Unleashing home health's potential: looking beyond today's Medicare benefit.

The best home health professionals—nurses, therapists, social workers, and aides—have known for a long time something that healthcare policymakers are just now beginning to grasp. They know that Medicare’s laser-like focus on shortterm, highly proscribed transactional healthcare services has handcuffed their ability to help their patients manage chronic conditions more effectively, enjoy a better life, and reduce preventable hospital stays. The Medicare home health benefit was designed largely as a short-term healthcare intervention under very limited circumstances, especially the requirement that the patient meet a strict definition of being “homebound. ” The services covered under the benefit are also limited, especially in contrast to the range of services typically covered under a progressive Medicaid home and community-based services waiver program. The strains on the healthcare delivery system have grown dramatically since Medicare’s early days, yet the Medicare home health benefit (not counting changes in payment mechanics) to this day remains essentially the same as it was back in the days that Gunsmoke, in all its black-and-white glory, was a major TV hit. A minority of patients with multiple chronic conditions now accounts for the majority of Medicare spending, yet today’s mainstream strategies for managing chronic conditions continue to be fragmented, episodic, and ultimately ineffective (Stanton, 2006). Fortunately, leading innovators in home healthcare are teaming up with leaders in government and other healthcare sectors to break down the traditional limits and silos that have stood in the way of outstanding and sustained care for vulnerable, chronically ill patients. They are developing new models of care that recognize the many points in the chronic care continuum where a patient can fall through the cracks and receive too little support at exactly the time he or she needs it most. The new models are recognizing that meeting these patients’ needs may require far more, or far less, than what is usually considered traditional home healthcare. Maybe in addition to skilled services, a patient can remain independent with more homemaking and aide services than a traditional episode would provide. The key point is that instead of focusing attention on the reimbursement system, the true innovators are focusing on the patient and the capacity of the professionals and caregivers available to care for them. It’s a huge change in outlook that can drive a whole new way of providing care. By way of example, two VNAA members have earned recognition for their own capacity as innovators and are now acting as Innovation Advisors to the federal Centers for Medicare and Medicaid Innovation (2011). Nancy Roberts, president and chief executive officer of VNA of Care New England, is one. To her, serving as an innovation advisor allows her to experiment with new models that will help the delivery system move toward the famed “triple aim” articulated by Dr. Don Berwick and the Institute for Healthcare Improvement: better care for individuals, better health for populations, and lower per capita costs (Berwick et al., 2008). Roberts is testing a particular approach to working collaboratively with a primary care practice to improve care transitions between institutional settings and homecare while educating, engaging, and empowering patients. Roberts reports that her agency intends to start small with this new program but that eventually it