Team 8 Environmental Analysis - AssistedCare Home Health_11.18.09

Cameron School of Business Professional MBA c/o 2011 Environmental Analysis Client: AssistedCare Home Health Presented by Group Justin Combs Chuck McDowell Michael Stark Thera Storm Catherine Wynne Table of Contents I II Industry Overview a Background Information…………………………………………………………………….…3 b Main Industry Features………………………………………………………………… …….3 c Forces of Competition………………………………………………………………….……….5 d Key Drivers of Change………………………………………………………………………… e Critical Factors of Success……………………………………………………………….…….8 f Attractiveness of the Industry………………………………………………………….….11 Marketing Analysis a Competitor Analysis………………………………………………………………….…… ….12 i Liberty Home Care ii Home Instead iii WellCare iv Pender Home Health b Feature Strategy Matrix (Page 33 of Appendix) ………………………….… 14 c Buyer/Customer Analysis…………………………………………………………… … 14 d Client Analysis…………………………………………………………………………………….16 i Value Proposition ii Positioning Map iii Positioning Statement e Marketing Mix Audit……………………………….……………………………………… …17 i Product ii Pricing iii Distribution iv Promotion f Appendix………………………………………………………………………………………… …24 Industry Overview Background Information AssistedCare, based in Leland North Carolina, operates two individual companies; AssistedCare Health & Home Care Specialists and AssistedCare Home Health Through these companies AssistedCare provide’s a variety of behavioral health and home health care services AssistedCare serves an area that encompasses 10 counties in North Carolina and provides quality care to private pay and Medicaid/Medicare clients AssistedCare Home Health was created in 1997 to allow the addition of skilled nursing and therapy services In their commitment to high standards, AssistedCare is a member of the Association for Home and Hospice Care of North Carolina, the National Association of Home Care, and the North Carolina Community Support Providers Council and is accredited by the The Joint Commission This industry analysis will focus on home health care The growing and complex home health care industry contains many service areas The industry employs skilled nurses, nursing aides, rehabilitation specialists and social workers As the industry grows, defining home health care becomes more complex The U.S Census Bureau lists in sector 62, at least four different NAICS 2002 (Economic Census 2002) codes related to home health: 621 {with product code 30260}, 6216, 62161 and 621610 (see appendix Table for more details) Some services are listed in the Census Bureau data as home health while others fall into the category of ambulatory Traditional home health care offers convalescent (defined as the period between the end of an illness or injury and the patient's recovery) services through nurses, nurse’s aides, social workers and rehabilitation therapists, often after hospital discharge Main Industry Features According to data from the CDC FastStats Home Health Care web page (at last census), 70.5% of all home care patients served were 65 years of age and older.1 Since the large majority of the customers (customers also referred to as patients) in this service industry are elderly (term used by The American Geriatrics Society in their positioning statement as well as by others in the health care industry) it is reasonable to look more closely at this age group A recent release from the National Institute of Health (NIH) outlined data found in the report "An Aging World: 2008" In this report it is estimated that the number of people over the age of 65 worldwide, at midyear of 2008, was 506 million That number is projected to increase to 1.3 billion by 2040 As a percentage, the proportion of elderly will double from 7% to 14% of the total world population in just over 30 years In the U.S., The American Geriatrics Society website states that every seconds a Baby Boomer turns 60 (they have an updated population clock for viewing) and that by 2015 nearly 15% of the U.S population will be elderly (http://www.americangeriatrics.org/) Table two in the appendix has been provided to give more information about the breakdown of U.S home health care data In analyzing table one it is made clear that this is a very large industry providing many jobs and adding a respectable amount to GDP, all while still in the growth phase Closer to home, the percent population of elderly living in North Carolina during 2000 was about 12% (over 980,000 people) That number is projected to increase to 18% (over 2.2 million people) by 2030 Table three in the appendix gives statistical information about the number of home health providers there are in N.C available to serve this growing population Table three also gives statistics on how N.C recently spent its health care dollars on home health and how federal dollars have been spent on N.C home health care Narrowing the focus even more, most counties in southeastern North Carolina are projected to have some increase in the elderly population (see appendix Table 4) AssistedCare primarily covers New Hanover, Bladen, Brunswick, Pender, and Columbus counties The total health care expenditures (not just home health) for this area recently totaled $533,911,914 Therefore, it comes as no surprise that a health care industry serving the elderly in this area should have the potential for growth and success This is supported by national, state and local data (see data included in the previously mentioned appendix tables) For example, the home health industry has experienced significant growth in the past years with 2009 revenue estimated at over $65 billion and revenue growth of 27% over that same period; $13,734,032 in 2002 (most recent census figures) Centers for Medicare and Medicaid Services estimate that the percentage of home health care expenditures will increase as a percentage of total health care expenditures from 2.8% in 2009 to 3.0% in 2014, an increase of over $1,000,000 Both the number of firms and total revenue continues to increase in the growth stage of the product life cycle As the “baby boomers” advance in age, demand for senior care will increase significantly allowing continued growth and contributing to an attractive landscape for both current competitors and potential entrants The pace of technological change is steady in the home health industry Many in home health are discussing ways to use technology to meet the growing demands of the industry The U.S is not the only country seeing an increase in quantity and level of care required by home health patients thus, technology is being developed for this industry all over the world If technology can be developed that will allow a limited number of caregivers to reach the growing number of patients, the industry stands to improve efficiency and potentially drive down costs to their patients In effect, such technology will decrease the "distance" from caregiver to patient This is especially important in areas with a large geographic distribution Most literature on home health technology points to the Internet and wireless communication as the most likely area for technology development The technology most often employed is that of remote monitoring Typically, common names given to this evolving technology is Telemedicine