Unsafe and Ineffective: Aseem Malhotra

SEARHC To Close Sitka's Home Health Department

Cindy Litman holds a photo of her late husband Tony. Litman says home healthcare was incredibly important to their family as they navigated Tony's advancing Parkinson's Disease. (Katherine Rose/KCAW) https://media.Ktoo.Org/wp-content/uploads/2023/08/16HOME1_01.Mp3

The Southeast Alaska Regional Health Consortium is closing its home health department in Sitka at the end of September. While the organization maintains that the closure is largely an administrative move, and that outpatient services – and in-home care – should be unaffected, some Sitkans are concerned that both the expense and quality of end-of-life care will change dramatically.

Sitkan Cindy Litman's home smells like warm flour and butter. She's just pulled a few trays of cookies out of the oven. Her three cats lounge in a living room filled with books and art and photographs. This is the home she and her late husband Tony shared in his final years.

Tony was diagnosed with Atypical Parkinson's Disease in 2014. At the time, they were living in a two-story home in Sitka.

"He got to the point where he couldn't navigate the stairs in our house, and our bedrooms and full bath were upstairs," Litman says. "It was a pretty small lot, and we weren't really able to make the changes we would need to make the house accessible."

They decided to move to Olympia, Washington, to be near family and easier access to the specialized care Tony needed. And while they had better access to neurologists and cardiologists, Litman says the experience taught her how fragmented healthcare in America is.

"What was striking to me was that there was no coordination of care between those different doctors, so he would see one person and they would have no idea what the other health providers were doing," Litman says. "And even though the health care was, I'm sure, considered good, it felt very alienating."And they missed Sitka, the community that had been their home for over a decade. Nine months later, friends back home were selling a house that would accommodate Tony's changing mobility. Even though they worried that there were no practitioners specializing in Parkinson's in Sitka, they jumped on the opportunity and moved back.

That's when they learned about what was then Sitka Community Hospital's home health program.

"It was my first experience, really, with coordinated care. They were much more in tune to his situation than his primary care physician," Litman says. "If it seemed like his medicine needed tweaking, or if he needed another kind of therapy or a swallowing test, they were right on top of it. These changes happened very frequently as his situation changed."

Tony passed away on Valentine's Day in 2019. Two months later, Sitka Community Hospital was acquired by the Southeast Alaska Regional Health Consortium, or SEARHC.

"The point of home health and post acute care, community based care, is we bring a comprehensive team to you," says Emily Rivas. She was the first clinical manager for SEARHC's home health department, which was created in 2018, a year before the SCH acquisition.

"From an allocation of resources standpoint, there's not a lot of duplication, because there's one plan of care, and everybody works together on that," Rivas says. "The communication is pretty tight, we're supposed to meet and discuss the patients as a whole, looking at their long term plan, chronic disease processes, build relationships, encourage better health habits."

"We will sit down and do your medication box, but then also take a look at your medications and see, 'Well 27 medications is just too gosh darn much. Let me call your cardiologist, diabetes doctor, and your primary and see if we can't get rid of some of this and make it a little bit easier.'"

Like its predecessor at Sitka Community Hospital, SEARHC's Home Health department provided everything from physical and occupational therapy to skilled nursing and end-of-life care in a home setting for anywhere from a dozen to 25 patients at a time. But this summer, SEARHC announced it would be closing the office.

"It's an administrative structure that creates some possibilities in terms of care, but also limits some possibilities in terms of care," says SEARHC's Chief Medical Officer Dr. Elliot Bruh. He says it's the home health "structure" they're getting rid of, but not the service.

"There's some types of care that people need in a home environment that don't qualify under that type of program. And then there's other kinds of care that we've been providing," Bruhl says. "There's been a lot of issues that we've been struggling with, and we've decided that we're going to close that entity, that structure, but that doesn't mean that we're going to stop caring for patients, or that we somehow can't provide care to patients."

Bruhl says SEARHC is closing the office mainly due to federal regulations that make operating it challenging and inefficient. He says the regulations are directed at larger cities and larger hospitals with more resources that can more easily sustain full home health programs with separate medical staffs.

"I would kind of describe it like building an international airport in a location where what you really need is an airstrip," Bruhl says.

Bruhl says SEARHC will continue to provide service referrals in the home environment through both its Mountainside Urgent Care Clinic and the hospital's outpatient clinic. And although it's never had a formal hospice program,the home health department has been providing some end-of-life services. Bruhl says they'll still be able to do that. Right now they're working through the logistics.

"We also provide really intensive types of end of life care in the hospital," Bruhl says. "And I think we're anticipating that we may, at times, project that care also into our long-term care facility when we need to. So our intention is not to abandon that care, abandon patients or leave patients who need that type of care without access to those services, it's just we're not going to provide it through this department."

Litman says the care her husband received through home health ensured the best quality of life possible, even as his health declined.

