Inside look at BIG changes for your top referral sources in 2019

When was the last time you talked with a Case Manager about their rehospitalization rate?

Or discussed your staff training aimed at preventing clients from returning to the hospital? 

Health care continues to change. The next 12 months are going to turn the world upside down for some of your Top Referral Sources. As you are bracing for the changes coming with Medicare Advantage, hospitals, skilled nursing facilities and home health are seeing significant changes to regulations, reimbursement and health care partnerships. Regulations are continuing to tighten. Payment continues to be driven away from fee-for-service towards value-based care. And partnerships are being won and lost based on 5-Star ratings. Position your message as a cost savings and value add to these referral sources over the next year to grow your business and gain referrals.

So, the world of your Top Referral Sources is changing. How do you position your home care business for success?  

Two ways:

1) Data drives referrals

2) Medicare Advantage is aligning Home Care Companies with Hospitals, Skilled Nursing Facilities, Home Health, etc. in expectations of value-based care, agency ratings and regulations

How much time do you spend preparing to market by reviewing Top Referral Sources performance? Or what changes are happening for them? Just like the feeling you get when you attend a family gathering and get stuck in a never ending conversation with your Uncle about how he’s the world’s foremost expert in mowing his lawn, you attract fewer conversations by talking all about yourself.  

MAKE IT ABOUT THEM.  This article is about what’s going in the minds of the people that have power of giving you referrals.  Understand the pain points. Find the Data. Talk to Referral Provider about their Data. Give them a solution to make it better.


SNF Pain Point -> Increase in Rehospitalization % is impacting facility relationships with referral hospitals, insurance preferred networks and 5-Star rating

Find the Data -> Nursing Home Compare shows Rehospitalization % has increased from 17.6% to 23.8% pushing the facility higher than the state and national average

Talk to Referral Provider -> Use this data as your discussion points to discover opportunities.  Talk to Administrators, DONs, Case Managers, Social Workers. Ask what circumstances have happened that may have led to patient’s going back to the hospital.

Provide a Solution -> Knowing RTH (Return to Hospital) is an important metric, your home care company tracks all patients who have been discharged from a facility and you will personally call the Administrator if a patient is starting to fail at home before going to the hospital. 

This is value that an Administrator cares about.

As someone who has marketed services for a home care company, as well as hearing countless sales pitches from marketers as a Nursing Home Administrator, it would be REFRESHING to talk about my facility data, pain points and someone helping me! Use data as your friend and set yourself apart from the muffin makers. Also, with Medicare Advantage moving into home care, it will be only a matter of time until your company will be measured by data too. Get ahead of the game.

Below are changes happening to hospitals, skilled nursing facilities and home heath. Take time to know the changes and then MAKE IT ABOUT THEM.


Top 2 Changes for Hospitals:

  • Value-Based Care.  Payers want to see outcomes for patients, no longer fee-for-service.  Hospitals are having to manage multiple different payment models that each have unique requirements and financial impacts.
  • 5-Star Rating. Consumers, payers and strategic partners are using CMS’ 5-Star rating system to make decisions having significant impacts for hospitals. Right or wrong, it’s happening.  

Value-Based Care

Payers want value not fee-for-service.  Medicare has historically paid for each service provided in the hospital (lab draw, doctor visit, surgery). With the incentive to provide more and more services without being linked to the patient’s improved health have left Medicare on an unsustainable path.  In the 2019 Medicare Report, Medicare Part A’s hospital fund only has enough reserves to pay claims until 2026. That’s it! CMS is scrambling to save money while still providing quality care. 

Various payment models are happening right now aimed at cost savings and quality care. Increases in quality outcomes include things like infections, surgical complications, patient satisfaction and hospital readmissions.  While decreases in cost of care include comparing if patients returned to the hospital for a costly ER visit, medicare spending per member and payments for types of hospital stays (heart failure, pneumonia, hip replacement, etc.).

Payment models include:

  • Medicare Shared Savings Program (MSSP): This voluntary program offers the different groups of providers to come together and form ACOs.  Once formed, an ACO can pick a “track” providing different levels of risk and financial incentive for providers based on outcomes and cost of care. MSSP participation has grown steadily and is the nation’s largest initiative aimed at value with nearly one-third of all Medicare A and B members included.  
  • Accountable Care Organizations (ACOs): Introduced under the Affordable Care Act, providers and payers have come together to form over 1,000 ACOs covering 32 million people. An ACO is formed when networks of providers (hospitals, physicians, specialists) get together and voluntarily contract with a payer.  Providers are initially paid by fee-for-service but at the end of designated periods, quality metrics and outcomes are reviewed. Payments are then adjusted, meaning the provider can gain or loss portions of the fee-for-service payments, putting more of the risk to providers.
  • Hospital Value-Based Purchasing Program (VBP): Hospitals are provided incentive payments based on the quality outcomes achieved for patients. Incentives are provided for rating patient care experiences, better outcomes at a lower cost of care and care transparency for the patient.