or Telehealth These systems can help nurses to document patients’ conditions instantly and provide accurate up-to-date records Systems may use devices such as sensors coupled with technology such as WLAN (Wireless Local Area Networks) or Bluetooth Video conferencing may also be used Newer areas of development involve wireless networks and mobile phones The systems available must meet at least two basic requirements: data transmittal must be accurate (integrity) and confidential Other features like ease of use, easy installation and security are important An article by Herzog and Lind gives great details on connectivity and networking (see diagram in the appendix) Various types of data can be monitored including blood pressure, weight, O2 saturation, respiratory rate and ECG (measures heart rhythm) Feedback from the caregiver or physician can occur via telephone or through computers More devices such as electronic stethoscopes (which can be used to remotely listen to heart and lung sounds) and blood glucose monitoring with corresponding insulin injection monitoring, are making care for higher risk patients feasible Patients that could benefit from Telemedicine include anyone from infants to elders Technology such as clothing with body sensors embedded in it, mattresses monitoring body temperature, pulse rates and sleeping patterns as well as motor and tremor testing (for Parkinson's) and medication monitoring devices (monitor if the container has been opened) are already here.6 This technology, however, is not without drawbacks Issues such as affordability (especially given many patients are on a fixed income) and party responsible for payment (the government, companies or citizens), ease of use (in a population that may not be familiar with the technology), legal issues (especially between state-to-state care), requirements of large databases and/or servers must be considered Another debate centers on the practice standards and ethics of Telemedicine Of note financially, Colorado became the first state to reimburse for Telehealth services For more information on home care technology, see http://www.hctaa.org/ Outside the realm of direct patient care, GPS systems are being used for routing, scheduling and improving efficiency of operation Industry performance potential may be measured by factors such as:   Aging population Prevalence of chronic diseases    Shifts in health care practice to move patients into home care and away from institutionalized care (from both a quality of care and cost perspective) Changes in profitability (e.g insurance reimbursements verses cost) Advancement in technology to allow for expanded services or improvement of existing services Forces of Competition The power of suppliers is moderate in the home health industry Home health providers purchase medical equipment and supplies needed to provide healthcare in patients’ homes Home health companies are generally local or regional and their purchases represent a small percentage of the supplier’s sales, thus increasing the power of the supplier The size of the supplier and consolidation within the supplying industry can also affect the power of the supplier In general, suppliers tend to be larger than the home health companies, excluding the few national providers, which support a moderately powerful supplier rating Wages and salaries represent the majority of home health care provider’s expenditures while purchases average only 20% of companies’ budgets Suppliers for the home health industry include medical supplies companies and medical device and equipment companies Day to day supplies, (generally disposable) are needed to provide care, such as bandages, soaps and personal hygiene supplies, catheters, syringes, and adult diapers More complex and expensive medical equipment is used less frequently Examples include heart and blood pressure monitoring equipment (see brief excerpt in appendix from NCHHS fees schedule, the maximum allowable amount paid by Medicaid for listed items) Buyers have little power in this industry as their purchases are a very small percentage of companies’ overall sales The purchase is made on an individual level for a family member in need of care Switching costs most often influence buyer’s decisions as they build a relationship with a certain healthcare worker and are unwilling to change providers The presence of switching costs further decreases the power of buyers Additionally, buyers may be heavily influenced by traditional care providers, such as primary care physicians or Gerontologists, who provide the majority of customer referrals Often the prospective buyer in this industry is the family caregiver A younger generation of buyer may turn to the internet for "shopping" or price comparisons especially when out-of-pocket expenses are involved This approach could very easily give more power to the buyer and is a trend worth watching closely in the industry Barriers to entry in the home health industry are low mainly due to the low level of capital needed at start up Overhead and fixed costs are low as a formal facility is not required and the majority of business functions are preformed in the patients’ homes Barriers to entry include the industry requirements for accreditation, establishment of certificate of need, qualification for Medicare and Medicaid reimbursement, and government regulation Larger providers with established distribution channels may create barriers to entry, however they are not considered to be severe Competition in the home health industry is high and very localized, as the industry is still very fragmented Rivalry among competitors varies in each local market The industry is fragmented nationally with the top four firms accounting for only 8.1% of the market.7 Therefore, most rivalry has been between small companies As the industry grows, new companies will enter the market and increase competition for market share The industry has experienced some consolidation over the last few years Local and regional markets that are less fragmented, with few major players controlling the majority of market share, will experience increased competitive rivalry The largest factor of competition is price However, the variety of service’s offered, quality of care, and reputation of the company are also very important When analyzing the home health industry using Porter’s Five Forces Model, the threat of substitute products seems to be the most influential and pivotal forces affecting the home health care industry Generally, the threat of substitutes or the demand for substitutes can be determined by evaluating:      Cost parameters The aging population Profitability within an area, which is largely determined by payer mix (see marketing mix price section for more discussion on the value of payer mix) Customer awareness of home care Changes in technology and changes in family structure (family member can no longer be the caregiver or vice versa).7 Substitutes for home care are primarily institutionalized care; care provided by a family member or volunteer, assisted living facilities, and adult day care services Family caregivers provide more than 80% of the long-term care for elders in the United States and experience a variety of transitions