Value-based care has been the guiding concept behind national healthcare policy for the three most recent administrations. Currently, Secretary Alex M. Azar II leads the Department of Health and Human Services (HHS) with value-based care identified as one of the four top priorities of his administration. Headlines on the HHS website declare "Americans deserve better, cheaper healthcare. HHS is working to transform our system from one that pays for procedures and sickness to one that pays for outcomes and health." The shift from paying for sickness to paying for health can only be understood as a shift away from hospitals and move toward home. Hospitals are for the sick, health is at home. Value-based care is about maximizing individual health and wellness, and this can only happen at home. In numerous speeches about value-based care, Secretary Azar defines the "4 Ps" of value-based care; patients as empowered consumers, providers as navigators of care, preventing disease before it occurs or progresses, and paying for outcomes. These concepts are a natural fit for care in the home and a critical opportunity to redesign the healthcare system with home at the center.
"Patients as empowered consumers" merges the idea of patients as the center of care with notion of being a consumer. Patients as the center of care is about ensuring patients' perspectives, values, and priorities are the primary consideration in healthcare decisions. Consumerism is built around the idea of choice. By choosing what to purchase, consumers influence the market. Merging the two ideas places emphasis on the patient choosing how they want to proceed with their healthcare decisions. Staying at home is one of the key choices patients consistently make and seek. Patients who are empowered consumers choose to stay home. They seek options to balance their health and wellness needs while staying wherever they call home.
The home-based care industry can support empowering patients by ensuring they understand the options for home healthcare. As the payment structure shifts to the Patient Driven Groupings Model, every patient will be identified as an institutional referral or community referral. Only patients with an institutional stay within the 14 days prior to the start of care are institutional referrals. Projections estimate that in this system, 65% to 75% of all home health billing episodes will be community referrals. These projections reinforce the desire to stay home and present an opportunity to ensure consumers know that home healthcare is an option-one that both helps them at home and to stay home. They do not have to have a hospital stay to access home healthcare; however, it does require a provider to match the patient's choice with available services.
The second P of value-based care, "providers as navigators of care," is a critical link to the community referral. Medicare-certified home healthcare starts with a physician order. In the value-based setting, physicians are no longer gatekeepers, rather, they are navigators. This is an important shift. As gatekeepers, the physicians were in control, setting the boundaries that limited patients' choices. This was neither patient centered nor patient empowerment. As navigators, physicians are knowledgeable guides who provide expert input to support patients' goals. When the core goal for the patient and the system is to stay home, both the provider and the patient must be knowledgeable about home healthcare. This shared need is another opportunity for home healthcare providers to educate and partner with providers. The more knowledgeable physicians are about home healthcare (e.g., what it is, how to get it, what if offers, how it impacts patients), the more likely they are to offer it to patients, support a patient request, and help move the system toward value-based care.
The partnership between providers, patients, and home healthcare continues with the shared goal of preventing new or worsening disease. This is the same as maximizing health and wellness. In short, it means reduce symptom burden and reduce the likelihood of sickness. Achieving either of these goals will help people stay home. This is the core goal of all home healthcare. Applying evidence-based knowledge helps each patient achieve and maintain their personal goals for health and wellness. The growth of data focusing on people receiving home healthcare is critical to developing skills and knowledge on reducing symptoms and new illness. As the industry learns about patients and identifies successful interventions by examining the Outcome and Assessment Information Set tool, the ability to focus on health and avoid sickness will increase. These data can be utilized for one patient at a time, for groups of patients with common conditions, and for the nation as a whole. Research at all levels on home healthcare and its impacts on patients will ensure that care in the home is recognized as the way to achieve value-based care.
Currently, the most discussed measure for home healthcare is the hospital readmission rate. In the future, this measure will only apply to 35% to 45% of home healthcare episodes. To realize the last P, "paying for outcomes," this measure will need to shift. Changing the measure to avoid all hospitalizations would more accurately reflect the goals of care and include all people receiving home healthcare. Ideally, the measure would more accurately reflect a successful outcome-staying home. Measuring the ability to stay home would place emphasis on the patient-driven goal, reflect a focus on health, and incorporate a variety of care providers in a shared goal.
Taken together, the "4 Ps" of value-based care clearly point to a radical shift toward care at home and away from sickness-based hospital care, though hospital care will remain important. There will be sicknesses best served in a hospital setting. However, hospitals are reserved for a minority of people. In a health-based model, focus will shift toward the majority of people who are not actively sick. We are all living in various states of health. People live at home with a wide variety of diagnosis and functional limitations. They strive for a state of health that allows independence best expressed in the homes they choose. Home healthcare is a core support to achieve this independence. The only way to "transform our system from one that pays for procedures and sickness to one that pays for outcomes and health" is to embrace home as a setting of care and home healthcare as the primary mechanism of value-based care.