Make it about THEM

For the first time hospitals are engaging with downstream providers to help them prevent a readmission and receive quality care post discharge. While in most cases hospitals are a ‘closed campus’ for marketers, there is a growing opportunity to engage Case Management Directors, Discharge Planners and even C-Suite executives in other ways.  Hospitals are apart of health care consortiums, coalitions, provider groups, among others, that focus on things like avoidable rehospitalizations. 

  • Communicate with hospital leadership. Trying to market in hospitals can certainly not feel like time well spent.  With hospitals now having skin in the game for what happens post discharge, hospital leaders are listening more than ever. Home care companies that develop relationships with managers, and even executives, can have a seat at the table as partnerships are formed. Show that you understand the changing landscape for hospitals. Communicate your programs aimed at helping hospitals keep clients safe at home (technology, quality care visits, caregiver training, etc.)
  • Know who’s involved in partnerships. ACOs are all the rage right now. Do you know who your top hospital partners with?  If the hospital is part of a larger system, partnerships can be happening at the local and corporate level.  Physician groups, skilled rehab centers, home health, etc. Ask who is in charge of organizing the ACOs, typically a care coordinator or partnership coordinator. Find out which companies have relationships with the hospital. Align your company with the partners to strengthen the partnership.

5-Star Rating

CMS initially launched Hospital Compare back in 2005, publicly sharing a small set of standardized quality measures.  What began with sharing 10 quality measures for 400+ hospitals has evolved into over 60 quality measures for 4,400+ hospitals nationally.  The 5-Star rating system was added in 2016. Linking the 5-Star rating to things like reimbursement and strategic partnership opportunities have provided opportunities for collaboration with providers. Additionally, consumers are making care decisions based on 5-Star rating and quality outcomes and hospitals are taking notice.

Find the RTH (Return to Hospital) Rating: Go to Click on ‘Unplanned Hospital Visits’, scroll down to view unplanned readmission. Compare the readmission ratings by procedure and medical condition.

Make it about THEM

Hospitals are starting to pay attention to important metrics like RTH, value of care and cost of care. Build your message around the value you can bring to the hospital in helping with these metrics. Use this data when talking with Case Management, as well as other key contacts, to set yourself apart. Do you know the name and contact info of the Case Management Director at each of the hospitals in your area? You should. That person drives discharge decisions every day that involve downstream providers.

  • Hospitals utilize caregivers in the hospital.  While the use of ‘virtual sitter’ computer technology is growing, hospitals still use caregivers when a patient is in need of one on one attention. Utilizing a caregiver can have a positive impact on the overall cost/value of care for the hospital, impacting 5-Star ratings.  Does Case Management know that about you?
  • Participate in care consortium groups.  Hospitals are developing groups aimed at coordinating care and improving outcomes with community partners.  Different than ACOs, these groups typically have ongoing meetings discussing topics with nearby providers on improving quality care. For example, a meeting could include hospital case managers, home health, nearby skilled nursing facilities and assisted living, discussing an increase in sepsis cases leading to hospitalizations. Participating in the group and being able to discuss how your company trains staff to contact the office if a client is having a noticeable change in condition or that your company is introducing technology where your clients check in each morning via a bedside device will bring value to the group.
  • Connect through Home Health.  Hospitals consistently discharge patients with home health services. Case Managers want you to make their lives as easy as possible for discharge.  If your home care company is partnered with the top home health company receiving discharges, that Case Manager might mention your company as an option during the discharge process. Do you have relationships with top home health partners?  If asked, is there a reason they wouldn’t recommend your company? Does management level at the hospital know your success rate avoiding rehospitalizations with your home health partners?

Skilled Nursing Facilities

Top 3 Changes for SNFs:

  • PDPM payment model is coming. Patient Driven Payment Model (PDPM) is replacing the current RUG based reimbursement on October 1, 2019, basing payment on diagnosis, instead of minutes of therapy provided.
  • CMS 5-Star Rating changes, again. CMS 5-Star Rating system is having significant impacts on admissions, partnerships and reimbursement at facilities across the country. 
  • Regulations changed, and not for the better. CMS initiated the Requirements of Participation (ROPs) which updated and expanded regulations for nursing homes for the first comprehensive revision since 1991. More regs, more oversight, more headaches for facilities. 


