AccentCare CMO Loengard: Palliative Care a ‘Huge Opportunity’

Home-based care provider AccentCare has been busy since its merger with Seasons Hospice & Palliative Care, exploring new technologies and care delivery strategies, as well as expanding business lines.

The two companies merged in early 2021 with designs on building a seamless care continuum in the home setting and recently unified all of its business lines under the AccentCare brand. Dallas-headquartered AccentCare is a portfolio company of the private equity firm Advent International.

The company employs roughly 30,000 staff who collectively serve more than 210,000 patients from over 260 locations across 31 states and the District of Columbia.

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Hospice News sat down with AccentCare Chief Medical Officer Dr. Anna Loengard to discuss the ways the company has evolved since the merger, including clinical innovation, new approaches to hospice general inpatient care and its growing acute-care-at-home business.

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AccentCare Chief Medical Officer Dr. Anna Loengard

AccentCare has been working on some clinical innovations, including the adoption of tech solutions to identify potential acuity. Can you add some more details on your work in that area?

We’re excited to be already using a couple of different solutions. We’ve deployed Muse. We’ve been using Medalogix for several years now to identify patients in home health who would qualify for hospice, and then to facilitate those conversations and get the patient to the right level of care.

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More recently, we’ve started using Muse to really help us to understand patient acuity within hospice. It actually has a number of different purposes. Humans are not the best at predicting when people are coming to the very end of life. We as hospice providers, and certainly [the U.S. Centers for Medicare & Medicaid Services (CMS)], have an interest in making sure that we are supporting patients and families in the very last days of life and measuring that.

One really helpful way that Muse can help us is to make sure we’re getting to the bedside at the right time. And then also, it can help us to understand who has more acute needs and who might benefit from the fact that we have the largest footprint of inpatient beds for [general inpatient care (GIP)] use across the country.

When you look at the landscape of hospice, [GIP] is under-offered. That’s how I would say it. I certainly recognize that for many years now, there has been a lot of scrutiny of GIP, and not inappropriately. However, I think that it meets a real need when patients are either at end of life or near the end of life — and when particularly families just need to be families without trying to manage acute, very uncontrolled symptoms.

Sometimes it really is beyond the capacity of family members to take care of these patients, and we really need an outlet to take care of them appropriately.

When we started exchanging emails about this interview, it was mentioned that AccentCare is making some adaptations to how you use GIP, described as a “step-up” rather than a “step-down.” Could you add some details about that?

Historically, [Seasons Hospice & Palliative Care] and now AccentCare created inpatient units, as a place for patients who were [hospital] inpatients and might have higher acuity needs and might otherwise not be able to access hospice. We do have freestanding units as well.

We provide that type of care in a variety of ways, but I think the focus has often been as a step down from the hospital. I think that there’s an opportunity — and we’re just sort of at the beginning of this journey — to identify patients in the communities where we have large home hospice and give them the opportunity to come into a GIP setting when they qualify.

One of the biggest challenges with GIP really starts with the discharge planning process, like from the get-go of even mentioning GIP. There’s confusion, and it’s not a lengthy benefit. Almost the better you are at managing symptoms, the shorter that stay is going to be.

It’s sort of a double-edged sword. You do the best thing for the patient, but then the family may not be quite ready to transition back home. We see a lot of pretty exhausted caregivers. I think that when they get that relief, sometimes it’s hard for them to think about going back to what may have been a very challenging caregiving situation.

But I think that there’s still value in thinking about how we serve patients who are already on our service, not just at admission from the hospital.

How are you balancing that with that regulatory scrutiny that you mentioned?

It’s an ongoing process of making sure that everyone’s educated about this, that we’re thinking about the discharge planning process from the start and making sure that our teams are really documenting appropriately and understanding who actually qualifies for GIP.

But I think that this is a continuous process for any hospice organization that does GIP. You have to be always mindful of making it very clear why the patient qualifies for that level of care, and that has to be almost as strong as the focus on what you’re managing. You have to develop the story and the justification of what it is that you’ll be providing.

