- Medication Management  Voice Activated - Wound Care  Reminders for: - Therapy Sessions - Medications - Physician Visits - Appointments - Care Team “Rounds” - Health Tips Health Records:  Enhanced Access to Care  Integrated EHR  Improved Outcomes  Seamless Data Sharing  Reduced Costs  Population Analytics  THA Group © 2013 “REVELATIONS”... TOMORROW - DAWNING OF A NEW AGE

1. THA Group © 2013
EVOLUTIONARY LEADERSHIP STRATEGIES
THE “NATURAL SELECTION” TOWARDS
VALUE-DRIVEN INNOVATIVE IN-HOME CARE
DELIVERY MODELS
GEORGIA PARTNERSHIP FOR TELEHEALTH
2013 Conference
THA Group
Joseph Ebberwein

2. THA Group © 2013
A STROLL DOWN MEMORY LANE…
THE EVOLUTION OF THE
IN-HOME HEALTH
CARE INDUSTRY

3. THA Group © 2013
THE EVOLUTION OF THE
IN-HOME HEALTH CARE INDUSTRY
Evolution:
“A gradual process in which something changes into a
different and usually more complex or better form.” - The
American Heritage Dictionary
Home Care’s Creation
1965 – In the Beginning…
 Medicare creates benefits for non-profit home healthcare
to substitute for last days of hospitalization

4. THA Group © 2013
THE EVOLUTION OF THE
IN-HOME HEALTH CARE INDUSTRY
1980 - Congress saw that this was good…
 Opened the benefit to full participation to proprietary
home healthcare
1988 - 1996
 Home health beneficiaries increased 225%
 Half of those patients received 200 or more annual visits
(Hospitals Prospective Payment System precipitated
need for Post Acute Service)
…the pay-per visit world flourished

5. THA Group © 2013
THE EVOLUTION OF THE
IN-HOME HEALTH CARE INDUSTRY
1997
 Congress passes Balanced Budget Act of 1997
 Medicare announces Interim Payment System (IPS) to
curb growth.
1998 - 1999
 CMS’ costs saving effort resulted in 1/3 of
Home Care Industry closing its doors.
EVOLUTIONARY LESSON:
Survival of the fittest and natural selection played out as over
1/3 of our industry became extinct.

6. THA Group © 2013
THE EVOLUTION OF THE
IN-HOME HEALTH CARE INDUSTRY
2000 - Demand for home health care continued to grow…
 Prospective Payment System (PPS) was created setting the
stage for the evolutionary concepts of adaptation and
improvisation to enhance chances of survival.

7. THA Group © 2013
THE EVOLUTION OF TECHNOLOGY IN
IN-HOME HEALTH
2001 - 2005
Advent of Telemonitoring Technology as a Tool
 Remote Telemonitoring technology
enabled knowing when the patient needed to be seen:
Doing the Right Thing, At the Right Time,
In the Right Place.
 Telemonitoring took some of the “guesswork”
out of home care
EVOLUTIONARY LESSON:
Those who improvised and adapted to technology
early survived - some just barely.

8. THA Group © 2013
THE EVOLUTION OF TECHNOLOGY IN
IN-HOME HEALTH CARE
2001 - 2008 In-Home Technology Tools
 Telehealth
 The total assimilation of the telemonitoring tool in the
strategic direction of a home care organization
 Point of Care Information Systems
 Electronic health records allowing flow of clinical information
to be seamless, in real time, and available to all clinicians
 Telephony/Teletriage
 Important methodology for data collection, care monitoring,
and patient education
EVOLUTIONARY LESSON:
Selection and integration of multiple homecare technologies
led to natural selection of the survivors.

9. THA Group © 2013
“THE TIMES THEY ARE A-CHANGIN”…
RELEVANCE TO IN-HOME HEALTH CARE
2009 - American Recovery and Reinvestment Act
(ARRA) - Stimulus Bill
Opportunities  Hospital Penalties for Readmissions
 4 out of 5 Diagnoses are Chronic Conditions
2010 - Patient Protection and Affordable Care Act
(PPACA) - Health Care Reform
Opportunities
 Pay-for-Performance  Chronic Disease Management
 Population Health Management  Employer Wellness
 Independence at Home Model  State-Based Initiatives and
 Hospital Re-Admission Reduction Advance Primary Care
 Community-Based Care Transitions  Cost Effective Management
 Meaningful Use and EHR Certification of the Medicaid/Dual Eligibles
 Bundled Payments
 Patient-Centered Medical Home

