"It's going to take work, but this is very doable," Ostrovsky says, referencing the necessary merger of medical and nonmedical interventions. "We need to have broader education of providers, hospitals, skilled nursing and home health—all the folks who could convene bundles—and be on the hook for them. These assets in the community are serious providers who can substantially decrease the cost of administering the bundle."

Not all such providers are created equal, of course. Their capabilities vary widely, and they speak a different language and have a different culture than medical providers, he says. Which is why close coordination and supervision of their activities with patients needs to be part of any hospital or health system's foray into convening bundles, if that's the route they choose strategically.

Finding Joy in Bundled Payments

"It takes a very unique hospital or health system to be risk-taking enough to do this on their own," Ostrovsky says. "Bundling is not easy. You need deep understanding of the financing mechanism. That said, patient navigators are like $13 an hour and can be impactful as long as supervision is there. Leading hospitals are realizing this, and the technology is really the last piece. Our take on it is that when hospitals acknowledge the financial incentives of bundles, they will increasingly use less-expensive assets to do this."