"When I think about even the last few years, when his mobility was so restricted, he lived a rich life. We had company, we had Christmas with all the grandchildren and their children," Litman says. "The idea that he would be in a skilled nursing home for that time, to me, just seems cruel and horrifying."

And expensive. Litman says Tony's home health costs were far less than had he lived in a skilled nursing facility – and Medicare covered the bills. She is skeptical that the same level of care will be provided outside of the home health umbrella, and she feels that the decision is primarily driven by finances.

"If you think about someone like Tony, if they had been in skilled nursing for two years, it would have been a million dollars. I mean, I can't even imagine how much money that would have cost instead," she says. "Medicare pays for home health because home health has been shown to be so effective in keeping people out of the hospital, that even part A, which is the hospitalization part of of Medicare, will pay for home health services. So it it concerns me that this is driven by by money, rather than by medical needs of people."

Rivas, who left SEARHC in 2020 and now works as a hospice nurse in Oregon, says home health helps create better continuity of care, and doesn't think the outcomes for patients can be replicated through outpatient services. She's disappointed that the program she helped establish is going away.

"In a town of 9000, what we put together was much better than nothing, and it would just be really unfortunate to have that integrated," Rivas says. "It takes time for people to build trust, especially in a community like Sitka, and to have that now, and then have it go away, it's gonna be really hard to change yet again, in such a short period of time."

SEARHC'S Home Health has eight staff, both medical and administrative, who were notified about the closure in July. Bruhl says all will be offered jobs in other departments beginning in October.

Loan Repayments Fortify Some In Mass. Health Care

In a move that one Massachusetts social worker described as an "answered prayer," the state will repay more than $140 million in student loans for almost 3,000 health care providers who serve communities in need.

An estimated 2,935 primary care and behavioral health providers will receive loan repayment awards in exchange for committing to work with eligible providers, such as community health centers and acute care hospitals, for four or five years.

The awards, which range between $12,500 and $300,000, are the first in the "MA Repay" program that former Gov. Charlie Baker's administration launched in November, funded by federal pandemic relief money as well as opioid lawsuit settlements.

They're also just the start: officials said Monday that another $120 million more will flow in the coming months thanks to funding lawmakers included in the new state budget.

The next round of awards will be targeted toward home and human services providers, continuous skilled nursing providers, and Department of Mental Health employees providing clinical care or case management, according to the Mass. League of Community Health Centers.

How much an individual provider received this round depends on their qualifications, work setting and hours worked, according to the Healey administration. A spokesperson said 39 people are set to receive $300,000 awards, all of whom are either full-time psychiatrists or child and adolescent psychiatrists.

In Brockton, Lt. Gov. Kim Driscoll pitched the "MA Repay" program as a "lifeline" that will help more providers overcome barriers and put down roots in areas with some of the most potent staffing shortages. She said "every single applicant" can receive a repayment award.

She contrasted the awards from a "Publishers Clearing House moment," referencing the sweepstakes in which winners are greeted with an oversized check.

"It's not a random knock on the door. We're reinvesting in all of you who are helping care for neighbors," Driscoll said, flanked by state officials and community health center leaders at an event in Brockton. "We're reinvesting in the individuals who are helping us heal. We're reinvesting in strengthening our communities by providing the type of health care we need on the ground every single day. I can't think of a better way to utilize public funding than to reinvest in ourselves."

A majority of the recipients work in "historically underserved" areas, many of which are Gateway Cities, according to the Healey administration.

Close to half of the recipients are people of color, 70 percent are women, and 47 percent are younger than 35, which Driscoll said is especially important "at a time when we want to make sure our young adults, this next generation, can launch."

Health care providers across Massachusetts have been struggling with staffing shortages for years, particularly during and in the wake of the COVID-19 emergency, that spill over into impacts on patient care and costs.

"Many, many people in health care have crushing debt," said Health and Human Services Secretary Kate Walsh. "The debt that young residents face or a social worker faces, particularly against their earning potential, is really staggering, so this loan repayment not only helps people stabilize their lives, stabilize their families, maybe they can buy a house some day, but it also keeps them working in the communities they've come to love with the patients they've come to love and respect."

Awardees became emotional when discussing the impact the loan repayment would have on their careers and their personal lives.

Linda Alvarez, a behavioral health clinician at the Brockton Neighborhood Health Center that hosted the event, said she will now be able to "truly focus" on supporting historically underserved patients.

"It is because of this opportunity that I find this to be more than a dream come true," Alvarez said, appearing to fight back tears. "For me, this is an answered prayer that opens so many opportunities to expand my love of helping as many people in need and gives my wonderful family and I the opportunity to dream and accomplish other goals we previously placed on hold."

Massachusetts League of Community Health Centers President and CEO Michael Curry said the funding will provide a boon for community health centers, which serve more than 1 million patients per year across the state.

"As we speak, health centers in Massachusetts are dealing with an unprecedented workforce crisis at a time when pent-up demand for care and services is at an all-time peak. This is constraining access to essential preventive services," Curry said.