10. THA Group © 2013
“THE TIMES THEY ARE A-CHANGIN”…
VALUE-BASED PURCHASING (VBP)
AKA ACCOUNTABILITY
2011 - Hospital VBP Plan Implementation
Opportunities  Care Transitions Program/Community-Based Organizations (CBOs)
Program - 4/12/11
 Data Collection for Hospitals Commences - 7/1/11
2012 - CMMI - Center for Medicare and Medicaid Innovation
Opportunities  Pioneer Accountable Care Organizations (ACOs)
Implemented - 1/1/12
CMS
 Medicare Shared-Savings ACOs Awarded - 4/10/12
CMMI
 Innovation Challenge Grants

11. THA Group © 2013
“THE TIMES THEY ARE A-CHANGIN”…
VALUE-BASED PURCHASING (VBP)
AKA ACCOUNTABILITY
2012 - CMS
 Hospital VPB Penalties Commence for Readmission - 10/1/12
Opportunities
 Deduction of 1% of DRG per Discharge, Creating an Incentive
Bonus Pool
HHS
 Deadline for Home Health VBP Plan (TBA)
2013 & HHS
Beyond -  Hospital VBP Penalties Deduction rises to 3% on 10/1/14
Opportunities  Future VBP Plans for Physicians, Hospice, and SNF’s
EVOLUTIONARY LESSON:
Those who collaborate in alliances and work in teams increase
chances of survival of the fittest.

12. THA Group © 2013
A “SEISMIC HABITAT SHIFT”…

13. THA Group © 2013
“THE CHANGE…A “SEISMIC HABITAT SHIFT”
A Shift from:
 Volume-Based Reimbursement Value-Based Reimbursement
 Short-Term Acute Long Term Chronic Care (all stages of life)
 Institution-Based Community-Based Care
 Provider Dictated Provider Counseled for Patient Ownership
of Self-Management
 Single Provider Responsibility Physician Directed “Practice Teams”
for Care
A Shift to:  Patient by Patient Individual Focus Population Focus
Quality
ACCOUNTABILITY for: Efficiency
“Slow-Spending”
BOTTOM LINE:
Survival Requires A Redesigned Healthcare Practice Model

14. THA Group © 2013
A MAJOR FORCE OF NATURE…
THE VALUE TSUNAMI
Creating a Culture that Embraces Change…
Relentless Pursuit Quality
of Value* =
Cost
Quality = Clinical Outcomes X (Patient Satisfaction +
Brand Image)
Cost = Clinical Efficiency X Accuracy X Capacity
*As Perceived by the Customer

15. THA Group © 2013
A CULTURE THAT EMBRACES
EVOLUTION NATURALLY EVOLVES
RELENTLESS PURSUIT OF VALUE
Past Current/Future
Leadership Hierarchical Servant Leadership
Continuum of Care Provider-Centered: Patients Patient-Centered: Service
Arranged Around Service Lines Lines Arranged Around Patients
Clinical Practice Philosophy Independent Practice Silos Team Practice
Patient Care Philosophy Nurturing Caregivers in Patient-Centered Care that
Patient-Dependent Role Empowers Patient for
Self -Management
Patient Care Delivery Face-to-Face In-Home Visits Remote Technology-Targeted
(Many Unnecessary Visits) Face-to-Face Visits
(Only Necessary Visits)
Compensation Volume Incented Outcomes Incented

16. THA Group © 2013
A CULTURE THAT EMBRACES
TECHNOLOGY NATURALLY
SPURS INNOVATION
Riding the Evolutionary Tsunami
Wave of Innovation
 Overcoming Fear of Technology
- “It Will Replace Me”
 Embracing Technology As a Tool
- “It Makes Me Look Good”
 Increased Efficiency
 Enhanced Quality
 Sophisticated Image

17. THA Group © 2013
ONCE YOUR CULTURE “ADAPTS” TO
TECHNOLOGY - YOU’RE READY
TO RIDE THE WAVE…
Providers Technologies Models
Hospital Systems Electronic Health Records
Care Transitions
Physician Groups Consumer Health Records
Medical Homes
Post Acute Care Remote Personal Telemonitors
Providers ACOs
• Home Health Medication Adherence Devices
• Hospice Disease Management
• SNF Medication Reconciliation Programs
• Rehab Centers Devices
Medicaid Health Homes
Assistance Monitors
Bind Providers Together Value Based Purchasing Models
Develop Shared Savings Collaborate on Joint Incentives
EVOLUTIONARY LESSON:
Commonality of Key Technologies Integrated Across Care Settings is
Necessary to Produce Value and Avoid Extinction