that are intertwined with those of their elders.8 However; questions arise concerning the level of care provided by non-professional caregivers Studies have shown that transitions from hospital care to home care can be "characterized by problems managing the elders’ care Hospital-to-home transitions were characterized by receipt of insufficient information about the elders’ condition, medications, and care management needs, and difficulties managing care at home" and that "misunderstandings about the elder’s medications and treatment plan often contributed to readmission to the hospital".8 Unlike some other U.S industries, patients needing home care services have only a few viable substitutes As the health needs of the patient become more advanced and complex, the number of available substitutes decreases The actual threat of the substitute likely depends on the level of care needed If the care needed, is a simple activity such as guarding a patient when they walk to making sure they not fall on the way to the bathroom, this care could be accomplished by sending the patient to adult day care for some period of the day If the patient requires 24-hour care, then a nursing home (or hospital if the condition is temporary) is a substitute threat Since these industries offer different level of services at different costs, they act more like indirect competitors Due to the lack of available resources, caregiver availability and cost, some may select home health or substitutes out of necessity - not choice Two institutional substitutes for home health care services are hospitalization and nursing home care These substitutes differentiate themselves from home health care by providing an institutional facility and, in some cases, greater comprehensive medical services Costs tend to be much higher for institutionalized care The home health care industry generally offers a more cost effective option to potential consumers “In 2004, Gentiva Health Services compared the average cost of a home care visit ($100) with the average cost of a hospital day ($2,700) and the average cost of a skilled nursing facility day ($400).” Home health care customers may require assistance for long periods of time, further expanding cost variations among substitutes Adding to the complexity of the issue is the fact the nursing home beds are limited and placement of a patient into such facilities can be challenging If a patient needs that level of care on a temporary basis, then a nursing home may not accept them or they may have an improved condition while on the "waiting list" and no longer require nursing home level of care Schwab et al evaluated the affordability and benefits of home and community based health services (HCBS) out of concern that "many of HCBS are nonmedical, these services are rarely covered by private health insurance or Medicare".9 The article reviewed the PACE program (Program of All Inclusive Care for Elders from the Health Care Financing Administration, 2000 - now called CMS) and a social HMO called SCAN (a government project) Their research found "The average market value of HCBS provided by SCAN to maintain an individual in the community is about $4,900 a year, or $408 per month Providing a package of services valued at nearly $5,000, equals a 25% increase in purchasing power This amounts to a substantial benefit for older people with limited incomes" Clearly cost of therapy favors home health, but there have been reports of fraud and abuse (see Medical Care Research & Review; Mar2004, Vol 61 Issue 1, p64-88) and concerns about quality of care Adult day care centers are growing in number but are still hard to find in some areas and they are limited on the services they typically provide This service is growing in popularity and could be considered a substitute for home health However, many of the activities involving patients are not billable to an insurance company Furthermore, private and government insurance agencies will be tightening payments for these services in light of their growing health care payouts, meaning patients or caregivers often pay cash for adult day care services Typical costs in our region are around $40-50 per day Since the cost over time can add up, more and more of these facilities are marketing their services as a once or twice a week service to give the caregiver a "break" from having to monitor the patient They may advertise giving the caregiver a day of freedom to shop or take care of things outside the home Volunteers or family members are more often only a relatively short-term substitute The more care a patient requires, the less likely the family member or volunteer can meet the needs of the patient Finally, the most threatening substitute is assisted living facilities Many provide different levels of care and offer a wide range of services The patient can "graduate" to different levels of care, often within the same general location As this industry grows in popularity, firms are buying property and developing communities to care for these patients as they transition through different types of care Assisted living communities may have a bank, pharmacy, grocery store as well as different structures for different patient needs A patient may start out in one location of the community in a small house or apartment and move through stages into other buildings such as a traditional nursing home From a cost perspective, services may be billed in much the same manner as a home health company On the down side, the popularity has caused problems with availability and has also allowed some firms to charge very high prices for living in their community Additionally, often a patient will end up selling their home to which they have emotional ties As the population of baby boomers age and the availability of health services are pushed to the limit, patients may begin looking to any or all of the abovementioned substitutes for care In reviewing this industry using the 5-Forces model, it is evident that home health is an attractive industry, but still faces challenges Supplier power is moderate, buyer power is low, barriers to entry are low, rivalry is region dependent (but generally considered low) and the threat of substitutes remains the biggest challenge in the industry In most areas, it will be possible for business to enter the industry without great difficulty, especially while it is in the growth phase Perhaps largest challenge for those wanting to enter the industry may be the low level of reimbursements (which translate into profits) For those already in the industry, threats from entry, local rivalry and the threat of substitutes pose the greatest challenge ahead These challenges all center around government regulation, health care reform and dynamic reimbursements Key Drivers of Change The key drivers of change in the competitive conditions of the home health care industry include the age profile of the population, federal funding via Medicare and Medicaid, per capita disposable income, and private health insurance membership At least one driver of change in the industry is alliances and acquisitions (reasons for this trend are discussed in the critical factors section) IBISWorld reports that firms in the U.S accounted for 7.8% of