Home Healthcare Partners (HHP) began a program designed to completely re-engineer its business model about three years ago. The principle steps taken, and others being planned, are briefly outlined in this paper. The genesis of the initial re-engineering decision was our belief that only superior systems will provide the framework of information and controls required to reduce operating costs and improve service delivery while also assuring improved HHP team member training and education. Also, we recognized that within the next few years some form of electronic patient chart will be required by both regulators and the industry. When this time comes, If HHP already has an electronic patient chart in use it can quickly become part of the broader Electronic Medical Record as the industry adopts standard transmission rules.

Management found it difficult to choose from available systems that might provide better solutions than the clinical and accounting systems used by HHP. Not only is conversion to a new suite of systems very costly and disruptive, but there is risk that any system adopted may not be consistently upgraded to meet rapidly changing industry needs. Which of the available systems will, and which will not adjust to needed changes seems, in some ways, not knowable.

HHP management decided that the safest approach was to unbundle its needs, thinking about each solution as part of an “a-la-carte menu” of solutions. This approach required identifying systems agnostic, stand-alone solutions, and then engineer them to work together seamlessly. The design adopted allows for the future substitution of an improved system for any component that is no longer viewed as “best of breed”. In order to accomplish our goals, a team of systems engineers having extensive experience with the home healthcare industry was retained and the re-engineering effort was undertaken. A brief description of the suite of systems developed by HHP and its engineer consultants follows. However, the first step taken down the path of changing the HHP business model took the form of an important addition to services offered, even before systems re-engineering began.

Remote Vital Signs Monitoring: established by HHP in early 2006 as VitalPartners 365, this has become a core service of our company which is planned to significantly expand in the future. When the service was first implemented, the decision was based on a “leap of faith” that monitored patients would benefit. It was reasoned that (i) daily monitoring would identify health issue exacerbations that periodic visits may not always catch and, (ii) daily health coaching would help patients improve their diet and lifestyle. Monitoring equipment is expensive and it is not reimbursed by payers which make it doubly important that the service is very beneficial to the patient. With the analysis of thousands of monitored episodes now complete, both assumptions have proven to be true. Re-hospitalization rates for those chronically ill patients who were monitored are sharply lower than such rates for similar patients who were not monitored. For this reason alone, VitalPartners 365 is a success. A pleasant and altogether unexpected surprise is the fact that the program has also added to HHP’s financial margins making it a true win-win program.

Data Warehouse: the foundation for all other newly designed system components, HHP’s data warehouse, known as the Cube, gathers data from clinical and accounting systems every hour.  A commercially available “Analyzer” interfaces with the Cube creating the capacity for all elements of clinical and accounting data to be married in whatever manner may be needed by management to better understand its business functions. New reports can be designed in ten to fifteen minutes. Once designed, reports can be accessed in four to five seconds, with data no more than one hour old.  Gross profit margins for lines of business, individual episodes, disease classification or virtually any other data category can be analyzed by joining actual (not average or standard) caregiver visit costs to the income generated by episodes under review. This is but one example of the types of relationships made possible by this system.

HHP no longer relies on systems generated (canned) reports, Crystal Reports, spread sheets or manually generated information. Managers are empowered to customize their own data views to obtain information most useful and important to them. When something unexpected is seen (ex.-high LUPA rate) the interested manager can drill down to the information about those patients generating such results, review their charts and answer questions in minutes. In a similar way, the company’s financial reports can be generated and analyzed.

The Cube gives HHP management fast access to much information realistically not available in any other way. Also, it can be easily adapted to acquisition projects making the due diligence process more accurate, faster and less costly than conventional methods. When an acquisition analyzed through the use of these tools is completed, all of the acquired organization’s data is in the identical form as that of HHP, eliminating the need to convert either the acquired or acquirer’s clinical and accounting systems to that of the other.

The Cube is virtually complete, has been implemented and is in use throughout the organization. Additional functionality is targeted for completion by March 31, 2009.

Mapping/Routing/Scheduling: building on the Cube’s foundation, Map-U was designed to improve field staff productivity. This geocode-based scheduling utility enables schedulers to identify and schedule caregivers with required skills, available time and nearest the patient who requires care. Map-U maps patients’ locations, relative to each caregiver’s starting point, designs the optimum routing for the caregiver’s daily visits and measures the distance between the locations of each patient scheduled. Mileage information can be used to calculate caregivers’ expense reimbursement for use of their personal cars. If for any reason one or more patient visits need to be changed to a different time of the day than originally scheduled, Map-U will re-design the routing, in mere seconds, indicating the most efficient drive-path. If there is some concern about the neighborhood in which a patient lives, the house and the neighborhood can be viewed by clicking on the system’s satellite tab. Clinicians print their next day’s visit route through their home or office computer, and also view Map-U information, while in the field by using a laptop, netbook, notebook or one of several popular cell phone models.

Map-U is now being rolled out system-wide.

Digital Pen/Operations Portal: developed with the objectives of improving patient information flow, reducing expenses and creating an electronic patient record, the Pen is HHP’s answer to the need for a point of care (POC) device to aid in accomplishing these goals. All patient relevant forms have been redesigned to take advantage of the Pen’s ability to “remember” information gathered by caregivers during the course of their patient care activities. While the Pen is used like any standard pen, its design includes a tiny digital camera, as well as pressure and vector sensors. Its battery is sufficient for ten continuous hours of use and automatically recharges when docked at the end of each work day. While docked, the Pen transmits information gathered during the work day, through the operation’s Portal, to patients’ electronic charts. Therefore, information needed for coding and billing is immediately available to HHP employees who specialize in these areas, speeding the billing process.

The Pen has several inherent advantages over conventional POC devices. Because only pen and paper are used and virtually no training is required, the Pen will be a very positive aid for recruiting new and retaining present field staff. While forms must be customized in a manner that enables the Pen to function, they can be printed on any standard printer at a cost that is little more than for forms produced by offset printing equipment. Also, the cost of each Pen is so small that one can be provided to every caregiver including home health aides and contract therapists. This means that the electronic patient chart will contain all information, not just information which has been gathered by selected caregivers.

The Pen is used only to “push” information to the patients’ charts through the Portal. Not all caregivers, aides for instance, need to access information from patients’ charts while in the field, but some do. Needed information can be reached, or “pulled”, through many models of cell phones, such as the iPhone and the Blackberry. If a larger screen is needed (which may be the case with caregivers who complete patient discharge summaries) a notebook, netbook or laptop can be used. This level of device flexibility is one of the system’s most important cost saving characteristics.

Other cost savings generated by the Pen/Portal combination compared to either conventional pen and paper or point of care systems are cost reductions in:

Also often overlooked when adopting a conventional POC system is the cost of redundant, or back up equipment, that is needed to maintain caregiver schedules in spite of periodic equipment malfunctions. Also, larger organizations find it necessary to implement sophisticated inventory maintenance and tracking systems, given their investment in POC equipment. Vigilant oversight is necessary if such systems are to be effective, but the Pen’s low cost virtually eliminates these needs.

The Pen/Portal systems roll out begins in March with completion scheduled by the end of April. Later in 2009, after the Pen and Portal are in full use by HHP caregivers, the Portal will be enhanced to allow physicians to review the charts of their patients and to sign orders electronically.

Supply Management Online---provides for the online ordering of nursing supplies which are drop shipped to the patients’ homes or directly to caregivers to replenish their car-stock. This system replaces a similar but more costly supply source used by HHP for the past year. This is a commercially available system not engineered by HHP or its consultants. Training and rollout has been completed at most offices and all offices will be using the system by 5/4/09.