How Timely Access to Home Health Care Impacts Cost and Outcomes
By Joseph Patrick, MS & Sarah Grace
November 16, 2023
When a patient experiences an acute event that requires hospitalization, it is common for them to need care once they leave the hospital. After this acute inpatient stay there are multiple post-acute care options for a patient, with the two most common being skilled nursing facilities (SNFs) and home health care. Wherever a patient goes after their inpatient stay, the goal of post acute care is to improve the patients’ health status while keeping down overall costs and the potential for complications. In a previous blog post we have discussed the critical importance of smooth care transitions for improving costs and outcomes among the SNF population. In that post it can be seen that SNF patients are typically patients with higher risk scores than those who go to home health, thus, have higher overall costs and more adverse events such as readmission rates.
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In this blog post we focused on analyzing home health care and the outcomes of patients who received home health care compared to those who did not. Overall, we found that home health care is associated with substantially better long-term outcomes in regards to cost, readmission rates, emergency department (ED) rates, and mortality; additionally, timely home health access is critical to minimizing adverse outcomes for patients and reducing costs. While this post is more of a deep dive in utilization and outcomes of home health, to learn more about home health in general you can read our previous blog post which describes the population that utilizes home health, how home health is funded, and how care at home health agencies differs from other care sites.
Methodology
We analyzed two factors from the 100% Medicare fee-for-service (FFS) claims:
- patient discharge disposition after a short-term acute care (STAC) inpatient stay, or where the patient was referred to receive follow-up care
- where those patients actually ended up within 7 days post-discharge from the acute care facility
Based on this, we were able to compare the outcomes from 90-day episodes between patients that received home health care and those that went home without post-acute services after discharge, even though they were directed to receive home health care. Furthermore, we compared costs and outcomes of home health care patients based on how many days it took to receive home health care to examine the effect of time-to-care on cost and outcomes. To gain an even deeper understanding of how home health access and outcomes differ across populations, we also analyzed beneficiaries based on race/ethnicity, Area Deprivation Index (ADI), and dual eligibility status, as well as by service line.
Analysis of Inpatient Discharge Patterns
Upon discharge from an inpatient facility, a patient is often referred to one of the variety of post-acute locations. Where they end up is determined through multiple factors, such as what their provider deems necessary, whether the patient is homebound and needs assistance, if the home health agency is Medicare certified, and patient preferences. Using discharge status codes on inpatient files, we are able to see where patients were referred to go for post acute care and where they actually ended up. For 2022 Medicare FFS STAC claims, home health was the most referred to post acute setting, making up 20.5% of all STAC discharges.
Figure 1
See methodology section below to see how we calculated dual eligibility status, race/ethnicity, and ADI
As can be seen in Figure 1, referrals to home health vary across population cohorts. Dual eligible patients and patients that live in distressed communities (ADI > 70) were referred to home health at a lesser rate than their counterparts. Dual eligible patients, who may have more complexity in their care, have a particularly different distribution of discharge disposition compared to all other cohorts. Only 18.2% of dual eligible patients were referred to home health compared to 21.3% for non-duals.
To examine where patients ended up 7 days post-discharge, post-acute claims were reviewed and the first location where a patient had a claim billed in the 7-day period post-discharge was identified as their next site of care. Figure 2 (IP discharges to HH and where they ended up within 7 days) shows that, overall, 62.6% of all patients who were referred to home health actually received home health services within 7 days; however, looking across the different cohorts, we find that racial and ethnic minorities, dual eligible patients, and patients in high distress areas have disproportionately lower conversion rates than their counterparts. Dual eligible patients are, again, the most disproportionately affected with having a 54.4% conversion rate versus 65.1% for non-duals. Racial and ethnic minorities have the second lowest rate at 57.6% compared to 63.7% for white beneficiaries. While it could be assumed that some of the non-conversions are due to patient refusals, much of it is likely due to insufficient service availability.
Figure 2
The numbers in figure 2 are particularly interesting if you combine them with the home health referral rates from Figure 1 to see the constrained pipeline of beneficiaries from at-risk populations compared to their counterparts. For example, in comparison to White beneficiaries, racial/ethnic minority patients are actually 3.1% more likely to be referred to home health compared to White beneficiaries, but are 10% less likely to convert their home health referral. If we control for population size and applied these rates to 10,000 White STAC patients and 10,000 racial/ethnic minority STAC patients it would result in 2,860 White patients receiving home health versus 2,667 racial/ethnic minorities, a disparity of 193 patients. Overall, viewing discharge dispositions and conversions to home health in tandem can present an opportunity to optimize post-acute pathing, find where patients are being lost in the pipeline from inpatient stay to home health, and allocate resources to maximize home health conversions
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Analysis of Patient Outcomes
We now know that not all patients referred to home health actually receive it, but how do the outcomes of these patient groups compare? Through our analysis we found that both costs and outcomes were substantially improved for patients who received home health compared to those who did not get home health; moreover, we found that the more timely the patients accessed home health, the better their results.