receipts generated by the industry in 2002.7 As an example, during fiscal year 2005, one firm acquired 21 companies and in 2006 another firm acquired a company with 130 locations The industry is becoming more dominated by large firms with increasing market share One acquisition reported by IBISWorld during 2006, topped $460 million and gave the firm 2% of the home health market share in the U.S At the moment no single firm dominates the industry, however once industry consolidation begins, the trend rarely reverses Elderly use home health care services more often than those in younger age categories People in this older age group qualify for Medicare, which helps to offset growing medical costs “[However,] federal funding of Medicare and Medicaid, together with government determined terms of access to such reimbursement programs, affects demand for home health care and other health care services Prices charged for those services are also affected as government reimbursement programs are increasingly challenging prices paid for health care services.”7 Per capita disposable income is also a key driver of change in this market As household income rises, the number of people covered by private health insurance also increases Additionally, there is more out-of-pocket money to pay for these home health care services in addition to co-pays and deductibles Critical Factors of Success There are many critical factors of success that home health companies must focus on in order to maintain competitive advantage Customers of home health care services have high involvement in their decision to choose between local providers within an area Providers must qualify for reimbursement from Medicare and Medicaid Since over 70% of all home health patients use either Medicare or Medicaid reimbursement to pay for service, home health care providers stand little chance of success without access to government reimbursement The variety of services offered by home care providers can increase their number of potential customers and provide opportunities for growth Quality control is incredibly important in the industry Patients have specific needs that require unique individual attention Maintaining a high level of quality helps companies to build a good reputation in their local market It is documented that government insurers and private insurers are monitoring quality of care as a method of determining reimbursement for home health services The threat of malpractice lawsuits and the potential reform of malpractice laws will continue to affect the home health industry There will be growing pressures in this industry to maintain effective quality control practices as it relates to both reimbursement and lawsuits Referrals from existing companies are major sources of business for home care providers, making reputation a critical factor of success Flexibility is also important due to the technological growth and changing nature of the industry As technological abilities change, allowing a wider range of services to be provided at home, and customers needs vary, providers must be ready and willing to alter the services they provide A growing area of competitive force is acquisitions and alliances The Balanced Budget Act of 1997 created the Medicare Interim Payment System and later gave rise to the current Home Health Prospective Payment System (see http://www.cms.hhs.gov/HomeHealthPPS/ for more details) This reimbursement structure was designed to decrease government spending on home health care and promoted alliances and acquisitions (see Timeline in the appendix) Successful alliances were created if the lead company was in the home health industry after 1995 and allied or acquired a company formed prior to 1995 Another factor for success in the industry is how well a business manages its clinical operations and training A study by Smith-Higuchi, K, et al found that recent changes in the health care system have led to increased responsibility for nurses managing more complex clinical cases.10 Home care patients require specialized nursing and the authors reported that not all undergraduate nursing programs offer home care learning opportunities for students They recommend on-the-job training from experienced home care nurses to facilitate learning of the specialized environment A higher percentage of experienced home care nurses would be a greater asset to the industry Perhaps, none of the aforementioned critical factors of success are more important than reimbursements in the industry The industry is attempting to address the reimbursement issue in a few new ways The role of managed care organizations (MCO) may impact the industry strategically (for more details on MCOs see http://en.wikipedia.org/wiki/Managed_care) Since home health care offers much needed services at reduced rates compared to institutionalized care, MCOs as well as government based programs may favor this industry in years to come as a more cost effect approach to health care A newer approach, termed "medical care at home", "adds a medical component - physicians, nurse practitioners, or physician's' assistants - to the traditional home health team".11 This approach has been shown to decrease hospital length of stays, which is a more costly form of health care Health care cost reductions due to home health care, could bring about a shift in reimbursement patterns from insurers that favor the industry, promote growth and attract competition Kodner and Kyriacou referred to "home care-based (HCB) managed chronic care programs as "a new, and as of yet, untapped resource".12 They define HCB-managed chronic care programs "as home-centered and home care–based managed care organizations that serve the frail elderly and other populations with chronic, disabling conditions Such programs have the following six “managed care” characteristics: (a) enrolled population; (b) comprehensive package of services; (c) prepaid, capitated financing, with responsibility for all or most care costs; (d) closed provider network; (e) case/care management; and (f) multidisciplinary or interdisciplinary team care, with clinical responsibility for quality outcomes." 12 Claiming the home health industry "itself is in the throes of transformation, marked by several major trends: the dramatic growth of the for-profit sector, vertical and horizontal integration, intense competition, rapid technological change, and unprecedented fiscal pressures," it could benefit from entering into the managed care arena Although too lengthy for discussion here, the article discusses how a Certified Home Health Agency (by Medicare) might consider managed care The opportunity for growth may depend on increasing services and gaining price competitiveness In addition, obtaining government subsidies, grants and to participate in programs like the PACE program present the industry with an opportunity to help shape its future and help itself financially In an effort to contain costs, The Balanced Budget Act of 1997 created a payment structure for government reimbursement of home health services (see Federal Register vol 74 (155), 40949 for more details) Two important sections of the Act created a "case-mix" per episode and "wage level" adjustment An episode is defined as 