Improving Access and Timely Care for Vulnerable Patients Referred to Home Health via Telehealth Physician Support
By Daniel Kevorkian, Irene Cole and Tony Kudner
AccentCare and Sound Physicians partnered to develop a scalable, evidence-based program that leveraged the COVID Public Health Emergency (PHE) telehealth waivers to speed access to Home Health services for eligible patients. The purpose of the AccentCare-Sound Transition Program was to:
- enhance access to home-health for the population of patients without an assigned community physician;
- improve clinician-to-physician communication, and;
- facilitate telehealth patient contact with a physician to overcome technology barriers.
Access to Care
Access to care provided in the home was in great demand during the pandemic. The HHS Office of the Inspector General reported that hospitals’ underlying problems with health care delivery were exacerbated during the height of COVID-19. Compounding these access issues, inpatient facilities needed to discharge patients rapidly to create bedspace for incoming sick patients, but fewer post-acute inpatient settings were accepting patients.
Primary care practices were also challenged by these constraints, which had an outsized effect on patients with chronic conditions requiring monitoring and follow-up, particularly patients with palliative and rehabilitation needs. Findings from a primary care simulation found that only 56% of the sample of 800 practices in the U.S. could be reached to request an appointment. Of those practices, the majority of appointments offered were some form of telehealth. Evidence repeatedly shows that complex, vulnerable patients are difficult to reach through telehealth, due to factors such as reduced resources and limited health literacy.
Barriers to Home Health Care
Home health care providers were in a unique position to facilitate inpatient discharges during the PHE. However, patients lacking a primary care provider were presented with an access barrier to home health due to federal regulations, and thus increased risk of adverse events. Extended transitions of care without adequate health care support have long been known to result in hospitalizations and other safety events. Patients without a provider willing to sign home health orders would typically be denied access to home health care until a follow-up provider visit was completed.
Regulations specify that Medicare certified skilled home health organizations must receive all orders for care from a patient’s assigned physician who must also certify the home health care. Further, the Affordable Care Act established a face-to-face encounter requirement for certification of eligibility for Medicare home health services.
A face-to-face encounter must be performed by a qualifying practitioner within 90 days prior to the home health start of care or 30 days after. Prior to the PHE, face-to-face encounters were required to be completed in-person and use of telehealth did not satisfy this requirement. In response to the lack of health care access during the COVID-19 pandemic, the Coronavirus Aid, Relief, and Economic Security (CARES) Act provided solutions such as allowances for face-to-face encounters to be performed via telehealth.
For patients without a primary community physician or those who had not been seen by their physician for a long time, home health regulations created a barrier to timely care. Navigating and coordinating one’s own care is becoming increasingly complex, especially for elderly and those with challenging social determinants. Adding to this complexity, the home health benefit is dependent on a face-to-face encounter between the patient and their certifying physician to be considered a necessary and billable service. Likewise, timeliness to home health start of care, as well as availability of primary care providers in the community, is imperative not only by regulation but for less burdensome transitions of care to the home to secure their health and safety.
The AccentCare-Sound Transition Program
During the PHE, AccentCare and Sound Physicians collaborated on a solution to increase access to home health care for patients without a community physician by leveraging telehealth and home health clinicians at the bedside.
The AccentCare-Sound partnership leveraged AMN® health care’s Virtual Care Management™ (VCM) tool to house all communication, scheduling, and complete virtual visits. Synchronous collaboration was accomplished during the virtual telehealth visit by including the remote Sound physician, the AccentCare clinician at the bedside, and the patient / caregivers. This opportunity for real-time collaborative assessment allowed for the patient’s care needs to be met immediately, inclusive of the patient and family as team members.
The program initiated when AccentCare received a home health order for a patient that did not have an identified physician. If the patient did not have a primary physician or the physician was not available to certify the home-health plan of care (POC) an AccentCare liaison would present the option to the patient and family for Sound to provide the needed certification and orders via telehealth. The patient was notified that they had the freedom to choose any physician and were not required to utilize Sound.
Upon patient approval, AccentCare scheduled the home health start of care, including the coordinated Sound telehealth contact through the VCM. The AccentCare clinician received consents from the patient or designated power of attorney for home-health services and for the Sound virtual visit. The comprehensive assessment of the patient’s physical status, living environment and functional ability would be completed, including a medication reconciliation. The home health clinician would then connect with Sound through the VCM, facilitating the technological link that otherwise presented a barrier to telehealth care for many vulnerable patients at home. When appropriate, the Sound physician provided verbal approval of the plan of care (POC) and electronically certified the home health POC.
