Business Solutions

HME Hospitality

How providers are customizing home access to meet unique patient needs.

• By Cindy Horbrook, David Kopf
• Nov 01, 2012

“There’s no place like home.” That’s a sentiment shared by both patients and the HME providers that serve them. Whether a patient is in a wheelchair, has difficulty seeing, or wants to grow old under the roof that has sheltered him or her for decades, all patients wish to enjoy safe, unfettered access to their homes.

And for providers facing an increasingly tough reimbursement environment, increased pre-and post-payment Medicare audits, and CMS’s roll-out of Round Two of competitive bidding, providing home access offers an important new revenue stream. Home access is almost entirely a retail business covering a spectrum of products that range in price and complexity from easy-to-install, low-cost grab bars to entire room or home remodels.

Moreover, home access is a logical point of expansion. Providers can leverage the businesses that they have built in order to branch out into home access. They simply need to survey their current businesses, and see how home access relates to it, says Jerry Keiderling, president of the VGM Group’s Accessible Home Improvement of America (AHIA) division.

“There are so many providers out there that deal almost solely with respiratory,” Keiderling notes as an example. “So that [home access] is a little bit different than if you’re a rehab provider, dealing with a lot deep, complex mobility issues. I think it’s a different outlook for each patient group.

“A respiratory provider is going to be looking at things like ADLs and simpler solutions for helping patients stay in their homes,” he continues. “While a complex rehab provider is looking at more involved solutions for independent living, or help for the caregiver or family member.

“Begin with your existing clientele and start from there,” Keiderling adds. “It’s not like finding a new market. It’s adding to your product and service offerings.”

Not only does providing home access let providers leverage their existing referral sources, but it also opens up whole new groups of potential partners for driving new home access business.

“The referral sources they’ll start out with are the ones that they know, that they’re comfortable working with,” Keiderling says. “And they will expand out from there, because a lot of those referral sources deal with certain subsets, or disease states. So as they get into new possibilities of product and service offerings, it opens up a new world for other referral sources.

Senior Patients

One clear category for home access is senior patients. For seniors, some of whom may be experiencing declines in eyesight, hearing and/or mobility, the home can quickly turn into a hazard. Between the slip and fall risks in the bathroom, burn risks in kitchen and difficulty climbing stairs, the home can pose a number of safety issues to the aging population.

And, beyond safety, formerly simple tasks, such as seeing the clock or hearing the doorbell, can present challenges. That’s why seniors plus home access equals a golden opportunity for HME providers to reach out to a different patient population with accessibility products they would likely need.

“It’s a very good opportunity,” AHIA’s Keiderling says. “It’s a natural progression for the typical HME or DME (provider) to be looking at this type of industry.”

Home accessibility products offer up-sell opportunities that can help drive cash sales revenue for the provider since those sorts of products are not covered by Medicare or private payor insurance, and the patient must pay for that on a retail basis.

“It’s not always selling, but up-sell can also be education,” Keiderling explains. “It can be simple conversations with a client. If you’ve been seeing clients on a regular basis for respiratory or mobility equipment or both, or maybe a bed, just simple conversation of not only how that equipment is working for them in the home, but what about the rest of the home.”

Often times, a senior will lament about how they can no longer cook, garden or maybe express concern about difficulty with rising out of their bed or favorite chair in the living room. And while bath safety items, grab bars and ramps as well for the entry and exit of the home are often considered some of the main home access products, items such as lifts and stand assists can help ensure safe home access for senior patients.

“They either fit under the chair, or maybe they have a swing around table for reading or to put the remote control or eat on, but they work as an assist for entry and exit out of a chair and then beds as well,” Keiderling says. “A lot of times beds are soft. They may not be exactly the right height for the best transfer in and out of bed, so a nice assist rail or a pole or a bedside mounted assist would help them.”

Seniors, in particular, offer different home access needs than other patient groups. Slips and falls are among the top fears that seniors have, and with good reason. They cause largest percentage of injuries of seniors, and can range from moderate to severe. Most slips and falls occur in the bathroom, which is what makes it biggest safety concern in a senior’s home, according to Keiderling.

“The bathroom is slippery,” he says. “It’s an area with water and usually tile flooring.”

And many seniors, when remodeling, updating or purchasing a new home, go for the shiny floor.

“Shiny gives you a feeling of clean, but it’s also slippery,” he continues. “Getting in and out of the bathtub or just being able to walk on the floor if there is a little bit of water, it’s very slippery. And then a lot of them will try to put those big furry rugs and then you have a trip point, so bathrooms are a big concern.”

