Roles and Priorities Guiding Medicare Advantage Postacute Home Health Referrals

ABSTRACT

Objectives: Home health care (HHC) helps patients—including those recently discharged from the hospital—regain function and maintain independence. The provision of postacute HHC is influenced by multiple players: Medicare Advantage (MA) plans, postacute care management companies (CMCs), hospitals, home health agencies (HHAs), and patients and families. This study sought to characterize the roles and priorities of these players in organizing and delivering postacute HHC.

Study Design: In-depth, semistructured interviews with 44 leaders of MA plans, CMCs, and HHAs across the US.

Methods: Interviews were recorded, transcribed, and analyzed using content analysis.

Results: MA plans and CMCs agreed that home is the ideal setting for postacute care; however, MA plans and CMCs varied in their involvement in referrals, and HHAs viewed their involvement as burdensome (theme 1). According to MA plan, CMC, and HHA leaders, a hospital’s role is to select the appropriate postacute care setting, but participants reported that selections can be influenced by relationships with MA plans and HHAs (theme 2). HHAs were reported to balance clinical complexity, staffing, patient location, and payer when accepting referrals, but they had relatively limited control in the referral process (theme 3). Participants expressed that patients prioritized prior experiences, recommendations, quality of care, access, and timeliness when making decisions; however, patients had a minimal role and limited information to guide decision-making (theme 4).

Conclusions: Findings can help policy makers, payers, HHAs, hospitals, and patients understand the varied roles and shared incentives in coordinating postacute HHC for vulnerable older adults.

Am J Manag Care. 2026;32(7):In Press

Takeaway Points

In this study, we investigated the complex relationships among Medicare Advantage plans, care management companies, hospitals, and home health agencies as patients are discharged to postacute home health care. Optimal care may be limited by insufficient patient and family involvement and administrative challenges. These results provide insights to policy makers, payers, providers, and patients to improve care coordination, transparency, and the quality and efficiency of postacute care delivery.

• Medicare Advantage plan and care management company involvement in referrals adds administrative burden for providers.
• Increasing transparency and patient/family involvement can improve access and outcomes.

Home health care provides skilled nursing, therapies, and aide services to help patients—many of whom are recently discharged from the hospital—regain function, restore health, and maintain independence in the community. Although postacute care can be provided in institutional settings such as skilled nursing facilities, most patients and caregivers prefer to receive postacute care at home.¹ Approximately 20% of patients discharged from the hospital in 2020 were referred for home health care, and Medicare is the primary payer of postacute care for adults 65 years and older.^2,3

More than half of Medicare beneficiaries are enrolled in Medicare Advantage (MA) plans,⁴ which are incentivized to coordinate care and reduce health care expenditures for their enrollees. To meet these goals, many MA organizations partner with postacute care management companies (CMCs), which offer services such as care coordination, referral management, and utilization management. Prior research data show that enrollment in MA is associated with a lower likelihood of postacute home health care receipt and that those who do receive postacute home health care have shorter lengths of stay and fewer visits for nursing and therapy than similar patients enrolled in traditional Medicare.^5-7 This lower utilization is also associated with worse functional status outcomes for MA enrollees.⁸

The provision of postacute home health care has the potential to be influenced by the MA plans that pay for home health care, the CMCs with which they partner to manage services, hospitals and other referring providers, home health agencies (HHAs), and patients and families themselves. Although prior research data show differential utilization of postacute home health care and resulting outcomes for Medicare beneficiaries enrolled in MA,^5-8 the mechanisms that underlie the relationships among the players involved and the ways in which these differential outcomes are achieved are unknown. To that end, this study sought to understand the roles and priorities of these players in organizing and delivering postacute home health care.

METHODS

This study included semistructured interviews with representatives from MA plans, CMCs, and HHAs. We used both purposive and snowball sampling to identify and recruit participants from 6 health care markets in the US across varied census regions with moderate to high MA penetration and 3 or more MA plans serving 10% or more of Medicare beneficiaries. Participants were identified within MA plans, CMCs, and HHAs in these 6 markets using professional networks and web searches and then contacted by phone or email and invited to participate. At the completion of each interview, we asked participants for connections to other relevant individuals in their markets.