We need to make sure that our documentation for all of our staff is really demonstrating the need just because we know there’s such heightened scrutiny there.

Can you update me on the progress of AccentCare’s Hospital-at-Home program?

We’ve actually been doing hospital-at-home home long before the waiver program that came in with the [COVID-19 public health emergency]. We started this with [the University of California at San Diego (UCSD)] and did this on a home health platform.

With the waiver program that came in November 2020, we’ve actually worked with Baylor Scott and White on a hospital-at-home program. 

We’re in the process of working with Medically Home and Kaiser Permanente Georgia on a hospital-at-home that would use the waiver program.

We’ve actually learned an enormous amount about the different ways that you can actually supply this program. We’re actually kind of relaunching and reimagining the program with UCSD right now and relaunching a lot this summer. We have a lot of interest in how you do this in the best way for patients.

Depending on the geography and the health system, doing it as a waiver program versus doing it as home health, there may be pros and cons that might push you in one direction or another.

If you do this on a home health platform, if you’re a system that’s looking at the total cost of care, this is actually a less expensive way of caring for a patient who has higher acuity and otherwise would need to be in the hospital. That needs to be part of the conversation as well.

I’ve had multiple conversations with other stakeholders in this space and the volume of patients is one of the biggest issues to the sustainability of hospital-at-home programs. The consistency of sending patients to this program is probably one of the single greatest challenges.

If you think about geography, I think an ideal model would be to have a home-based provider, provide the hospital-at-home and have multiple hospitals referring into that. In that circumstance, then patient access becomes less of an issue.

The other thing that’s really interesting to me about not doing this on the current waiver program is that you can actually refer patients from a clinic. They don’t even need to go to the emergency room. From a cost perspective, that’s another consideration.

Can you add some color around the hospital-at-home partnerships that you mentioned? How did those come about, and how do your organizations collaborate clinically?

With Baylor Scott and White and UCSD, we have joint ventures with each of them for home health. That’s kind of the genesis of those relationships.

UCSD came about because of our joint venture with them, so we were very highly aligned with their population health enterprise. It was really in collaboration with them that we developed the hospital-at-home program, for which we use the moniker “acute care in the home,” just to kind of separate the two models. One is on a home health platform and one has all the requirements of the waiver under the public health emergency.

And then we have a referral relationship with Kaiser in Georgia, and so they approached us there as they’re looking to provide this kind of higher-level acuity care in the home.

To what extent do these programs collaborate with your hospice and palliative care teams?

I do think that there’s just a huge opportunity around palliative care generally.

We have so many more of our joint venture partners and strategic partners who are getting into greater amounts of risk themselves. Whether that’s Medicare fee-for-service or [Accountable Care Organization Realizing Equity, Access and Community Health (ACO REACH)], or whether it’s Medicare Advantage contracts or other payers. What we see is that they really want to reduce the cost of care for this highly complex patient population that oftentimes has mobility issues and a hard time leaving the home.

As we look at how we can help them and be the best partner for them, I do think that the role for having provider-based care in the home, whether we’re supplying our nurse practitioners and physicians in our medical group or a partnership with their own palliative care services. I think there’s a huge opportunity around that.

We have a palliative care path within our home health organization. And if you think about interdisciplinary home-based care, which is what palliative care is, it’s also home health. It’s interesting that a lot of palliative care has been very provider-driven. There’s a business model for that in the hospital, but there’s not really a business model for it elsewhere. And so I think there’s a big opportunity to really to optimize how we provide palliative care with our interdisciplinary teams, and then adding either providers within a health system or our own providers to really manage those patients.

That’s sort of the nut that everyone’s trying to crack, how to manage acute unscheduled care needs. I think that the Dispatch Healths of the world and other providers are trying to figure out how you do that, and we’re looking at how we kind of put together an ecosystem that we could bring into any of our partnerships to help manage this.

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