Figure 3 shows the percentages of patients who went to home health versus home without home health that had a readmission, ED visit, and died within 90 days of discharge. For the entire population, patients that go home without home health care are 43% more likely to die within 90 days compared to those who received home health. This trend continues for readmission and ED visits. Patients that go home without any home health are 35.6% more likely to be readmitted and 15.6% more likely to have an ED visit compared to those who receive home health. This table also shows the average 90 day total cost of care, including hospital stay, between patients who receive home health and those who go home without home health care. Overall, we see about a $2000 reduction in 90 day cost per episode; when compounded across episodes, this could result in significant savings opportunities at a population level. These trends are relatively consistent across patient demographic sub-cohorts.
Figure 3
| Cost and Outcomes Between Patients Referred to Home Health and Received Home Health Compared to Patients Referred to Home Health Who Did Not Receive Home Health |
|||||
|---|---|---|---|---|---|
| % Discharges | % of Episodes with 1+ Readmissions | % of Episodes with 1+ ED Visit | Mortality Rate 90-Day | Total Cost of Care | |
| All Discharges | |||||
| Home Health | 62.6% | 29.2% | 24.3% | 8.1% | $38,218 |
| Home with No Home Health | 34.9% | 39.6% | 28.1% | 11.6% | $40,279 |
| % Difference | – | +35.6% | +15.6% | +43.2% | +5.4% |
| Medical Discharges | |||||
| Home Health | 57.1% | 33.9% | 26.5% | 10.8% | $38,541 |
| Home with No Home Health | 39.9% | 41.9% | 29.5% | 12.9% | $40,415 |
| % Difference | – | +23.6% | +11.2% | +19.4% | +4.9% |
| Surgical Discharges | |||||
| Home Health | 75.8% | 21.3% | 20.6% | 3.6% | $37,736 |
| Home with No Home Health | 22.8% | 30.5% | 23.6% | 6.5% | $39,833 |
| % Difference | – | +43.1% | +14.7% | +80.8% | +5.6% |
While the findings highlighted above are based on all discharges combined, it is reasonable to assume that the trends may vary based on the reason a patient is in need of care. Breaking out by medical vs. surgical discharges, we find that the home health conversion rate for surgical discharges is much higher than for medical discharges. This can likely be explained by the elective nature of many surgical procedures, which allows for advanced arrangement of home health services. Narrowing in on the musculoskeletal discharges (major diagnostic category 8), the conversion rate is even higher, with 80% of patients directed to home health receiving it within 7 days. Otherwise, conversions and outcomes are relatively consistent for other major diagnostic categories (MDCs), with conversion rates ranging from 50-60% among the largest MDCs.
Importance of Timely Access to Care
Patients who receive home health care fare substantially better compared to those who do not, but how do outcomes change based on how many days it takes to receive home health? We found that receiving home health care in a timely manner is potentially the most important factor in reducing adverse outcomes and reducing cost for patients.
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Figure 4 below shows the ED rates, readmission rates, mortality rates, and 90 day total cost of care by the number of days it took to receive home health, where a very strong relationship between days to home health and outcomes can be clearly seen. As each day passes, outcomes get progressively worse. Between receiving home health within one day and 7 days, the percentage of patients with a readmission increases by 40.4% (27.2% compared to 38.2%), the percentage of patients with an ED visit increases by 31.2% (22.7% compared to 29.8%), mortality increases by 22.3% (7.6% compared to 9.3%), and 90 day total cost increases an average of $2,289 per patient. Ultimately, with each passing day it takes to receive home health, the positive benefits associated with it are incrementally wiped away.
Figure 4
While timely initiation of care is critical to costs and outcomes, the ability to access home health services quickly post-discharge varies across populations. Figure 5 below shows the distribution of days to the start of home health care. Overall, about 46% of patients receive home health services within 0-1 days. This rate is higher among surgical discharges, with 56% of patients receiving care quickly. Among medical discharges, however, home health care is initiated within a day only 40% of the time. Among patient demographic cohorts, racial/ethnic minorities and dual-eligible beneficiaries were able to access home health services less quickly than their counterparts.