18. THA Group © 2013
THA GROUP’S EVOLUTION

19. THA Group © 2013
IN-HOME HEALTH CARE’S EVOLUTION
DAY BEFORE YESTERDAY
Remote Telemonitoring Ushered in the
Age of Telehealth
 “Telehealth”
- The total assimilation of the Telemonitoring Tool into the
strategic direction of home care organization: it’s clinical
model and it’s business model
 Practice of Telehealth requires:
- Integration of Point-of-Care Technology & Remote
Telemonitoring System
- Virtual / “Telephonic” Visits and seamless flow of real
time data result in enhanced clinical plans of care
and protocols

20. THA Group © 2013
IN-HOME HEALTH CARE’S EVOLUTION
DAY BEFORE YESTERDAY
Practice of Telehealth Produces Value:
High Quality
Clinical Outcomes

21. THA Group © 2013
IN-HOME HEALTH CARE’S EVOLUTION
DAY BEFORE YESTERDAY
Practice of Telehealth Produces Value:
Clinical
Efficiencies
Total Visits
Skilled Nurse Visits

22. THA Group © 2013
IN-HOME HEALTH CARE’S EVOLUTION
DAY BEFORE YESTERDAY
Practice of Telehealth Produces Value:
• Enhanced Capacity
And Productivity
• Grew Volume 50%
Without Added CCM’s

23. THA Group © 2013
IN-HOME HEALTH CARE’S EVOLUTION
YESTERDAY
Adaptation & Emerging Business Models:
 78M Baby Boomers Coming
will demand further adaptation
 75¢ - 85¢ of every Health $
Spent on Chronic Disease =
Unsustainable system

24. THA Group © 2013
IN-HOME HEALTH CARE’S EVOLUTION
YESTERDAY
Adaptation & Emerging Business Models:
 Clinical Provider Partnerships across settings is critical to the
sustainability of future health care models - Care Transitions &
Care Management
 Empowered patients/families with “tools” for self management
–AKA: Adaption to Inevitable Chronic Disease
EVOLUTIONARY
HYPOTHESIS:
Collaboration should result in
Reprogramming of DNA…
Old Practices and Habits

25. THA Group © 2013
IN-HOME HEALTH CARE’S EVOLUTION
YESTERDAY
Mutation:
Integrated Disease Management
Pilot Project (2007-2008)
 Demonstrate that chronic illness can be
managed successfully by combining:
- Partnered Physicians
- Empowered Patients / Families
- Homecare Provider Practicing Telehealth

26. THA Group © 2013
IN-HOME HEALTH CARE’S EVOLUTION
YESTERDAY
Mutation:
Two phases: Intervention and Follow-Up
 Patients agreed to:
- Monitor / transmit vital signs daily
- Call the homecare provider before visiting Emergency
Department (ED), except in true emergencies
 Physicians agreed to:
- Not direct patients to EDs for non-life threatening
exacerbations
 Telehealth Provider agreed to:
- Educate, monitor, coach, call daily, and respond within
15 mins with care coordination

27. THA Group © 2013
IN-HOME HEALTH CARE’S EVOLUTION
YESTERDAY
Mutation:
Results:
Intervention Phase: 6 months
Re-hospitalization Rates:
7% - Pilot
Compared to
34% - Medicare
Claims Data (90 days)

28. THA Group © 2013
IN-HOME HEALTH CARE’S EVOLUTION
YESTERDAY
Mutation:
Results:
Follow-up Phase: 6 months
Re-hospitalization Rates:
23% - Pilot
Compared to
50% - Medicare
Claims Data

29. THA Group © 2013
IN-HOME HEALTH CARE’S EVOLUTION
YESTERDAY
Mutation:
EVOLUTIONARY LESSON:
Highest probability of sustainability must be founded on 3 pillars of rock
solid support via collaboration between:
- Empowered Patients / Families
- Technology Driven In-Home Care Providers
- Physician Integration

30. THA Group © 2013
IN-HOME HEALTH CARE’S EVOLUTION
TODAY
Natural Selection:
 Results from regional
hospital partnership
 Hospital awarded
American Heart
Association award
for reductions
 30 Day
Rehospitalization
Rate (27 months) = 8.4%
Evolutionary
Lesson:
Care Transitions
is Critical

31. THA Group © 2013
IN-HOME HEALTH CARE’S EVOLUTION
TODAY
 Able to directly correlate utilization
to interventions
 $104,000 (32%) decrease in hospital charges
 Need for on-going monitoring
is indicated
EVOLUTIONARY LESSON:
Need to stratify patients with a formal system tool

32. THA Group © 2013
IN-HOME HEALTH CARE’S EVOLUTION
TODAY
 “Worst Offenders”
 Self-funded
 Multiple Chronic Conditions
 Major Psychosocial Challenges
 Significantly reduced
hospital charges by 85%
EVOLUTIONARY LESSON:
3 months is not adequate to activate for self-management