He added, "This will actually make a difference. This program will keep desperately needed providers in communities that need them most."

The debt relief comes at a time when many other Americans with student loan debt are preparing to resume monthly payments. A pandemic-era pause on student loans is about to expire and the U.S. Supreme Court in June rejected President Joe Biden's plan to wipe away about $430 billion in student loan debt.

Brockton Neighborhood Health Center CEO Susan Joss, whose facility employs 10 recipients of loan repayment awards, praised the program as a way to keep workers employed at community health centers, which often do not pay as much as other health care facilities.

"A lot of health centers, including ours, in Massachusetts are struggling financially. We had money to support us through COVID. At BNHC, we're estimating it was about $42 million in COVID funds came in. Now, that's gone," Joss said.

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Future Leader: April Stewart, Vice President, Access & Innovation, 24 Hour Home Care

The Future Leaders Awards program is brought to you in partnership with Homecare Homebase. The program is designed to recognize up-and-coming industry members who are shaping the next decade of home health, hospice care, senior housing, skilled nursing and behavioral health. To see this year's Future Leaders, visit https://futureleaders.Agingmedia.Com/.

April Stewart, the vice president of access and innovation at the Los Angeles-based 24 Hour Home Care, has been named a 2023 Future Leader by Home Health Care News.

To become a Future Leader, an individual is nominated by their peers. The candidate must be a high-performing employee who is 40-years-old or younger, a passionate worker who knows how to put vision into action, and an advocate for seniors, and the committed professionals who ensure their well-being.

Stewart sat down with HHCN to talk about her path to home-based care, the rise of value-based care, quality of life considerations and more.

HHCN: What drew you to this industry?

Stewart: Key experiences in high school inspired me to pursue a career in home- and community-based services. I met my now lifelong friend who has a developmental disability in 9th grade. He never let his disability get in the way of full community inclusion.

As his friend, I became part of his circle of support and learned how big an impact person-centered care can have in empowering people to live the life they choose — which is most often in their own home and community. He now lives in his own apartment with support staff who help with instrumental activities of daily living.

The opportunity to make a difference every day through empowering this level of independence and choice for people with disabilities with onsets at any age is my life passion.

What's your biggest lesson learned since starting to work in this industry?

Policy and regulation plays a huge role in access to services and person-centered flexibilities in care. I learned the importance of involvement in health care advocacy to ensure policy, regulation and funding levels line up to enable value-based, culturally competent and accessible care.

If you could change one thing with an eye toward the future of home care, what would it be?

I would love to see caregiving and home care services be more integrated into the health care community.

Our caregivers are the eyes and ears in the home, and already actively notice and take action on change of conditions, ensuring care plans are followed, etc. There is so much potential to be a more integrated part of managing chronic conditions with improved data exchanges and communication with our clinical partners serving mutual clients.

What do you foresee as being different about the home care industry looking ahead to 2024 and beyond?

I think like most health care, we are moving from a volume-based to a value-based system. COVID-19 showed the health care industry and our communities the critical role home- and community-based care plays in capacity-building for the system and care outcomes.

I think we will start seeing more innovative and integrated programs that encompass home- and community-based care as key elements. I believe we will start seeing a higher demand for data and outcome-based reporting versus. Task-based reporting in the near future.

In a word, how would you describe the future of home care?

Transformative.

I think we are experiencing a high level of change industry-wide in home care. The market is very different than it was when I joined the industry 15 years ago. Health care is moving away from focusing on deficits — bathing, transfers, getting dressed, etc. — and towards creating quality of life.

It's more common now for people to want to talk to us about their goals. Goals are typically about independence, socialization, community inclusion and preserving personal identity while managing a chronic condition. Personal care becomes an input into personal goals and overall health rather than consistently getting a bath being the end goal of our services.

I think we are going to see innovative care models, staffing solutions and goal-based care plans to provide better value and outcomes to the people we serve.

If you could give advice to yourself looking back to your first day in the industry, what would it be and why?

Don't be afraid to specialize or take an untraditional career path. When organization leaders used to ask what future roles I was interested in, early in my career I would say what I thought they wanted to hear. Or I felt like I had to say something that fit into a traditional bucket of "realistic" opportunities.

For example, there were clear paths to becoming a sales or operations leader as new territories were launched. I always had an internal fear of being bucketed into a specialty too early and struggled to admit that I wanted to do something different than our typical growth paths. What I didn't realize is that these fears held me back from having genuine conversations that could have supported company and personal growth.

Since becoming more open about what I want to do and the impact I want to make in my career, I have been empowered to take on a unique role leading service access and innovation. The health care innovation role is becoming more common as a focus area in health care organizations interested in staying on top of a rapidly evolving health care market.

If you have a special interest or an opportunity where leadership is actively asking for your input on your career path, take the risk of saying what is truly on your mind and heart. It may just lead to your dream job and ability to make a unique impact.

To learn more about the Future Leaders program, visit https://futureleaders.Agingmedia.Com/.

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