Figure 5
Pulling It all Together
After a short term acute inpatient stay, we’ve seen that receiving home health care is beneficial both in terms of outcomes and costs for patients compared to those who do not receive home health. Furthermore, it is critical that patients receive home health as soon as possible after their inpatient stay in order to capture as much savings and maximize patient outcomes as much as possible. While the effect of home health is nearly equal across all populations analyzed, there are significant disparities for historically at-risk populations when it comes to getting referred to home health and home health conversions. Further, these findings underscore the importance of home health in recovery from surgical care, and the gap to be filled in terms of increasing access to home health after discharge.
There are a few key limitations in this analysis that should be considered in contextualizing the findings. First, the accuracy and completeness of the patient discharge status code as an indicator of post-discharge referral has not been well-studied. Secondly, while a patient’s failure to receive timely home health care – or home health care at all – could be attributed to gaps in capacity and responsiveness on the part of the care providers, it could also be attributed to patient responsiveness and willingness to engage in getting home health care. The day of the week of discharge may also have an impact on timely follow up. Finally, in addition to acute care facilities, SNFs are a significant source of home health referrals, as are patients coming from outpatient and ambulatory settings, but these are not part of this analysis.
Despite these limitations, the findings highlighted in this analysis can help us to gain insight into the benefits that can be obtained from receiving home health, and the importance of getting patients into home health care as quickly as possible. It can also be seen as an opportunity to increase health equity if proper resources are dispersed to at-risk populations to mitigate disparities in access to home health.
Key Takeaways
- Understand the pipeline of patients from short term acute inpatient stays to home health care.
- Much of the time, when a patient is directed to receive home health services following an acute discharge, they do not actually receive these services.
- Among patients directed to home health post-discharge from an acute setting, those that actually received it have substantially lower mortality, ED, readmission rates, and 90-day total cost of care compared to patients that were referred home health but did not receive home health.
- Getting timely access to home health after discharge is incredibly important for reducing negative patient outcomes and costs.
- Access to home health differs greatly based on race/ethnicity, living in high distress areas, and dual eligibility status.
Methodology
To perform the analysis we leveraged claims billed at inpatient facilities, including short-term acute (STAC) inpatient claims, post-acute care claims, and the medicare beneficiary summary file (MBSF). To identify STAC claims, we identified facilities based on the facility CMS Certification Number (CCN). General and specialty STACs can be identified through the CCN, with the 3rd through 6th digits being between 0001 and 0879. Short term acute episodes were then constructed following the Bundled Payments for Care Improvement-Advanced (BPCI-A) methodology, with 90-day episodes triggered by any DRG. Inpatient stays where the patient passed away, did not have continued Fee for Service (FFS) enrollment, or were being treated for ESRD were excluded from this analysis.
The identification of referred discharge location is done through the discharge status code on the inpatient claims files. To identify where patients ended up after 7 days post discharge, the first post-acute location where a patient billed in the 7-day period was identified as the next site of care. Ties were broken by leveraging the discharge status codes from the STAC claims. Patients that did not have any post acute care location within 7 days were considered as having gone home without receiving any post acute care.
We segmented patients into several health equity cohorts via multiple data sources. Dual eligible patients were identified using the dual status code columns in the MBSF file, and if a patient was coded as 01, 02, 03, 04, 05, 06, or 08 during any month within a year, the beneficiary was counted as dual eligible. Anyone who did not fit that criteria is considered non-dual. Race and ethnicity cohorts were developed using the RTI race code column in the MBSF file. If the beneficiary is coded as Black/African American, Asian/Pacific Islander, Hispanic, or American Indian/Alaskan Native then the beneficiary is recorded as racial/ethnic minority. If the beneficiary is coded as unknown they are excluded from either the white or racial/ethnic minority cohorts. To group patients that live in “distressed areas” we used the ADI score, which is between 0 and 100. We used scores above 70 to indicate those that are more in high distress areas.
How CareJourney Can Help
At CareJourney, we see refining post-acute routing as one of the core drivers of value-based care success. With access to the complete CMS Medicare claims dataset, CareJourney can provide other valuable insights around home health and other post-acute optimization, that may include:
- Post-acute provider profiles to ensure you have a refined network of high-quality, efficient post-acute providers
- Utilization patterns to understand which provider groups actively have relationships with particular post-acute providers
- Episode analytics, to understand the variation in utilization and costs associated with post-acute care within the course of treatment for specific procedures and conditions
If you are currently a member and interested in how CareJourney can help you gain insights into post-acute care, please reach out to support@carejourney.com for more information. If you are not a CareJourney member, please email us at info@carejourney.com.