How Home Health Agencies Can Adapt To Team And Hhvbp Models

The landscape of home health care is evolving through the introduction of two key models designed to improve patient outcomes and reduce costs: the expanded Home Health Value-Based Purchasing (HHVBP) model and the Targeted Episode-Based Medicare Access and Payment (TEAM) model.

These initiatives incentivize home health agencies to provide high-quality, coordinated care while addressing the challenges associated with insufficient treatment for chronic health conditions. Ultimately, they aim to create a more efficient health care system for Medicare beneficiaries.

The primary model currently impacting home health providers is the expanded HHVBP model, according to ATI Advisory. This model adjusts Medicare payments based on a home health agency’s (HHA) performance on quality measures compared to their peers, rewarding agencies that deliver high-quality care.

In a fee-for-service health system, Medicare beneficiaries who qualify for home health care often receive inadequate and uncoordinated care for their chronic health conditions, according to ATI Advisory. This situation leads to increased emergency department (ED) visits, hospital admissions or placements in skilled nursing facilities (SNFs).

How the expanded HHVBP model affects HHAs

The expanded HHVBP model aims to improve the quality and efficiency of home health care. It was implemented on Jan. 1, 2022, and includes Medicare-certified HHAs in all 50 states, the District of Columbia and U.S. territories. The calendar year 2022 served as a pre-implementation year during which CMS provided HHAs with resources and training. The first full performance year was 2023, and the calendar year 2025 is the first year for payment adjustments based on performance in 2023.

The expanded HHVBP model builds on the success of the original model, which improved total performance scores among home health agencies by an average of 4.6%, according to the Center for Medicare and Medicaid Services (CMS). The original model also decreased unnecessary ED visits, improved patient mobility and reduced Medicare spending by $141 million.

“The expanded HHVBP model seeks to enhance the quality and efficiency of home health care across the nation, improving patients’ experiences with their care through better support of physical function and addressing health issues to prevent ED visits,” a CMS spokesperson told Home Health Care News. “This expanded model builds upon the original model’s success. In the original model, targeted quality improvement activities by HHAs resulted in reductions in unplanned acute care hospitalizations and SNF stays, ultimately lowering inpatient and SNF spending. Based on the success of the original model, the U.S. Secretary of Health and Human Services (HHS) and the CMS chief actuary decided to expand the HHVBP model to further reduce Medicare spending and enhance the quality of care.”

The current measure set for the expanded HHVBP model uses data reported by HHAs through the Home Health Quality Reporting Program (HH QRP), Medicare claims and Home Health Care Consumer Assessment of Healthcare Providers and Systems surveys. To ease the reporting burden, HHAs are not required to submit additional data.

“For Medicare-certified HHAs with sufficient data, CMS will apply a reduction or increase of up to 5% to an HHA’s Medicare fee-for-service payments based on their performance relative to their peers in the same cohort,” the spokesperson said. “The expanded model incentivizes Medicare-certified HHAs to provide higher quality and more efficient care to beneficiaries within the Medicare Home Health Prospective Payment System.”

How TEAM affects HHAs

The TEAM model also significantly impacts home health care agencies by promoting a coordinated, team-based approach to patient care. This approach can lead to improved quality, reduced costs and better patient outcomes for complex post-acute care needs, particularly through enhanced communication and collaboration among health care providers involved in a patient’s care plan.

The TEAM model encourages home health agencies to closely collaborate with other health care providers, such as hospitals, specialists and social workers, to ensure seamless transitions of care and coordinated management of patients, especially those with multiple chronic conditions.

“TEAM is a continuation of many efforts we’ve seen before, including HHVBP, which emphasizes delivering more care at home and holding providers accountable for their outcomes, including readmissions—this is a common metric across all programs,” Brian Fuller, managing director at ATI Advisory told HHCN. “What makes TEAM different is its mandatory nature, which brings together providers with varying degrees of experience and capability. This could present both opportunities and challenges for home health providers.”

Not only is the TEAM model mandatory, but it is also available in 188 markets across 741 hospitals, representing 20% to 25% of all markets nationally.

“The scale is impactful for the industry, and many home health providers will likely feel its effects more broadly than ever before. For many of these providers, this may be their first experience responding to an HHVBP model with all the associated expectations and opportunities that come with it,” Fuller added.

How home health can adapt to TEAM

For home health agencies to successfully implement the TEAM model, they must focus on developing a collaborative, interdisciplinary team approach. This means that all team members— such as nurses, therapists, social workers and home health aides—must work together to provide comprehensive patient care in a home setting. It is essential to maintain clear communication, establish shared goals and define specific roles for each team member while actively involving the patient and their family in the care plan.

“In TEAM, selected acute care hospitals will coordinate care for individuals with traditional Medicare who are undergoing one of the surgical procedures included in the model, and assume responsibility for the cost and quality of care from surgery through the first 30 days after the Medicare beneficiary is discharged from the hospital,” said the CMS spokesperson. “HHAs can play a crucial role in the 30 days following a patient’s hospital discharge. Specifically, HHAs may partner with acute care hospitals in the model to support the coordination and transition of care for patients. This collaboration reinforces patient continuity of care and promotes positive long-term health outcomes.”

HHAs need to define distinct roles for each health care professional on the team, specifying their contributions to patient care based on their expertise and licensure.

Regular communication among all team members is vital to quality patient care. This should include frequent meetings, quick updates, detailed documentation and effective use of technology to share patient information. Leveraging telehealth technology can facilitate remote connections among team members, enable patient monitoring and provide virtual consultations when necessary.

“Hospitals don’t seamlessly connect to what happens outside of their four walls, and so things like the sharing of information, making sure the most accurate information about patients is available to everyone involved in their care, connecting to follow-up appointments is a challenge,” Fuller said. “Anything that the home health agency can do to help take some of the load of being the care coordination quarterback off the hospital is valuable. Technology becomes a core enabler to that data sharing and exchange.”

The care plan should revolve around the patient’s needs and preferences. It is important to actively involve the patient and their family members in the decision-making process, ensuring they understand the treatment plan and can effectively assist with daily activities.

Caregivers also should conduct a thorough assessment of the patient’s home environment to identify potential safety hazards and customize the care plan to fit the home setting. It is also essential to connect patients with necessary community resources, such as transportation, meal delivery and support groups, to address social determinants of health.

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