We developed 2 interview guides (1 for MA and CMC representatives and 1 for HHA representatives), piloted them with industry experts, and made revisions. Interviews with MA and CMC representatives asked about home health benefit design, network development, and the postacute care referral process, among other topics. Of note, we did not initially intend to interview CMC representatives, as we were not aware of the significance of their involvement until after we conducted the first MA interviews. Once we learned of their relevance, we added CMC-specific questions to the MA interview guide and began actively recruiting CMC participants, typically through engaging with MA leaders who had participated in interviews. Interviews with HHA representatives asked about relationships with payers and referring providers, the referral and admissions process, and payment processes. Interviews were conducted by telephone or videoconference, depending on participant preference, from March 2023 to June 2024. Interviews lasted approximately an hour, were audio recorded with participants’ consent, and were professionally transcribed. Interview transcripts were reviewed for accuracy and deidentified by members of the research team.

Transcripts were analyzed using a modified approach to content analysis. We developed preliminary coding schemes specific to each interview type based on the questions asked in our interviews. These coding schemes were then refined iteratively based on the new content that emerged during analysis of the first several transcripts. After these first transcripts were coded, the coding schemes were finalized, and all transcripts were coded independently by at least 2 team members. Team members then met to reconcile coded transcripts and summarize findings from each interview. During weekly team meetings, we discussed emerging interpretations, determined that thematic saturation had been achieved, and maintained a comprehensive audit trail that documented team discussions and decisions.⁹ NVivo 1.7.1 (Lumivero) was used to manage coded data. This study was not considered human participants research by the Brown University Institutional Review Board.

RESULTS

We conducted 44 interviews, including 18 representatives from 14 MA organizations, 5 representatives from 5 CMCs, and 21 representatives from 19 HHAs. MA participants included presidents, vice presidents, and chief executive, medical, and development officers. The organizations they represented were regional or national in scope, varied in their size and CMS quality ratings, and collectively enrolled more than 20 million MA enrollees in 2023 (> 62% of the total MA market).¹⁰ CMC participants included directors, chief medical officers, and vice presidents. HHA participants included directors, presidents, chief executive and operating officers, and administrators. The agencies were regional or national in scope and ranged in organizational age and the number of new patients seen in 2020. See Table 1 for characteristics of participating organizations.¹⁰

Our analysis of these interviews revealed that most MA plans and CMCs agreed that home is the ideal setting for postacute care and that institutional care should be avoided whenever possible; however, MA plans and CMCs varied in their involvement in postacute home health referrals, and HHAs tended to view MA and CMC involvement as adding burden to the referral process (theme 1). MA plan, CMC, and HHA leaders viewed the role of the hospital as to select the appropriate postacute care setting and reported that hospitals prioritized ease of placement and timeliness/responsiveness of HHAs in making these selections; interview participants also reported that referral decisions could be influenced by relationships with MA plans and HHAs (theme 2). HHAs were reported to try to balance clinical complexity, staffing, patient location, and payer when accepting referrals, but they had relatively limited control in the postacute referral process, in part because they had limited information about patients until they accepted the referral and made the first home visit (theme 3). Participants expressed that patients prioritize prior experiences; recommendations from family, friends, and providers; quality of care; and access to and timeliness of service when making home health decisions; however, participants reported that patients had a minimal role in the decision-making process and limited information to guide their decision-making (theme 4).

Theme 1: MA and CMC Priorities and Roles in Postacute Home Health Referrals

In interviews with MA, CMC, and HHA leadership, participants described how MA plans and CMCs approach referrals to postacute home health. In describing their perspectives on home health, most MA plan and CMC representatives agreed that home is the ideal setting for postacute care and that institutional care should be avoided whenever possible (theme 1A). They provided reasons including that home health aligns with patients’ preferences, that patients had better outcomes when they were at home, and that home health is less expensive than institutional care. MA plan and CMC representatives also discussed their priorities for deciding which HHAs patients should be referred to, including adequate staffing, geographic fit, and quality (theme 1B). Despite MA plan and CMC assertions that home health is the ideal setting for postacute care, HHA leaders often noted that MA plans do not reimburse as if home health is a priority (theme 1C).

Participants reported that MA plans and CMCs had variable roles and involvement in postacute home health referrals (theme 1D). Some described the ways in which MA plans and CMC partners directed or led the referral process and the selection of particular HHAs. Others described involvement in or collaboration on home health referrals. Still others described that MA plans and/or CMCs were not involved in referrals or indicated that they were not allowed to direct care or influence patient choice. HHA leaders gave their perspectives on MA and CMC involvement in home health referrals and tended to view it as adding burden to the process (theme 1E). See Table 2 for representative quotes.

Theme 2: Hospital and Other Provider Priorities and Roles in Postacute Home Health Referrals

MA plan, CMC, and HHA representatives discussed the priorities and roles of hospitals and other providers in the postacute home health referral process. Reported priorities of hospitals and other providers included referring patients to HHAs that are high quality, are able to cover their geographic location, and can adequately support the patients’ complexity and care needs. In practice, priorities also included that HHAs are responsive to referral requests, easy to work with, and able to initiate care quickly (theme 2A). This also meant that prior relationships between providers and HHAs played a large role in decision-making.