Medicare is changing from RUGS to PDPM, the biggest change since 1998. PDPM is setup to move patients down the care path faster (hospital to snf to home health/care) by reducing payment the longer a patient stays in the facility. The most significant change is payment is no longer dependent on how many minutes of therapy is provided to the patient. This means patients are: spending less and less time in hospitals and SNFs, receiving less therapy and returning home quicker and sicker and with less eyes to watch them. But now, facilities are being rewarded or penalized by those discharged patients going back to the hospital post discharge.

Make It About THEM

Know RTH % numbers and talk avoiding rehospitalizations. Patients being sent home ‘sicker and quicker’ is an opportunity to be an important safety net.  Facilities are watching the RTH numbers and patients want to remain at home. Your company knows the numbers for your top referral sources and is the solution to keeping patients out of the hospital. Stand out from the home care crowd, few are talking to facilities about the numbers and helping to solve their problems by making it about them .

Find the RTH % numbers: Go to Nursing Home Compare (, search for your top referral sources, click on ‘Quality of Resident Care’, scroll down to Short-stay resident care and check out the % of Rehospitalization. (Know that this data 9 months old)  The National Average is around 22%.

Discuss the facility RTH %.  Talk to Case Managers, Social Workers, Administrators, Directors of Nursing.  Ask how is it trending. Share data on success you have had keeping clients out of the hospital (even if you software doesn’t have reports like this, meet with your team and reviews clients over the last 90 days and see if anyone has gone to the hospital.  Now start recording this info for you company moving forward.) This is a long game conversation with referral sources. 

  • Do you remember why the last discharged patient ended up going to the hospital?
  • Do your discharged patients ever miss follow up PCP appointments?
  • Do the patients ever have difficulty getting to the pharmacy to refill prescriptions from their SNF stay? Any confusion around taking the right medications at the right time?
  • Do you think any rehospitalizations might have been avoided in the last 30 days? What would have helped?

CMS 5-Star Rating

CMS’ Nursing Home Compare 5 star rating system has evolved since inception in 2008.  It has grown into ‘the rating’ for facility choice and quality for SNFs. Partnerships with hospitals, ACOs, physician groups, etc. are being formed and realigned largely based on a facility’s star rating.  It matters. The rating system consists of an Overall Star Rating, Health Inspection (Survey) Rating, Staffing Rating and Quality Measures Rating (RTH and other metrics). In April 2019, CMS again changed how they determine the ratings, resulting in over 52% of the 15,000 facilities seeing a change in their Overall Star Rating.

Find 5-Star Rating:  Go to, click on your referral facility.  Look for the Overall Star Rating. 3-Star overall is typically the lowest threshold that outside providers are willing to look at and engage in partnerships (Medicare bundle programs, physician group preferred provider lists, Hospital discharge preferred providers, etc.).  Note: Having a high Staffing Star Rating and Quality Measures Rating can automatically add an Overall Star, so Staffing and Quality Measures had a significant impact.

Make it about THEM

Know your referral source’s star rating.  Talk about it with Case Managers, Social Workers, Rehab, Administrators, Directors of Nursing. Congratulate the facility for the hard work in achieving the star rating. Look for the opportunity in the data.  Do you see high quality measures but lower staffing rating? An opportunity to assist with staffing. How about a higher RTH rate? Opportunity to be preferred company for keeping discharged patients out of the hospital.   Look at the last survey under Health Inspections, are there any areas that were cited were supplemental staff could help? Nurses aides, staffing, dietary, etc.

Offer to provide staff in the facility. Adequate staffing in SNFs is at crisis levels in many parts of the country. Look at the recent deficiences (tags) received by the building and look for any related to sufficient staffing. Also, look to see how the staffing hours compare against state and national averages. Facilities are under heightened scrutiny related to having enough nurses and nurses aides to provide care to patients. Receiving tags or even fines for not having enough staff could mean big problems for a facility.  Solution: If a facility is facing short staffing (particularly on the weekends) offer to staff 1 or 2 caregivers, who can pass waters and food trays, change linens, take out trash, transport residents to the dining room and back, engage with residents and so much more. For an Administrator at a SNF looking at the budget, your company charging $28/hour for a caregiver versus paying $50/hour for a nurse or $35/hour for a nurses’ aide can make financial sense.

New Regulations

For the first time since 1991, CMS has revamped the rules of the road in SNFs. Expanding from 176 tags to 190 tags, the revised Requirements of Participation (RoPs) use updated ‘person centered’ language with the intent to meet the needs of the individual resident. Particular areas of regulations have increased focus, for example the number of tags for Resident Rights have increased from 27 to 35, as well as Abuse and Neglect from 6 to 10 tags.    The regulation revisions are so expansive that CMS has implemented them in phases over a four year period, the last phase to be implemented by November 28, 2019.