The Sound physician remained available through VCM during the 60-day home-health episode for additional consultations between the clinician and patient, as well as for communication of orders and patient needs throughout the episode. AccentCare provided home health care to the patient and facilitated a follow-up appointment with a local community physician of their choice. Once the patient attended the follow-up visit, the oversight for home health care was transitioned to the community physician.
The AccentCare-Sound teams piloted this program for 6 months and successfully admitted 296 patients, all of whom had a virtual visit with a Sound physician. This pilot sample was shown to have started home health care for these patients more efficiently than the industry average. Program patients had a timely initiation of home health care 98.6% of the time, as outlined by Medicare’s definition of home health Timely Initiation of Care (TIC). In comparison, the Texas state average for home health TIC was 96.7% and the national average was 95.8%, according to an internal report by Strategic health care Partners. Since the pilot, over 1,000 additional patients have participated in the expanded program with similar results.
Characteristics of the Sample
Timely Initiation of Care
Timely Initiation of Care (%)
Age Distribution (in years old)
40 to 60
61 to 80
Medicare & Medicare Adv
Some examples of timely orders and care were: 1) a patient needing venipuncture for laboratory analysis, Sound providing the order, and the clinician being able to draw the lab immediately while in the home, and 2) a patient needing a medication not on their inpatient discharge documentation, the Sound physician providing the order for the home-health POC and sending the order to the patient’s pharmacy. The real-time care coordination between Sound and AccentCare was vital in caring for patients who were within days of their inpatient discharge.
Qualitatively, the feedback from AccentCare clinicians, participating Sound Physicians, and patients was positive.
“I admitted a patient who had a mild [stroke, and]had been released home from the hospital and her primary care doctor had a waitlist of over a month. The patient was thrilled to be able to have a doctor lay eyes on her following her hospitalization and ensure she was getting the care she needed.” – AccentCare Clinician
“With my telemedicine presence, I was able to guide the home health staff, as well as the patient through what to expect going forward. We were able to make sure the patient was compliant with medication[s] and understood the importance of nephrology and primary care follow-up.” – Sound Physician Medical Director, Telemedicine
“We had a couple who had both tested positive for COVID who were extremely worried for their health and unable to get into see their primary physician. SPs gave them peace of mind and allowed them to quarantine at home and keep others in the community safe.” – Patient Feedback via AccentCare Executive Director
“I have been extremely pleased with how convenient [the program is] for both the patients and clinicians. In the field we often have such a hard time getting ahold of a doctor for concerns or plan of care discussions and SPs eliminates that stress.” – AccentCare Clinician
“Being able to have open communication with a patient’s doctor has given us the ability to better serve our patients and ensure there is no delay in care.” – AccentCare Clinician
Where to Go From Here
AccentCare and Sound have improved access to home health care for vulnerable patients discharging from a hospital without a primary care provider.
Through this program, patients who would not have had access to home health services are now able to start care faster than the industry standard. The ability to provide real-time care collaboration between the home-health clinician, the patient/family, and the physician allows for faster solutions for patient issues without delay. Widespread utilization of telehealth physician coordination could significantly improve home health care which is dependent on physician coordinated care yet struggles with timely access to physicians.
The AccentCare-Sound Transition Program has demonstrated a feasible process and two main positive outcomes. First, 100% of the sample gained access to skilled home health and a primary provider to start care, and second, timely initiation of care was higher than both national and state averages. The program requires collaboration between multiple entities, and workflows are dependent upon supportive health care regulations and policy. Federal policy allowing integrated, ongoing use of appropriate telehealth while a suitable long-term primary care physician can be found could significantly improve access to care, facilitate more nimble communications among care team members and potentially avoid costly rehospitalizations and acute care utilization.
Solutions that are supported by permanent regulatory change allowing for virtual physician visits to qualify as the required face-to-face encounter would deploy flexible, modern-day solutions our vulnerable patients. The addition of a certified home health clinician at the bedside facilitating the visit serves to maintain or increase the quality of the physician assessment. This pilot demonstrated the value of allowing physicians to complete virtual assessments to qualify as the required Medicare face-to-face encounter. Although the CARES Act permitted this practice during the PHE, there is urgency to make a permanent regulatory allowance. Doing so could improve patient access to home-health services and primary provider assessments to patients who would otherwise not qualify while a long-term primary care provider is being found for the patient.