33. THA Group © 2013
IN-HOME HEALTH CARE’S EVOLUTION
TODAY
Natural Selection:
EVOLUTIONARY LESSON:
Collaborative/Integrated Health Care occurs when Technology Enabled
In-Home Health Care Models evolve into Care Management Models to
improve the Transitions of Care across settings

34. THA Group © 2013
DAWNING OF A NEW AGE…

35. THA Group © 2013
BACK TO THA’s DNA
The Value Equation: Quality
Cost
Maximize value by doing:
The RIGHT Thing Patient-Centered Chronic Care Management
Physician-led, integrated Care Team
The RIGHT Way empowered by health information technology
The RIGHT Place AT HOME
The RIGHT Partners Patient / Family, Patient's MD, & Care Team
The RIGHT Team RN Patient Advocate, Health Coach, Care
Delivery Team
The RIGHT Practices Evidence-based best practices coupled with
activation for self-management
The RIGHT Processes Patient Stratification Tool, Care Transitions

36. THA Group © 2013
IN-HOME HEALTH CARE’S EVOLUTION
TOMORROW - DAWNING OF A NEW AGE
The Reinvention of In-Home Healthcare Tomorrow
…The RIGHT Model
Innovation in Management of
High Cost, At Risk Patients
Leading to:
• Lower Overall Cost of Care
• Improved Clinical Outcomes
• Enhanced Quality of Life for Patients and Families
Aligning Interests of:
• The Patient
• The Care Providers
• The Payors

37. THA Group © 2013

38. THA Group © 2013
“REVELATIONS”…
TOMORROW - DAWNING OF A NEW AGE
THE RIGHT MODEL -
 Nurse Practitioners
New Patient-Centered
 RN Patient Advocates
Care Team
 Behavioral Specialists
 Health Coaches
 Clinical Specialists:
 Palliative Care
 WOCN
 Respiratory
 Rehabilitation
 Nutritionist/Dietician
 Medical Social Worker
 Pharmacists

39. THA Group © 2013
“REVELATIONS”…
TOMORROW - DAWNING OF A NEW AGE
The RIGHT Technology
Remote Telemonitoring Video “Virtual Visits”
 Algorithmic Software  Allows for “Virtual Visits” For:
- Specific for Chronic
Disease Management  Nurse Practitioner Consults
With Physicians
 Software Delivers Chronic - “Virtual ED” Visits -To Prevent
Disease Patient Education Rehospitalization
& Reinforcement (videos)  Pharmacy “Virtual” Consults
 Behavioral Specialists “Interventions”
 Data Analytics by Specific
Chronic Disease

40. THA Group © 2013
“REVELATIONS”…
TOMORROW - DAWNING OF A NEW AGE
The RIGHT Technology
Remote Medication Remote PERS (Personal
Adherence Emergency Response
System)
 Programmable device to  Software that discerns
deliver medicine at body position and alerts/
specific dosage and time summons help
 Tracks and alerts “missed”  Panic button with audio
medications  Increases independence
 Increases independence

41. THA Group © 2013
“REVELATIONS”…
TOMORROW - DAWNING OF A NEW AGE
The RIGHT Technology
Integrated EHR Systems Personal Health Record
Across Providers
 HIEs  Single source for patient’s
 Dashboard for real time salient health information
decision support information  Housed on secure site
 Provides a “bridge” to
physicians and other
providers

42. THA Group © 2013
“REVELATIONS”…
TOMORROW - DAWNING OF A NEW AGE
The RIGHT Technology
Customizable Point of Care Customer Portals
EHR/ Clinical Intelligence
 Embedded evidenced-based  Provides MDs, patients /
best practices families, & payors real time
“Makes it nearly access to data
impossible not to do the  Enhances communication
RIGHT THING” tailored to customer preferences
 Transforms in-home (email, text, etc.)
healthcare delivery
model

43. THA Group © 2013
RESEQUENCING OUR DNA
The RIGHT Partners
 IDENTIFY THE RIGHT PARTNERS
 Hospitals (Rehospitalizations)
 Physician Groups (Medical Home)
 Payors
 PAYORS
 Medicare Advantage Plans
 State Medicaid Plans
 Medical Care Management Organizations (CMOs)
 Commercial Insurers
 Self-Insured Employee Groups
 Third Party Payors

44. THA Group © 2013
THE RIGHT TIME…
Environmental Changes
Legislation
 ACA - Supreme Court Decision
CMS Senior Leadership
 Demonstration Projects
 New Care Delivery Models
Sequestration
 Continued reduction in payments to providers
EVOLUTIONARY LESSON:
If a species is unable to adapt to environmental changes,
it becomes extinct.

45. THA Group © 2013
The RIGHT Time Is…
NOW!