Gentiva Health Services has committed to expanding its recently established Advanced Illness Management (AIM) palliative care model in 2024, including its unique approach to reimbursement.
The company has its roots in the former Kindred at Home. Once among the nation’s largest home health and hospice providers, Humana Inc. (NYSE: HUM) acquired the company in 2021. The following year, the insurance giant divested Kindred’s hospice and personal care segments, selling a 60% stake to the private equity firm Clayton, Dubilier & Rice (CDR) for $2.8 billion. CDR later rebranded the company as Gentiva.
In 2023, Gentiva began looking for ways to care for a broader swatch of the seriously ill population, including those who were not expected to recover but were also not yet eligible for hospice. This led to the development of the company’s AIM program, which is housed within its palliative care arm Empatia.
However, efforts to fill that gap in care often struggle due to limited reimbursement, primarily managed through Medicare fee-for-service, Gentiva COO Nick Stengle said in a panel discussion at the Home Care 100 Conference in Scottsdale, Arizona.
“There’s truly a need in this palliative space, sort of this gap between restorative care and end-of-life care where the patient and their family typically are not quite ready to begin discussing end of life,” Stengle said. “Palliative can sometimes help bridge that gap that actually exists. So we as a company sat back and contemplated what is a path to achieve this, to fill this void as a company in a sustainable fashion.”
Gentiva seeks to embody this vision through the AIM program, with plans to circumvent the need to work directly with Medicare or other payers.
The AIM program uses a risk assessment tool to design a clinical pathway that addresses patient needs at the lowest cost. The tool factors in clinical concerns as well as the home environment, caregiver resources and social determinants of health.
The care model is driven primarily by nurse practitioners who visit as often as once a week, according to Stengle. Patients enrolled in the program also receive services from nurses, case managers and social workers. Clinicians are reachable 24/7, including through telehealth support.
With this clinical system in place, there remained the challenge of securing sufficient reimbursement to sustain it. To do this, Gentiva looked beyond traditional reimbursement structure and instead leaned into partnerships with entities like physician groups that have Medicare Advantage contracts.
“These are large physician groups that haven’t built their own risk-bearing entities, where they are at risk for a subset of their Medicare population where they get a capitated rate. We identify in partnership with them through a risk stratification tool which patients are eligible for are a model, and we will help provide care and coordination with that physician group in the patient’s home,” Stengle said. “We truly identify that 1% to 3% of patients that are generally trending towards needing more and more than life care, potentially eventually hospice, but in that interim period, creating a lot of medical expenses.”
Among Gentiva’s objectives in the AIM program is to help ensure patients can continue to receive care in their homes without resorting to hospitalizations or emergency department visits. This aligns with most patients’ wishes and supports greater quality of life, according to Stengle.
Their physician group partner pays the palliative care provider a per-member, per-month fee through a contractual agreement that includes risk sharing. Consequently, Gentiva would receive a portion of the cost savings generated by the reductions in higher acuity care and improvement in patient outcomes.
“In effect, we created a reimbursement structure of our own, no fee-for-service. We’re not charging Medicare for a visit. We’re doing as many visits as we feel are needed for that patient,” Stengle said. “We’re providing the overlay of RNs, social workers, and none of that’s reimbursed directly from Medicare. We’re able to provide that patient better care, better quality of life, and as a result, a lower total cost of medical expenses of which we get a share.”