60 days The case-mix model uses OASIS (an 80-item instrument designed to measure health status) as a basis for establishing payment rates per episode 13 The problem is that the case-mix model may not provide adequate reimbursement for services So, how governments and the industry work together to create a financial model where no one loses? There are a couple of interesting financial models unique to the home health industry, but financial models in the industry can be challenging One of the first models developed (by Weissert et al) was called "titrated budgeting" They believed that "Titration of care would reallocate resources to maximize marginal benefit for marginal cost" 14 The problem, according to Greene, is "Many of these methods have been based on analyzing home care in terms of its ability to prevent or reduce the likelihood of expensive or otherwise adverse outcomes for clients and payers" However, "more rigorous evaluation studies" have "repeatedly found that home care costs on average consistently exceed the actuarial value of the reduction in risk for the adverse events they seek to deter, thereby leading to increased overall costs" 15 ”Titration budgeting", is "a prudential notion of using the minimum amount of home care services required to achieve a given effect or otherwise satisfy a condition, but no more" Greene writes, "Specifically, the titration budget is meant to be calculated so as to equal the total monetized actuarial value or expected benefit generated by home care by virtue of decreasing the risk of costly events" Although logical, "titration budgeting as it has been proposed to date will not be cost effective in any demonstrable sense and is logically problematic as well" Greene's method uses a corrected equation to provide "a budgeting framework and standardized algorithm within which case managers have information they need to consistently allocate home care resources cost effectively based on systematic considerations of relative marginal costs and benefits, allowing for relevant differences in client characteristics and prospects" If used correctly "it should be possible to undertake a practical program to improve on the current performance of home care programs in terms of the efficiency with which they allocate their budgets among clients" Putting it another way, "Properly implemented, titration budgeting can increase the overall net benefits provided by home care agencies to clients through better targeting of resources to those for whom they produce the greatest benefit, and home care programs can thereby offer a better return on funds provided to them" The way in which a home health company manages fixed revenue for the various services it provides is a key to success in this industry Efficiency and cost containment (i.e expenses) are the few areas of fiscal survival that home health companies can have control over Industry wide, profits margins are reported to be 5%, but that can vary within segments of the industry Ultimately, companies may have to alter some of the services they provide to maintain margins It is important to look at one aspect of how this industry typically attracts customers/patients as a critical factor of success (information specific to AssistedCare will be provided in the client analysis distribution and promotion section of this analysis) Given that health care workers have a large influence on how patients and caregivers make their decisions about long-term care, Kane et al "compared long-term-care recommendations among various types of health professionals".16 They found that out of the Advanced Practice Nurses, Gerontologists, Geriatricians and Primary Care Physicians, Registered Nurses and Social Workers studied, only Registered Nurses were "highly supportive" of home health care compared to other types of long-term care If this data holds true for all areas in the U.S., the home care industry must enhance its relationships with many health care providers if it is to improve "referrals" from these providers Another approach might be creating pressure on insurers to offer better or stabilized payment rates for patients willing to be treated by a home health service (e.g creating incentives for patients to get cheaper but equal quality of care in the home) This could in turn, lead to better or stabilized reimbursements for home health which could reduce home health spending in traditionally more expensive health care environments (i.e institutions) This could be accomplished by creating MCOs (see above) or by scientific documentation (i.e studies or programs such as PACE) on the benefits of using home health services as opposed to other types of health care, which would apply pressure on insurers to pay well for home health services Some issues might negatively affect success in this industry and are worth mentioning here "Tradition bound and highly regimented home care industry is fraught with chronic staffing shortages, constrained reimbursement, and ever-increasing regulatory demands." 12 As a result of the rising cost of health care in the U.S and due to the recent economic recession, reimbursements from government and private insurance are likely to decrease Consider the current reimbursement situation described by Weissert et al: "State governments, if they are to comply with the federal law, must pick and choose among frail poor people seeking a subsidy for home care to find those who, without it, would be in a nursing home As selection criteria, most assessors use the need for human help in activities of daily living as one key indicator of need for nursing home care Some add cognitive criteria Others take medical conditions or need for therapeutic services into account Other important criteria may include availability of family caregivers, and in a few cases, a judgment as to the relative cost of keeping the client at home with multiple services versus the cost of supporting the client in a nursing home States use a variety of methods to weight the relative importance of these factors in making their judgment of who would and would not be in a nursing home without home care They may add a point to a total score for each condition observed, or additional points for additional severity of each condition Or they may add multiple points for some conditions and few to none for others Above some threshold score, clients are deemed eligible for care, below it, not eligible." 14 Simply, is it ethics, the economy, or both deciding on healthcare services and who makes the determination? 