Participants expressed that the role of hospitals and other providers is to lead the postacute referral and discharge planning process (theme 2B). In this process, discharge planners and other team members give patients the opportunity to select an HHA, usually by providing a list, but participants noted that discharge planners can be influenced by several factors. Consistent with the varying roles of MA plans and CMCs in the referral process, some participants reported that relationships between hospitals and MA plans/CMCs influenced referral options: Some MA plans and CMCs placed staff in hospitals to facilitate discharge and referrals. Participants also described HHA liaisons working with hospitals as potentially influencing patient choice and HHA access. See Table 3 for representative quotes.

Theme 3: HHA Priorities and Roles in Postacute Home Health Referrals

Interview participants described the priorities and roles of HHAs in postacute home health referrals. HHAs expressed that home is the ideal setting for postacute care (theme 3A). They described home health care as an effective mechanism to keep patients healthy and out of the hospital while allowing them to receive care in the comfort of their homes. HHA and MA plan representatives were mainly aligned in their description of HHA priorities for making postacute home health referral decisions. Both discussed priorities such as clinical complexity, staffing ability, and geographic location (especially rurality) of the patient. HHAs also reported the balance between payer type and the importance of relationships with health care systems contributing to referrals.

HHAs and MA plans reported that HHAs preferred to be integrated into discharge planning and highlighted the importance of their relationships with health care systems to best determine whether they could care for the patient (theme 3B). Some HHA and MA plans reported having HHA liaisons—representatives from the HHAs in hospitals—who partner with hospital clinicians on discharge planning, inform patients about their options, and determine whether they can staff and accept a referral. Other HHAs described that since the COVID-19 pandemic, they have been unable to staff HHA liaisons in hospitals, which limits their relationships with those systems. Because HHAs are generally not part of the discharge planning process until a referral has been accepted, HHA and MA plans both noted that HHAs do not receive enough information during the referral process to have a clear clinical picture of the patient’s condition and needs. Agencies described the need for flexibility in visits after initial assessment and the ability to determine the appropriate care plan. See Table 4 for representative quotes.

Theme 4: Patient Priorities and Roles in Postacute Home Health Referrals

Throughout interviews with MA plan, CMC, and HHA representatives, the priorities and roles of patients in the postacute home health referral process were discussed. Participants noted that in making decisions, patients care about prior experiences; recommendations from family, friends, and providers; quality; and access to and timeliness of care (theme 4A). Prior experience was reported to be a primary driver of patient choice, and some expressed that in the absence of prior experience with or awareness of home health, patients were not receptive to receiving home health care.

Participants also discussed the extent to which patients were able to choose their postacute HHA (theme 4B). Because of the number of players involved and their roles and priorities, perspectives differed on the ability of patients to play a role in HHA choice. Participants also expressed that when patients are involved in postacute home health decision-making, there are challenges, including that quality measures do not tell the full story and that options may be limited based on their insurer network or in their geographic location. See Table 5 for representative quotes.

DISCUSSION

In describing the roles and priorities of various players in postacute home health referrals, participants identified standards and practices for how the process should work: Referring providers should lead discharge planning, and placement decisions should be based on clinical needs and HHA quality and staffing. Patients should have an active role in decision-making, guided by adequate data, and should make the final choice. However, participants discussed how these ideals were compromised in practice. For example, MA organizations and the CMCs with which they work may influence discharge planning through their administrative requirements. In addition, discharge planning decisions are often constrained due to time sensitivity, limited HHA options (particularly in rural areas), and other factors. Relationships between hospitals and HHAs play a substantial role in discharge decisions, HHAs report not having enough information about patients to inform their decisions to accept referrals, and patients are largely not meaningfully included in the process.

Our findings align with and extend previous research regarding patients’ roles in postacute home health decision-making. Although participants in our study expressed that patients should have a major role in postacute care decisions and should have appropriate information and support needed to make those decisions, in reality, patients have a limited role and rely primarily on recommendations when selecting an HHA. This is consistent with previous research that found that patients were not aware of available quality reporting and that discharge planning staff were hesitant to provide data due to anxieties about influencing patient choice.^11-13 Research examining the impact of including home health quality of care and patient experience star ratings to guide consumers found that patients were more likely to select high-quality HHAs after the introduction of the ratings but that the impact was not as strong as in other settings such as nursing homes, where a single summary star rating is used.¹⁴ In combination with our results, such findings indicate that patients would benefit from additional resources and support in making postacute home health decisions. In an effort to enhance patient involvement, perhaps measures of shared decision-making—and the role of MA in that decision-making—could be added to the Hospital Consumer Assessment of Healthcare Providers and Systems survey. Additionally, models such as the Agency for Healthcare Research and Quality SHARE Approach,¹⁵ which offers guidelines to facilitate meaningful clinician-patient dialogue, could be implemented in hospital settings to support person-centered decision-making.