Since home access products aren’t typically covered by Medicare or private payor insurance, providers may experience push back from seniors on fixed or tight budgets. However, home access doesn’t have to be all or nothing.

“They need to look at long term plans and maybe separate a project out if necessary. Look at what needs to be done today and what will you probably need next year or three years down the line, and split that project up, if possible,” Keiderling explains. “That can help that budget tremendously because today may only be a grab bar, but we know that within a year or two it may be a ramp, but that gives you time to plan for that, to search for funding or raise the cash from family.”

Keiderling also recommends that providers know about various funding resources available in their area and be able to discuss the qualifications for those resources.

“It’s very important for the provider to know any and all possible funding sources in their area that may apply. Some areas have waiver programs. There are community-based living programs that are available,” he says.

It’s no secret that the population of seniors continues to grow. According to the 2010 Census, there are 40.3 million people age 65 or older. The AARP reports that by 2030 one in every five Americans will be age 65 or older. And these are folks that want to live their golden years in the comfort of their home, which gives providers an opportunity to reach out with accessibility products that help make that happen.

“They love their home,” Keiderling says. “That’s where they have lived for 50 years. They want to keep that feeling of being safe.”

Tailor-Made Access

However, at a certain point, providing home access can start to get a little more specialized. While a patient might fit a certain category, their needs might actually go beyond the typical needs of a category. Many patients might suffer multiple conditions, or they might have conditions that either grow more serious or engender co-morbidities over time, that require additional home access services, Keiderling notes. Multiple subsets will require multiple solutions.

“You could almost look at it as a form of disease state, if you will,” he explains. “Those with arthritis, or hip [conditions], or debilitating disease, there are different apparatus and equipment and services that each one of them could need right away or in the future.

“And then some patients are going to be in dual or multiple subsets,” he continues. “They could be bariatric and in a wheelchair. They might also have diabetes, which could lead to eyesight problems, it could lead to even wound care, which would impact what bed they are in and how they transfer in and out, and how they are bathing.”

Simply put, many patients can’t be pigeon holed. Such has been the experience of Rob Horkheimer, MPT, CAPS, CEAC, ECHM, co-owner of Bridgeway Independent Living Designs LLC (BILD), which serves patients in southeastern and central Wisconsin and northern Illinois. BILD offers its clients a compelling blend of therapeutic and construction expertise.

Horkheimer has a deep background as a therapist, having specialized in working with spinal chord rehab patients. He co-owns the business with his brother-in-law, Joe Caravella, CAPS, who has 20 years’ experience in the construction industry. Better yet, their spouses are therapists, as well. Together, the family business provides home adaptations for a wide variety of patients, Horkheimer says.

“We see a lot of people who are aging, who want to stay in their homes,” He says. “We see a lot of people with traumatic injuries; people who are caregivers; a lot of parents caring for children with disabilities. We see a fairly broad variety of different folks.”

Seeing that wide variety of patients shined a light on the fact that customization in home access was key.

“We saw a lot of our patients’ needs weren’t being met,” Horkheimer explains. “Either items were being sold to them or remodels were being done for them that really didn’t suit their needs, and didn’t suit their needs as their needs progressed, as well.

“We take a very individualized approach in terms of who we work with and what their limitations are,” Horkheimer adds. “You might have a combination of different groups or multiple groupings together in one patient.” In fact, one patient might have the same or similar impairment or limitation as another, but can have different of home access needs, because the impairment has affected them in different ways, Horkheimer says. They might be able to move differently, for instance.

“For example, someone who’s wheelchair-bound from a stroke vs. paraplegic vs. quadriplegic,” he says. “But even within a group. For example, say we were looking at patients with paraplegia who are wheelchair bound, we could have individuals who function very, very differently, or who require very different medical equipment, or different approaches. One person might have a lot of tone, and spasticity and tightness, that forces them to operate in one way, versus another who has good arm strength, versus another who might have rotator cuff issues.”

And the same can be said for different home access products. This will, in turn, mean different things for different patients. For instance, two walk-in tubs could be totally different. One could have the entire tub on a higher level, which requires the patient to lift his or her feet up into the tub, and that could be unworkable for a patient with tight hamstrings or weak arms or poor balance, Horkheimer explains.

“It depends on the individual and how they function,” Horkheimer says, explaining that having the right skillset is critical in recognizing the relationship between DME and patient condition, and being able to make the right match between solution and limitation.

“Being a therapist, the one thing I can says is that having a therapeutic or medical input is important,” he adds.

A Case in Point

Horkheimer recalls an instance where one client was having frequent falls in the workplace. The issue was that she wasn’t drinking so that she wouldn’t have to make frequent trips to the restroom, and then getting dehydrated. Horkheimer worked with an occupational health nurse who worked with the client, and reviewed how she was approaching the situation.