10 population 2020 Projected 32,176 180,344 62,134 62,129 246,651 86,340 83,161 population 20291 Projected population 2029 5,914 31,085 10,491 10,154 46,570 15,633 13,587 (65+ y.o.) Projected population 2010 4,831 19,237 8,017 7,073 26,862 8,324 8,818 (65+ y.o.) Health Care Expenditures $33,475,646 $131,390,602 $55,283,852 $48,914,047 $258,676,359 $55,085,455 $60,782,785 (source = DemographicsNow) Average Household Income (source = $41,670 $59,910 $42,251 $43,830 $60,368 $51,695 $45,816 281 913 411 208 2,981 645 488 21.0% 19.2% 21.1% 24.1% 16.9% 20.1% 22.9% DemographicsNow) Commercially Insured (source = NCDOI HMO data 12/08 % Uninsured ages 0-64 18.6% N.C 18.6 % N.C 18.6% N.C 18.6% N.C 18.6% N.C 18.6% N.C 18.6% N.C (2005 CATCH-NC rate rate rate rate rate rate rate data) Medical Facilities Brunswick New Sampson Bladen Co Columbus Co.Duplin Co Pender Co Planning data Co Hanover Co Co Liberty Home Liberty Home Columbus Tar Heel Liberty Home Pender Home Sampson Home Health Care Care Home Health Home Health Care Health Home Health Agencies serving each county Bladen Home Health Well Care Liberty Home Well Care Well Care Care Pender Home 3HC Health AssistedCare AssistedCare Liberty Home Well Care Well Care Care Liberty Home 3HC Care Pender Home Pender Home HealthKeeperz Health Healthkeeperz Health AssistedCare Liberty Home Tar Heel Care Home Health AssistedCare AssistedCare Home Carolina/East Instead Home Care Columbus Southeastern Well Care Home Health Home Health Tar Heel Home Cape Fear Valley Home Sampson Health Health Home Health Sampson Home Pender Home Health Health Carolina/East 28 Pender Home Health Continuum Home Care Continuum Home Care Cape Fear Valley Home Health Home Instead Home Care Pender Home Health Well Care Southeastern Home Health Medi Home Health Amedisys Home Health Age Group3 Amedisys Home Health Number Number Served (2007 Served data) < 18 18-40 41-59 60-64 65-74 75-84 > 85 Totals 18-64 > 75 32 59 240 87 207 241 154 1020 386 395 Number Served Number Served Number Served Number Served Number Served 58 151 521 224 564 599 336 2453 896 935 38 58 230 96 297 331 223 1273 384 554 103 221 707 336 864 1185 820 4236 1264 2005 35 66 192 116 244 264 158 1075 374 422 75 88 297 123 341 424 222 1570 508 646 78 113 438 286 753 751 418 2837 837 1169 http://www.osbm.state.nc.us/ncosbm/facts_and_figures/socioeconomic_data/population_estimates/county_projections.shtm http://www.osbm.state.nc.us/demog/countytotals_agegroup_2029.html http://www.dhhs.state.nc.us/dhsr/ncsmfp/2009/2009plan.pdf NCDHHS - Example of Medicaid Fee Schedule (Demonstrates the complexity of healthcare billing on the state level Allowable billing for both products and services) HCPCS CODE RC420 RC424 RC430 RC434 RC440 RC444 HCPCS CODE RC550 BILLING UNIT visit 1visit visit visit visit visit BILLING UNIT visit DESCRIPTION THERAPIES Physical Therapy Physical Therapy - Evaluation Occupational Therapy Occupational Therapy - Evaluation Speech Therapy Speech Therapy - Evaluation DESCRIPTION - SKILLED NURSING VISITS Skilled Nursing Home Health 29 MAXIMUM RATE/UNIT $ 118.64 $ 118.64 $ 118.64 $ 118.64 $ 118.64 $ 118.64 MAXIMUM RATE/UNIT $ 111.85 RC551 Skilled Nursing Visit RC559 Skilled Nursing - Other Visit RC580 Home Health - Other Visit RC581 Home Health Visit Charge RC589 Home Health Visit - Other HCPCS CODE DESCRIPTION - HOME HEALTH AIDE RC570 Home Health Aide HOME HEALTH CARE MEDICAL SUPPLIES SKIN CARE (DECUBITUS) SUPPLIES HCPCS CODE DESCRIPTION E0188 Synthetic sheepskin pad E0191 Heel or elbow protector E0199 Dry pressure pad for mattress, standard mattress length and width HOME HEALTH CARE MEDICAL SUPPLIES SOLUTIONS HCPCS CODE DESCRIPTION A4216 Sterile saline or water, 10 ml A4217 Sterile saline or water, 500ml A4244 Alcohol or Peroxide, per pint A4246 Betadine or PhisoHex solution, per pint Therapeutic agent for urinary catheter irrigation (acetic acid - 250 to A4321 1,000 cc) visit visit visit visit visit BILLING UNIT visit $ 111.85 $ 111.85 $ 111.85 $ 111.85 $ 111.85 MAXIMUM RATE/UNIT $ 51.17 BILLING UNIT each each each MAXIMUM RATE/UNIT $ 26.43 $ 8.49 $ 27.24 BILLING UNIT 10 ml 500 ml pint pint MAXIMUM RATE/UNIT $ 0.40 $ 2.66 $ 1.02 $ 5.94 bottle $ Sample Section of Medicare HCPCS Coding Manual (Sample is 28 of 9,981 entries - demonstrating the complexity of healthcare billing on the federal level) G0151 00100 SERVICES OF PHYSICAL THERAPIST IN HOME HEALTH SETTING, EACH 15 MINUTES G0152 00100 SERVICES OF OCCUPATIONAL THERAPIST IN HOME HEALTH SETTING, EACH 15 MINUTES G0153 00100 SERVICES OF SPEECH AND LANGUAGE PATHOLOGIST IN HOME HEALTH SETTING, EACH 15 G0153 00200 MINUTES G0154 00100 SERVICES OF SKILLED NURSE IN HOME HEALTH SETTING, EACH 15 MINUTES G0155 00100 SERVICES OF CLINICAL SOCIAL WORKER IN HOME HEALTH SETTING, EACH 15 MINUTES G0156 00100 SERVICES OF HOME HEALTH AIDE IN HOME HEALTH SETTING, EACH 15 MINUTES G0166 00100 EXTERNAL COUNTERPULSATION, PER TREATMENT SESSION G0168 00100 WOUND CLOSURE UTILIZING TISSUE ADHESIVE(S) ONLY G0173 00100 LINEAR ACCELERATOR BASED STEREOTACTIC RADIOSURGERY, COMPLETE COURSE OF THERAPY G0173 00200 IN ONE SESSION G0175 00100 SCHEDULED INTERDISCIPLINARY TEAM CONFERENCE (MINIMUM OF THREE EXCLUSIVE OF G0175 00200 PATIENT CARE NURSING STAFF) WITH PATIENT PRESENT G0176 00100 ACTIVITY THERAPY, SUCH AS MUSIC, DANCE, ART OR PLAY THERAPIES NOT FOR G0176 00200 RECREATION, RELATED TO THE CARE AND TREATMENT OF PATIENT'S DISABLING MENTAL 30 7.50 G0176 00300 HEALTH PROBLEMS, PER SESSION (45 MINUTES OR MORE) G0177 00100 TRAINING AND EDUCATIONAL SERVICES RELATED TO THE CARE AND TREATMENT OF G0177 00200 PATIENT'S DISABLING MENTAL HEALTH PROBLEMS PER SESSION (45 MINUTES OR MORE) G0179 00100 PHYSICIAN RE-CERTIFICATION FOR MEDICARE-COVERED HOME HEALTH SERVICES UNDER A G0179 00200 HOME HEALTH PLAN OF CARE (PATIENT NOT PRESENT), INCLUDING CONTACTS WITH HOME G0179 00300 HEALTH AGENCY AND REVIEW OF REPORTS OF PATIENT STATUS REQUIRED BY PHYSICIANS TO G0179 00400 AFFIRM THE INITIAL IMPLEMENTATION OF THE PLAN OF CARE THAT MEETS PATIENT'S G0179 00500 NEEDS, PER RE-CERTIFICATION PERIOD G0180 00100 PHYSICIAN CERTIFICATION FOR MEDICARE-COVERED HOME HEALTH SERVICES UNDER A HOME G0180 00200 HEALTH PLAN OF CARE (PATIENT NOT PRESENT), INCLUDING CONTACTS WITH HOME HEALTH G0180 00300 AGENCY AND REVIEW OF REPORTS OF PATIENT STATUS REQUIRED BY PHYSICIANS TO AFFIRM G0180 00400 THE INITIAL IMPLEMENTATION OF THE PLAN OF CARE THAT MEETS PATIENT'S NEEDS, PER G0180 00500 CERTIFICATION PERIOD Available at http://www.cms.hhs.gov/HCPCSReleaseCodeSets/ANHCPCS/itemdetail.asp?filterType=none&filterByDID=99&sortByDID=1&sortOrder=descending&itemID=CMS1216704&intNumPerPage=10 This Timeline represents how growth in the industry (and increasing expenditures) has led to government restrictions on reimbursement 31 Connectivity and Networking Diagram for H.H Technology 32 Feature Strategy Matrix Features AssistedCare Home Instead Pender Home Health Liberty Home Health WellCare Nonskilled Nursing Services Bathing and Personal Hygiene Dressing Nail and Skin Care Linen Changes for Incontinent Patients Bathroom Assistance Help with Walking, Turning and Positioning Wound Dressing Changes (Not Requiring a Skilled Nurse) Self-Administered Medication Assistance & Blood Sugar Checks Light Housekeeping and Cleanup Laundry Essential to the Patient's Health Care Trash Removal Meal Preparation Grocery Shopping Errands Oxygen Monitoring Diabetic Monitoring Gastric Tube Feeding Oral Suctioning Transportatio n, prescription pick-up Bathing & dressing Bathroom assistance Assistance with walking Nail & skin care None Prepare Meals and clean kitchen Home telemonitoring Linen and laundry Light housekeeping Socialization in the community Shopping and errands Keeping appointments Monitor diet and eating habits Pet and plant care Bathing Bathroom Assistance Coordination of Medical Equipment Dressing Help With Walking Home Management Services Meal Preparation Private Duty Nursing Personal Emergency Respond Units Turning, Positioning & Transferring 33 Features AssistedCare Home Instead Pender Home Health Liberty Home Health WellCare Skilled Nursing Services Diabetic and Medication Teaching Cardiac Care Pain Management Diabetic Care Venipuncture Injection Administration Case Management Catheter Care Transition to Home Care Restorative Nursing TeleHealth Home Infusion Wound Care Physical Therapy Occupational Therapy Speech Therapy Short or Long Term Available in Skilled Nursing or Assisted Living Facility, Hospital, Vacation Rental or Residential Dwelling Overnight and Weekend Service Available Professional Staff to Meet a Full Range of Needs None Skilled Nursing Physical Therapy Medical Social Services Occupational Therapy Home Health Aide Speech Therapy Diabetes Home Program Wound Care Program Home Medical Equipment and Supplies Home Infusion Therapy Palliative Care Bridge Program with Lower Cape Fear Hospice Infusion and Oncology Services Cardiac Care Wound Care Speech Pathology Physical Therapy Central In-take Occupational Therapy Skilled Nursing Physical therapy Occupational Therapy Speech Therapy Medical Social Work Home Health Aide Psych Nursing Chemotherapy IV Therapy Wound Care Patient Teaching Nutritional Support Palliative Care Pediatric Nursing None Available, must inquire Available Overnight & weekend services as well as Short & Longterm Available, must inquire Number of Employees Approx 200 Approximatel y 120 40 115 105 Employed Skilled Nurses 60 none 30 Approx 30 51 Private Duty Nursing 34 Features AssistedCare Home Instead Pender Home Health Liberty Home Health WellCare Employed Unskilled Nurses 125 109 None Approx 60 Number of Clients 450 125 Over 400 Approx 100 774 Payments Accepts Medicare/Medicai d and most private insurance plans Accepts cash for services that insurance is not accepted Cash Less than 5% have long-term care insurance that would cover unskilled services Accepts Medicare/Medicai d and most private insurance plans Rarely takes cash Accepts Medicare/Medicai d and most private insurance plans Accepts cash for services that insurance is not accepted Accepts Medicare/Medicai d and most private insurance plans Accepts cash for services that insurance is not accepted Target Consumer Families of aging senior citizens and hospital outpatients needing additional care Push technique: Targets area hospitals to gain doctor and nursing referrals for outpatients Alzheimer Patients and elderly Outpatients of Pender Memorial Health Homebound patients needing additional medical attention Use mostly pull-technique in gaining patients through website marketing To you, it's about finding trustworthy care for your aging loved one To us, it's about providing the highestquality inhome care services to fit you and your family's needs Patients of Pender Memorial hospital are referred to Pender Home Health services Families of aging senior citizens and hospital outpatients needing additional care Push technique: Targets area hospitals to gain doctor and nursing referrals for outpatients Focus on Hospice Care as well as the Independence, Compassion and Care that they provide patients 360 Degrees of Care Distributio n Service Claims / Brand Positioning Fulfilling all your home health care needs with a full range of services Pender Memorial Hospital entered into an affiliation with New Hanover Regional Medical Center in order to better provide a full range of services to the community 35 Push technique: Targets area hospitals to gain doctor and nursing referrals for outpatients RESEARCH (Links) Top down view http://www.americangeriatrics.org/ US Census http://factfinder.census.gov/servlet/ACSSAFFFacts? _event=&geo_id=01000US&_geoContext=01000US&_street=&_county=&_cityTown=&_state=&_zip=&_lang=en &_sse=on&ActiveGeoDiv=&_useEV=&pctxt=fph&pgsl=010&_submenuId=factsheet_1&ds_name=null&_ci_nbr= null&qr_name=null®=null%3Anull&_keyword=&_industry= http://www.census.gov/prod/2009pubs/p95-09-1.pdf http://factfinder.census.gov/servlet/SAFFEconFacts? _event=&geo_id=01000US&_geoContext=01000US&_street=&_county=&_cityTown=&_state=&_zip=&_lang=en &_sse=on&ActiveGeoDiv=&_useEV=&pctxt=bg&pgsl=010&_submenuId=business_2&ds_name=&_ci_nbr=&qr_n ame=®=null%3Anull&_keyword=&_industry=6216 http://factfinder.census.gov/servlet/IBQTable?_bm=y&-fds_name=EC0200A1&-_industry=621610&NAICS2002sector=8701030&-ib_type=NAICS2002&-_lang=en&-geo_id=01000US&-NAICS2002=6216|62161| 621610&-ds_name=EC0262SLLS1&-NAICS2002subsector=8701031 http://factfinder.census.gov/servlet/IBQTable?_bm=y&-dataitem=*&-fds_name=EC0200A1&_industry=621610&-NAICS2002sector=8701030&-ib_type=NAICS2002&-_lang=en&-geo_id=01000US&NAICS2002=621|6216|62161|621610&-ds_name=EC0262A1&-NAICS2002subsector=8701031 New release 9/09http://www.census.gov/hhes/www/hlthins/hlthin08.html Alternative site that is direct to health care stats http://www.census.gov/econ/census02/data/industry/E621.HTM http://www.dhhs.state.nc.us/aging/cprofile/cprofile.htm http://www.ibisworld.com/industry/retail.aspx?indid=1579&chid=1 http://www.schs.state.nc.us/SCHS/data/index.html http://www.ncpublichealthcatch.com/ReportPortal/design/view.aspx http://www.shepscenter.unc.edu/data.html http://linc.state.nc.us/ 36 https://edis.commerce.state.nc.us/Portal/main.do North Carolina Data http://southnow.org/southnow-publications/carolina-context/cc1.pdf http://www.osbm.state.nc.us/ncosbm/facts_and_figures/socioeconomic_data/population_estimates/county_pr ojections.shtm OR can be found at: http://www.osbm.state.nc.us/ncosbm/facts_and_figures/socioeconomic_data/population_estimates.shtm Home Health Care http://0-www.ibisworld.com.uncclc.coast.uncwil.edu/industry/default.aspx?indid=1579 http://www.homeandhospicecare.org/ http://www.nahc.org/ http://www.ocbhs.org/provider_corner%20Final.htm http://cdc.gov/DataStatistics/ http://www.dhhs.state.nc.us/dhsr/ncsmfp/2009/2009plan.pdf **Note LOTS of data on home health in the US http://www.cdc.gov/nchs/data/nhhcsd/curhomecare00.pdf http://www.cdc.gov/nchs/data/hus/hus08.pdf Aging Study of New Hanover County http://www.ncdhhs.gov/aging/demograpic/8_AgingStudy_NewHanoverCounty.pdf Aging Study of Brunswick County http://www.dhhs.state.nc.us/aging/demograpic/3_AgingStudy_BrunswickCounty.pdf What about UNCW's role in health care http://www.uncwil.edu/aa/Reports/Final%20Task%20Force%20Jan%2030-1%20Revised%20Feb%2008.pdf 37 Listing of Home Health agencies in N.C http://www.ncdhhs.gov/dhsr/data/hhlist.pdf Financial Sites/General Stats Global view of GDP for health care industries in the U.S http://www.bea.gov/industry/ Home Health billing/coding (most in NC) http://www.ncdhhs.gov/dma/fee/hh_090108.pdf http://www.ncdoi.com/Consumer/consumer_providers.asp http://www.nchealthinfo.org/health_topics/health_care/Health_Insurance.cfm http://www.nchealthinfo.org/ http://www.medicalpmrg.com/articles/payor_mix_analysis.html Federal register 40949http://www.ilhomecare.org/uploads/pdfs/HHPPS%20Proposed%202010%20republication81309.pdf http://www.thefederalregister.com/d.p/2009-08-06-E9-18587 How to reference the citation in used in the paper: http://library.duke.edu/research/citing/workscited/index.html Conducting an industry analysis http://www.sbtdc.org/pdf/industry_analysis.pdf Examples of facilities http://www.emeritus.com/ http://www.assistedseniorliving.net/facilities/south-carolina/charleston-sc/ 