Our findings add to the understanding of the role of MA in postacute home health care. The Medicare Payment Advisory Commission has expressed concerns regarding home health utilization and spending.¹⁶ A potential benefit of MA is that it could be used to limit overuse of home health care, but findings to date have been mixed about reductions in utilization and associated outcomes for patients.^5-8,17-20 Our findings shed light on the nuanced ways MA may influence postacute home health care and build on those of another article resulting from these interviews, in which we documented the additional burden from MA prior authorization and utilization management policies on postacute home health care.²¹ Taken together, these findings suggest that although there may be a role for MA in limiting home health overutilization, implications for access to home health for beneficiaries with MA and more long-term health care utilization are not fully understood.

MA organizations and CMCs have the ability to control which HHAs provide home health for their patients, and they vary in their direct involvement in the discharge planning process. CMCs wield substantial power in discharge planning, and our research is the first, to our knowledge, to examine MA and CMC relationships and roles with regard to discharge planning. Currently, MA is not required to report whether they work with CMCs. Given the power of CMCs, additional transparency would be beneficial and would support further research on how the confluence of CMCs, MA, referring providers, and HHAs impacts patient access to high-quality postacute home health care.

Limitations

This study has several limitations. Although we included a robust sample of MA plans, CMCs, and HHAs that varied in region, age, size, and quality, results may not be generalizable. Those who chose to participate in our study may differ from those who did not. As noted in the Methods, we did not initially intend to interview CMC representatives, as we were not yet aware of the importance of their role. As a result, we did not create a separate interview guide for MA vs CMC participants. This may not facilitate a distinct understanding of the role of CMCs. Additionally, although we present perspectives on the roles and priorities of hospitals and other referring providers and patients and their families regarding postacute home health, it is important to note that these perspectives came from MA, CMC, and HHA representatives. Future research should obtain the direct perspectives of all stakeholders.

CONCLUSIONS

Findings from this research highlight opportunities for improvement and streamlining of postacute home health referrals and are consistent with advancement toward meeting the Quintuple Aim.²² MA, CMCs, referring providers, HHAs, and patients have varying roles and priorities in the postacute care discharge planning and referral process. HHAs must balance patient care, administrative burden, and relationships with hospital discharge planners while maintaining a payer mix that offsets low MA reimbursement. MA plans use CMCs to facilitate administrative processes, and both entities may influence the selection of an HHA. Hospitals were key decision makers and prioritized discharging patients efficiently and based on prior relationships. In conclusion, the multiple players in postacute home health referrals and delivery for MA beneficiaries have roles and objectives that introduce additional complexity, and patients are not routinely involved as key partners in HHA referral decisions. Findings can help policy makers, payers, HHAs, hospitals, and patients understand the varied roles and shared incentives in coordinating postacute home health care for older adults. n

Author Affiliations: Brown University School of Public Health (EAG), Providence, RI; Johns Hopkins University School of Nursing (JB, EB, KST), Baltimore, MD; University of Colorado Anschutz School of Medicine (MD, CDJ), Aurora, CO; Widener University Jack & Nancy Dwyer School of Nursing (JMS), Chester, PA.

Source of Funding: This research was supported by the Commonwealth Fund, a national, private foundation based in New York, New York, that supports independent research on health care issues and makes grants to improve health care practice and policy. The views presented here are those of the authors and not necessarily those of the Commonwealth Fund, its directors, officers, or staff.

Author Disclosures: Dr Jones is a consultant for the Carelon Home Health Clinical Guidelines Panel. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (EAG, CDJ, KST); acquisition of data (EAG, JB, MD, JMS, EB, CDJ, KST); analysis and interpretation of data (EAG, JB, MD, JMS, EB, CDJ, KST); drafting of the manuscript (EAG); critical revision of the manuscript for important intellectual content (EAG, JB, MD, JMS, CDJ, KST); statistical analysis (EAG, JB); provision of patients or study materials (JB); obtaining funding (EAG, KST); administrative, technical, or logistic support (EAG, JB, EB, KST); and supervision (EAG).

Address Correspondence to: Emily A. Gadbois, PhD, Brown University School of Public Health, 121 S Main St, Providence, RI 02903. Email: emily_gadbois@brown.edu.

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