Make it about THEM

SNFs are reeling with the massive changes under RoPs and need empathy and support.  Talk to management in the facility about the time and resources dedicated over the past 4 years to understanding and complying with the dizzying number of rules.  Facilities are under intense scrutiny to ensure things like staffing levels are adequate, residents are safe from abuse and neglect and residents individual preferences are honored.  Home care is a great solution to all of these. The consequences under RoPs for violations can be severe: including tags, large fines, reduced star rating and risk of impacting external partnerships (hospitals, insurance groups, physician groups, etc.). In the face of significant issues, paying for home care can seem like an easier route.  Have these conversations about utilizing home care:

  • Supplement on a low staffing day
  • Resident to resident altercation and need an intervention to show resident was kept safe
  • Accompanying a patient to an external appointment when staff and family not available
  • Patient that is a fall risk and needs one on one engagement
  • Process for being preferred provider in facility

Home Health


Patient Driven Groupings Model (PDGM) is the biggest change in Medicare Home Health reimbursement in 20 years. This follows hospitals and SNF changes incentivizing value of care over volume of care.  Starting Jan. 1, 2020, reimbursement will be based on diagnosis and complexity of the patient, replacing the current PPS system of more therapy equals more money. Sound like PDPM for SNFs?  Yes, PDGM reimbursement is no longer based on therapy visits.  Additionally, it will require more office staff time by shortening the billing and coding cycle from 60 to 30 days providing 432 possible ways to categorize a patient, wow!

Make it about THEM

Therapy now becomes an expense every time they visit the patient, and therapists wages are expensive. This expense will change behavior of Home Health companies, looking for less costly alternatives.  Things like remote monitoring, phone/video conferencing and use of therapy aides most likely will increase. Less staff in the home and less eyes on the patient provides home care opportunity. Medicare Advantage plans are trying to figure out how to fill the care gap created by PDGM.  Position your company as a solution for Home Health by:

  • Co-Market with a Home Health. Partner with a home health company for discharge from hospital, IRF, SNF, etc. Home Health companies need a reliable partner to supplement care to ensure the patient doesn’t return back to the hospital.
  • Fill in the new care gaps. With less therapy and less eyes on a patient at home, home health companies are still penalized if a patient readmits to the hospital.  Market your service to fill in the gaps in time when home health is not present. Ensure the patient gets to a follow up doctor appointment, receives the medication refills through the mail, knows how to contact the home health company if an issue comes up with a patient, etc.

CMS 5-Star Rating

Starting in 2003, CMS posted quality measures from Home Health Companies on for public viewing.  CMS added star ratings for Home Health in 2015 (along with Hospitals in 2016, Hospice in 2017 and SNFs being the first back in 2008.) Star ratings have become increasingly valuable as home health companies develop partnerships with hospitals, physician groups, SNFs, ACOs, etc.  Overall star rating is based on two categories: quality outcomes and patient survey results.  For quality outcomes, CMS looks at eight measures, including timeliness of starting service and rehospitalizations. Patient surveys are administered by third-party vendors and ask patients five key metrics (that count for the star rating), including agency communication, overall care provided and if patients would recommend the agency to family and friends.  

Find the Home Health Star Rating: Go to, search your referral source. View the overall star rating and compare against other referral sources in your area. Click on ‘Quality of Patient Care’ and scroll down to Preventing unplanned hospital care and compare the RTH %.  Click on ‘Patient Survey Results’ and view the five key metrics compared to state and national averages.

Make it about THEM

You know just as well as Home Health companies what it is like being a care provider among many care providers in your area.  Home Health can set themselves apart with star ratings. You cross paths frequently with Home Health across your service area.  Stop and connect with the marketer. Tell them congrats on the great RTH number, patient feedback on communication, patients recommending services, etc. Don’t stop there, ask the marketer to introduce you to the operations manager back at the office. 

  • Discuss your system for communicating with the Home Health company for clients who are 30 days or 90 days post discharge from a hospital or SNF.
  • Discuss how your training for staff and caregivers about medications reminders includes discharge process from a facility, need for follow up appointment with primary care physician, and conflicting medication lists can cause confusion for patients at home.
  • Discuss your training focus that your staff knows the impact a rehospitalization can have on a Home Health agency and communication path if a patient on service is declining.

There is a lot of information here about referral providers. Bottom line is that BIG changes are coming (or are already here) for people who give you referrals for business.  The number of home care companies who take the time to understand these changes and how that affects decision makers is a small number. Set yourself apart. Understand the Data. Drive your referrals.