Q&A: Joan M. Marren, RN, MA, MEd - Executive Consultant in Home Care, PDV Health Consulting

We’ve heard a lot about hospital and home care issues during the COVID-19 pandemic. One of our own--Joan Marren, a Home Care expert and current PDV Health executive consultant--recently shared her insights into this area.

Q: What is your background and experience in Home Care?

Joan: I worked with the Visiting Nurse Service of New York for 37 years, of which, for 19 years, I was their Chief Operating Officer. Most of my career as a professional nurse has been in the home care and community-based services field. I retired from my position as COO with the Visiting Nurse Service in 2013. Since then, I have been doing consulting with organizations primarily in the home care organizations, licensed agencies, certified agencies, etcetera, and a lot of focus on operational and quality improvements. 

I've also done some work in managed long-term care, which is really a community-based long-term care program. Our work there was primarily focused on the professional development of the nurse case management staff and how to implement different programs that would expand their knowledge and skills and boost their sense of professionalism in the work that they do, and so on. 

Q: If you were in a Home Care company and you had a crisis of people infected with COVID, and you had a supply chain of COVID PPE that you need to purchase for each time a nurse visit occurred, it would probably lower down the number of visits they could do a day and increase the cost. How do you think you would approach this? Since you're familiar with the responsibilities of a nurse, and when a nurse goes out and makes a visit, you want to know what a home health aide does when they go out and make a visit--what do you think you can do to help them? 

Joan: Well, I think first and foremost, the staff of a Home Care organization has to feel that the company that they work for is concerned about and committed to their safety. So, the organization has to have available the appropriate protective Personal Protective Equipment. The staff has to have easy access to it. I think, for the most part, the organizations that serve the community have consistently accepted the care of patients who have COVID-19 just as they have consistently served through almost any epidemic or an emergency that you can think of. The community-based agencies have very consistently stepped up and done whatever was necessary to continue to provide service to the community members in need now. They obviously need instructions and training in not just how to use the personal protective equipment, but they also need instruction in the actual virus, how it's spread, how they can protect themselves, how they can protect the family members of patients in the home, how they can maintain their homes properly so that they diminish the potential for spread.

Q: When this pandemic hit, it obviously caused a shortfall in the revenue cycle and the core structure, and we’re seeing another surge. Do you think Home Care reorganization needs to be looked at since productivity may slow down, and how do you think it should be done? 

Joan: My feeling is since the Home Care industry has been under such pressure financially over the last several years, to a large extent, most organizations have already undergone a lot of reorganization including eliminating staffing considered non-essential. Now, maybe there's still some opportunity for it, but healthcare leadership thinks of an organization like Visiting Nurse Service of New York. I think they've progressively, over the last several years, eliminated more and more positions that they perceive as non-essential, except for the delivery of care. I think that they've looked for ways to increase their purchasing power.

Q: What are your thoughts about value-based health care where maybe their revenue cycle could increase if they looked at the quality indicators that may give them more money from the payer?

Joan: That's certainly the case. In fact, even while I was still with Visiting Nurse Service of New York, we had a number of value-based contracts that provided an incentive for the organization to get higher reimbursement if the quality met certain standards. So, I certainly think organizations would be looking to expand on whatever they may have already put in place vis-a-vis value-based purchasing. I'm on the board of an organization that serves North Central Pennsylvania and the southern tier of New York State.

They have a home care organization, and they have a hospice as well, but they're looking at and have been implementing a broader percentage of their business as value-based contracts. While I think there's maybe an opportunity to expand on that, I think there were a couple of issues there. For the most part, I think most organizations, if they have any strategic sense, have already moved in that direction. And number two, you have to have a payor that's willing to go there with you.

For example, the organization that I'm on the board of, we were discussing this fairly recently, whereas the government payors were willing to provide advances to this organization and most others, as they were encountering the kind of extraordinary expenses that we see organizations having to undertake during COVID, none of the commercial payors were willing to do that. 

I think that some of that has to do with the willingness of commercial payors to get on board with some of these things as well. Perhaps it's a lesson for building really positive relationships with them during good times so that in bad times, you can leverage those relationships to improve upon what you may need.

Q: So, what I hear you saying is that both the revenue cycle in many ways besides just organic growth and business development, but the contracting is a part of the revenue cycle, and the cost structure really needs to be looked at and maybe could be improved somehow in some of the ways that you just mentioned? 

Joan: Right. I do think that organizations must continue to look at whether they are using the right level of the prepared person to deliver the right kind of care at the right time? I do think that one of the big changes that may be a structural change that is with us into the future that could end up also changing the cost structure is the expansion of telehealth. And there's applicability there even within home care agencies.

I think home care agencies, like so many healthcare providers, have expanded their use of telehealth. Whereas it might have been a difficult way in the past to deliver services more accessible and available to the community, now it's become the way they deliver those services.

On home care agencies, I spoke recently with the head of a prominent mental health service about how they have been continuing to provide services to their community through the use of telemedicine rather than their typical in-person services in the home. They still believe that they need in-person services for things like their crisis intervention team or the more types of emergency-type services.

But I think organizations are really looking at what will make sense, both now and in the future, to continue to deliver through a telemedicine or telehealth kind of approach, and that will definitely affect their cost structure.

Q: So right now, if someone was struggling financially with their home care agency, what are the top three things you would recommend they do, besides hiring you?

Joan: I think what you said before, how can we restructure our home visiting mission and purpose into a combination of deliverance service in-person and through technology? So, what makes the most sense? What will be the most efficient? For example, even at VNS, we found it really difficult to hire sufficient numbers of speech pathologists. So, we started pretty early on delivering speech pathology services via tele-video, telehealth. When I talk about telehealth, I think it's what we're doing now. It's seeing a person on the screen being able to assess them, question them, and so on and so forth.

I'd say re-look at care delivery services to determine what makes the most sense for which method of service delivery.

I'd say what you said earlier. Are we deploying the staff with the right preparation most effectively for the kinds of care delivery that need them the most? And I'd say the whole idea of the efficiency of their maybe billing and collections, that becomes increased. Basically, the whole idea of cash flow.

Q: Yeah, that's something that I was going to mention to you in the revenue cycle, which we didn't get into, but definitely, I agree.

Joan: Yeah, that becomes so much more important. Especially, when you really depend on the cash flow to meet payroll, to meet the immediate expenses of trying to respond to the epidemic. 

Also, a lot of organizations need to rethink their fundraising as well. Fundraising has become extremely important for every single organization. I can't believe, myself, the number of requests for donations I'm getting from an array of organizations out there.

But I think it's challenging in many ways. In a good way, the creativity of fundraising is amazing. You see the number of virtual events that are taking place and how those can be organized in such a way that they really still are as effective, if not at times more effective, than some of the kinds of events that they've had in the past. 

In some ways, you might attract a group of people who ordinarily might not have traveled to an event but will, in fact, consider participating in an event virtually. So, I think that's a real challenge for organizations as well going forward because I think their fundraising practices will also be changed by this over time.

Thank you, Joan, for your insights!

Do you have a question on home care and community-based services? Reach out to us at PDV Health Consulting.