The patient was envisioning herself getting to the restroom using a device to help her stand and had thought about elevating toilet seats and grab bar systems, but she lacked the quadricep strength to even kick out her legs. Going with an elaborate, expensive solution would have guaranteed she would have fallen and hurt herself.

Plus, the toilet had essentially been “enclosed” in grab bars, making it impossible for the client to slide onto the toilet, which is what she needed to do. So, the “cage” of grab bars was removed and replaced with flip-down grab bars that the client could flip up in order to let her scoot onto the toilet, and then flipped down to let her move side-to-side and adjust herself as needed.

“It was about taking into account not only the products, but what the client can best utilize to her advantage,” Horkheimer explained.

Assessment Beyond Checklists

Lists and tools for assessing home access needs can truly help providers evaluate patients’ requirements, but nothing beats some hands-on observation and consultation. For example, initially, Horkheimer says he assembled checklists to help determine patients’ access needs, but they only went so far, he says.

“To be honest, when I do assessments now, I don’t follow a specific structure,” he explains. “There are a lot of good assessment instruments out there, and I think it’s good to familiarize yourself with them if you’re going to be doing evaluations, and initially use a guide.

“But what I always tell our team, in terms of how were looking at how individuals function, is that the best thing you can do is to ask as many questions of each individual as possible, in terms of their situation, what their goals are, what their priorities are, and what doesn’t work for them,” he explains. “Ask questions and listen.”

Then the provider has to follow up that consultation with observation.

“The key thing is to go through a process with a client and observe how they function,” Horkheimer explains. “Because a lot of times you’ll have people tell you they do things one way, but then you observe how they try to do it, and it’s totally different. It’s really insightful in terms of determining what will work best.”

Product Specific or Patient Specific?

If anything, success in providing home access solutions that will suit a patient’s unique needs over the long haul often comes down to not just understanding patient needs, but understanding products and how they can and should be applied to those needs, says David Hartley, CEO of Home Health Depot Inc. in Indianapolis, Ind. Home Health Depot specializes rehab with more than 20 RESNA ATPs on staff, and provides a wide range of home access services, including entire home remodels, for its clients.

“We’re talking about a relative, finite number of products for home access,” Hartley explains. “For our company, we’re talking about front door, rear door access; wheelchair ramps or vertical platform lifts. Once we’re in the home, we’re looking at stair lifts and bathroom modifications. If you need home access, if you have any type of mobility-related issue — whether you’re elderly, a child with special needs — you tailor the products to the patient, but the pool of products doesn’t really change.”

In fact, a give-and-take often develops between the home access products a provider offers and the patients it serves. In a way, both will start to shape and define each other, Hartley notes.

For instance, the relationships a provider builds from a business development standpoint will often drive different groups to a provider’s home access business. For example, if a provider is trying to reach seniors, and works home shows and health fairs, or advertises with Google ads and the like, then they will start to specialize in the services that seniors want. That might be stair lifts and walk-in tubs.

In any case, once the provider starts to specialize in certain types of products, it can then better present those products to their various customers, based on their needs. For Hartley, this means creating tiered products and services.

“For our aging-in-place division, we divide our products into what we call simple and complex aging-in-place products,” he explains. “The simple products would be things like a basic wheelchair ramp, and basic vehicle lifts and stair lifts. The complex products would be more like larger projects where you’re going to be on-site for two, three, four, five weeks.”

The bigger, more complex services are often referral drive, whereas the more standard, simpler products are often displayed on Home Health Depot’s retail floor, with traffic driven by advertising and local events.

But again, while there are sets of products, there aren’t necessarily true “sets” of patients. There might be some generalities, but in the end, the provider needs to take a consultative approach to work through the issues a client and apply the right solutions.

“That’s really the strength of HME companies and the reason why more HME companies need to move into the home access business,” Hartley says. “We have, as an industry, a completely different viewpoint when we visit with the patient than does, say, a contractor. That’s not to say anything bad about a contractor, but a contractor is going to talk to a patient or a family and they’re going to say, ‘We need a wheelchair ramp,’ and the contractor is going to say, ‘I’ll build you a wheelchair ramp.’

“Our staff, because most of them are certified aging in place specialists, and came up through the HME side of things, are going to go out and say, ‘I’ll be happy to quote you on the wheelchair ramp, but while I’m here, can we go look at your bathroom?’” he continues. “… Our sales people really don’t sell. They simply present solutions to problems.”

This article originally appeared in the November 2012 issue of HME Business.