38 http://www.bishopgadsden.org/ Senior Living Study (example of great paper on subject) Report: http://www.reri.org/research/article_pdf/wp153.pdf http://www.aoa.gov/AoARoot/Aging_Statistics/index.aspx 39 References CDC 2000 National Home and Hospice Health Survey, Current Home Health Care Patients, Table CDC FastStats for Home Health Care [cited 19 Sept 2009} Available from http://www.cdc.gov/nchs/fastats/homehealthcare.htm NIH Unprecedented Global Aging Examined in New Census Bureau Report Commissioned by the National Institute on Aging NIH News [released 20 July 2009; cited 19 Sept 2009] Available from http://www.nih.gov/news/health/jul2009/nia-20.htm Carolina Context The Program on Public Life August 2006 (1) [cited 9/19/09] Available from http://southnow.org/southnow-publications/carolina-context/cc1.pdf Herzog, A and Lind, L 2003 Network Solutions for Home Health Care Applications Technology and Health Care 11(2), 7787 Available from EBSCOhost at http://0-search.ebscohost.com.uncclc.coast.uncwil.edu/login.aspx? direct=true&db=hch&AN=9481289&site=ehost-live Singh, G., O'Donoghue, J, Soon, C.K 2002 Telemedicine: Issues and Implications Technology and Health Care 10(1), 110 Available from EBSCOhost at http://0-search.ebscohost.com.uncclc.coast.uncwil.edu/login.aspx? direct=true&db=hch&AN=6166744&site=ehost-live Synder, J 2007 Home Care Heats Up H&HN: Hospitals and Health Networks 81(7), 56-58 Available from EBSCOhost at http://0-search.ebscohost.com.uncclc.coast.uncwil.edu/login.aspx?direct=true&db=hxh&AN=25888165&site=ehost-live IBISWorld Industry Report Home Care Providers in the U.S 62161 [updated 19 Aug 2009; cited 19 Sept 2009] Available from http://www.ibisworld.com/industry/retail.aspx?indid=1579&chid=1 Bull, M and McShane, R 2008 Seeking What's Best During the Transition to Adult Day Health Services Qualitative Health Research 18(5), 597-605 Available from EBSCOhost at http://0-search.ebscohost.com.uncclc.coast.uncwil.edu/login.aspx? direct=true&db=hch&AN=31995115&site=ehost-live Schwab, T et al 2003 Home- and Community-Based Alternatives to Nursing Homes: Services and Costs to Maintain Nursing Home Eligible Individuals at Home Journal of Aging and Health 15(2), 353-370 Available from EBSCOhost at http://0-search.ebscohost.com.uncclc.coast.uncwil.edu/login.aspx?direct=true&db=hch&AN=9606404&site=ehost-live 10 Smith-Higuchi, K., A Christensen, J Terpstra 2002 Challenges in Home Care Practice: A Decision-Making Perspective Journal of Community Health Nursing 19(4), 225-236 Available from EBSCOhost at http://0search.ebscohost.com.uncclc.coast.uncwil.edu/login.aspx?direct=true&db=hch&AN=8706863&site=ehost-live 11 Meyer, R 2009 Consider Medical Care at Home Geriatrics 64(6), 9-11 Available from EBSCOhost at http://0search.ebscohost.com.uncclc.coast.uncwil.edu/login.aspx?direct=true&db=hch&AN=41330214&site=ehost-live 12 Kodner, D and Kyriacou, C 2003 Bringing Managed Care Home to People With Chronic, Disabling Conditions: Prospects and Challenges for Policy, Practice, and Research Journal of Aging and Health 15(1), 189-222 Available from EBSCOhost at http://0-search.ebscohost.com.uncclc.coast.uncwil.edu/login.aspx?direct=true&db=hch&AN=9039239&site=ehost-live 13 Elias, J, Ferry, R, Treland, J 2000 When World Views Collide: A Commentary on Home Health Care Case-Mix and Patient Outcomes Experimental Aging Research 26(3), 181-188 Available from EBSCOhost at http://0search.ebscohost.com.uncclc.coast.uncwil.edu/login.aspx?direct=true&db=hch&AN=3280729&site=ehost-live 40 14 Weissert, W, Chernew, M, Hirth, R 2003 Titrating Versus Targeting Home Care Services to Frail Elderly Clients: An Application of Agency Theory and Cost-Benefit Analysis to Home Care Policy Journal of Aging and Health 15(1), 99-123 Available from EBSCOhost at http://0-search.ebscohost.com.uncclc.coast.uncwil.edu/login.aspx? direct=true&db=hch&AN=9039236&site=ehost-live 15 Greene, V 2005 Prospective Budgeting for Home Care: Making Titration Work Journal of Aging and Health 17(4), 399424 Available from EBSCOhost at http://0-search.ebscohost.com.uncclc.coast.uncwil.edu/login.aspx? direct=true&db=hch&AN=17712135&site=ehost-live 16 Kane, R., Bershadsky, B., Bershadsky, J 2006 Who Recommends Long-Term Care Matters Gerontologist 46(4) Abstract Available from EBSCOhost at http://0-search.ebscohost.com.uncclc.coast.uncwil.edu/login.aspx? direct=true&db=hch&AN=22247057&site=ehost-live 17 Gilmer,L North Carolina Budget Cuts Targeting Health Care Programs and Initiatives North Carolina Healthcare Report [released June 2009; cited 19 Sept 2009] Available from http://www.carolinashealthcarelaw.com/?p=730 18 General Assembly of North Carolina 2009 sess., Session Law - 451., Senate Bill 202 110 Available from http://www.ncleg.net/Sessions/2009/Bills/Senate/PDF/S202v8.pdf The National Association for Home Care and Hospice: “Basic Statistics about Home Care” Updated 2008 Available at http://www.nahc.org/facts/ 19 20 “The Market is out there.” Gail Walker 2004 PRIMEDIA Business Magazines & Media Inc 21 Evans, G., et al 2008 Income Health Inequalities Among Older Persons The Mediating Role of Multiple Risk Exposures Journal of Aging and Health 20(1), 107-125 Available from EBSCOhost at http://0web.ebscohost.com.uncclc.coast.uncwil.edu/ehost/detail?vid=2&hid=111&sid=295acf98-5653-42ca-97f07be3a6974b22%40replicon103 22 Mandel, I 2009 Health Care by Age, Gender & Class Research Starters, Sociology of Health & Medicine 1-5 Available from EBSCOhost at http://0search.ebscohost.com.uncclc.coast.uncwil.edu/login.aspx? direct=true&db=rst&AN=36267969&site=ehost-live 23 " 2007 Disability Status Report: North Carolina" Cornell University Available from http://www.ilr.cornell.edu/edi/DisabilityStatistics/ 24 Lin, C.J., Meit, M 2005 Changes in Medicare Home Health Care Use and Practices in Rural Communities Journal of Aging and Health 17(3), 351-362 Available from EBSCOhost at http://0search.ebscohost.com.uncclc.coast.uncwil.edu/login.aspx?direct=true&db=hch&AN=17135986&site=ehost-live 25 McAuley, W.J., et al 2004 The Influence of Rural Location on Utilization of Formal Home Care: The Role of Medicaid Gerontologist 44(5), 655-664 Available from EBSCOhost at http://0search.ebscohost.com.uncclc.coast.uncwil.edu/login.aspx?direct=true&db=hch&AN=14894005&site=ehost-live 26 "Strategies for achieving best value in commissioned home care", Bethan M Davies and Paul R Drake Available from http://0-www.emeraldinsight.com.uncclc.coast.uncwil.edu/Insight/viewPDF.jsp? contentType=Article&Filename=html/Output/Published/EmeraldFullTextArticle/Pdf/0420200304.pdf 41 42 ... 58 230 96 297 331 223 1273 384 554 103 221 707 336 86 4 1 185 82 0 4236 1264 2005 35 66 192 116 244 264 1 58 1075 374 422 75 88 297 123 341 424 222 1570 5 08 646 78 113 4 38 286 753 751 4 18 283 7 83 7... 13, 587 (65+ y.o.) Projected population 2010 4 ,83 1 19,237 8, 017 7,073 26 ,86 2 8, 324 8, 8 18 (65+ y.o.) Health Care Expenditures $33,475,646 $131,390,602 $55, 283 ,85 2 $ 48, 914,047 $2 58, 676,359 $55, 085 ,455... RATE/UNIT $ 1 18. 64 $ 1 18. 64 $ 1 18. 64 $ 1 18. 64 $ 1 18. 64 $ 1 18. 64 MAXIMUM RATE/UNIT $ 111 .85 RC551 Skilled Nursing Visit RC559 Skilled Nursing - Other Visit RC 580 Home Health - Other Visit RC 581 Home Health