Advance Care Planning Protocols and Hospitalization Rates in Home Health Value-Based Purchasing

Abstract

Advance care planning is a conversation about personal values, future treatment choices, and designation of a surrogate decision-maker, that someone has in advance of a health crisis. Most existing studies on advance care planning have taken place outside of home health among populations with HIV/AIDS, cancer, dementia, and end stage renal disease. The U.S. home health population is living longer with chronic conditions such as pulmonary and cardiovascular illnesses, and hospitalization is a poor outcome. In 2016, Medicare implemented the Home Health Value-Based Purchasing Model, in which reimbursement rates for agencies in 9 regionally representative states were dependent on quantitative measures of quality performance. Part of the program was a process-level mandate requiring agencies to report on advance care planning. The aim of this study was to examine the relationship of home health advance care planning protocols with hospitalization rates. Descriptive and regression analyses were conducted on survey data of protocols and agency data of demographics and outcomes. Statistical significance was found in the positive correlation between advance care planning protocols and hospitalization. Recommendations are made for broadening the scope of evaluation of quality in home health to include goal-concordant care and transitions to appropriate services.

Emergency Department Use and Advance Care Planning in Home Health Value-Based Purchasing

“…17 Our current findings that ACPP score intensity is associated with ED use in HHVBP agencies-complemented by the Fourth Annual Report's interpretation that ED use is being used as a proxy for hospitalization-suggest a similar phenomenon to the one described in our 2021 findings. 16,17 As with the 2021 findings, HHAs with more robust ACP protocols may be successfully diverting or transferring to other services the patients who do not desire to use the ED in case of symptom exacerbation. These current findings are also congruent with our previous finding of 2022 that HHAs with more robust ACP protocols tend to have high percentages of patients with cardiac and pulmonary diagnoses, whose conditions are punctuated by exacerbation events, suggesting that these patients do prefer to use acute care services.…”

“…17 These 2021 findings suggested that HHAs that implement robust ACP protocols are then left with populations of patients who do want to use acute care services. 17 Implementing ACP protocols, HHAs may gain information about patient preferences that cause them to recommend diverting or transferring patients to other services such as such PACE (Program of Allinclusive Care for the Elderly), skilled nursing facilities (SNF), and home hospice, all of which provide alternatives to acute care services through symptom management in place, 24 hours a day, 7 days a week. 17 Our current findings that ACPP score intensity is associated with ED use in HHVBP agencies-complemented by the Fourth Annual Report's interpretation that ED use is being used as a proxy for hospitalization-suggest a similar phenomenon to the one described in our 2021 findings.…”

“…17 Implementing ACP protocols, HHAs may gain information about patient preferences that cause them to recommend diverting or transferring patients to other services such as such PACE (Program of Allinclusive Care for the Elderly), skilled nursing facilities (SNF), and home hospice, all of which provide alternatives to acute care services through symptom management in place, 24 hours a day, 7 days a week. 17 Our current findings that ACPP score intensity is associated with ED use in HHVBP agencies-complemented by the Fourth Annual Report's interpretation that ED use is being used as a proxy for hospitalization-suggest a similar phenomenon to the one described in our 2021 findings. 16,17 As with the 2021 findings, HHAs with more robust ACP protocols may be successfully diverting or transferring to other services the patients who do not desire to use the ED in case of symptom exacerbation.…”

“…18 Meanwhile, HHAs may refer patients with other serious illnesses to other services in line with their goals and treatment preferences that do not include acute care services. 17 Together, the 3 studies suggested that HHVBP agencies with robust ACP protocols were associated with higher hospitalization rates, higher ED use rates, and higher proportions of patients with cardiac and pulmonary diagnoses.…”

Cardiac and Pulmonary Diagnoses and Advance Care Planning in Home Health

“…The present study builds on our previous findings about ACP protocols and hospitalization rates in Home Health Value-Based Purchasing, where there was an unexpected yet statistically significant positive correlation between robustness of ACP protocols and hospitalization rates. 16 The interpretation of those findings was that HHAs with more robust protocols may be using ACP appropriately: Diverting or transferring to other service lines those patients who indicate that their goals are inconsistent with the rehabilitative focus of home health, thus leaving the agencies with higher proportions of patients who would want to return to the hospital for aggressive, curative measures. Given the current literature from the acute care setting indicating low engagement in ACP by persons with HF and COPD despite frequent hospitalizations 8,9 ; the purpose of the present study was to determine the relationship between the total percentage of cardiac and pulmonary diagnoses and advance care planning protocols in US HHAs.…”