HOME HEALTH CARE SOLUTION

Report submitted to
Haldia Institute of Technology, 
Haldia for the award of the degree
Of

Bachelor of Technology in Computer Science and Engineering

By

Shreya Shandilya (00219052)

Arjun Kumar Ram (00219011)
Akriti Prasun (00219003)
under the guidance of
Moumita Ghosh

DEPARTMENT OF INFORMATION TEC HALDIA INSTITUTE OF

TECHNOLOGY, HALDIA

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DECLARATION
I/We certify that

a. The work contained in this report is original and has been done by me/us under the
guidance of my/our supervisor(s).
b. The work has not been submitted to any other Institute for any degree or diploma.
c. I/We have followed the guidelines provided by the Institute in preparing the report.
d. I/We have conformed to the norms and guidelines given in the Ethical Code of Conduct of
the Institute.
e. Whenever I/we have used materials (data, theoretical analysis, figures, and text) from other
sources, I / we have given due credit to them by citing them in the text of the report and
giving their details in the references.

Signature of the Students

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 CERTIFICATE

This is to certify that the Dissertation Report entitled, “Home Health Care Solutions”
submitted by Mr./Ms. “Shreya Shandilya, Arjun Kumar Ram, Akriti Prasun” to Haldia
Institute of Technology, Haldia, India, is a record of bonafide Project work carried out by
him/her under my/our supervision and guidance and is worthy of consideration for the award
of the degree of Bachelor of Technology in Information Technology of the Institute.

------------------------------------
Project Mentor

-----------------------------------
- HOD

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 ACKNOWLEDGEMENT

We would like to express our gratitude and appreciation to all those who supported us during
the making and completion of this report. First, we wish to express our sincere gratitude to
our mentor, Moumita Ghosh, for her enthusiasm, patience, insightful comments, helpful
information, practical advice and unceasing ideas that have helped us tremendously at all
times in our research and writing of this report.  Her immense knowledge, profound
experience and professional expertise enabled us to complete this research successfully.
Without her support and guidance, this project would not have been possible.

We also wish to express our sincere thanks to our HOD Dr. Soumen Paul and all the faculty
members of Information Technology department, Haldia institute of Technology for their
support and guidance throughout the making of this project.

Finally, last but by no means least, we are thankful to our family and friends for their support
and useful insights in our journey of making this project a success.

Thanks for all your encouragement!

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 ABSTRACT

We hereby propose a doctor patient managing system that helps doctors in their work and
also patients to book doctor appointments and view medical progress.
Currently, the scenario is such that the patient who’s suffering from any disease has to go to
the doctor’s clinic in order to book an appointment. There is no such software that can tell the
patient what disease he/she is suffering from based on the symptoms given. To sort out this
we have introduced this application.

The Future of Home Health project sought to support transformation of home health and
home-based care to meet the needs of patients in the evolving health care system.

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 TABLE OF CONTENTS

TITLE PAGE i

DECLARATION ii

CERTIFICATE iii

ACKNOWLEDGEMENT iv

ABSTRACT v

CONTENTS PAGE NO
Chapter 1 Introduction 7
Chapter 2 Factors Driving Change 8
Chapter 3 Efforts In The Formal Care Sector 13

Chapter 4 The Future of Payment and Delivery 16

Reform

Chapter 5 Conclusions 20
Study References 21

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CHAPTER 1
INTRODUCTION
India’s health care sector provides a wide range of quality of care, from globally acclaimed
hospitals to facilities that deliver care of unacceptably low quality. Efforts to improve the
quality of care are particularly challenged by the lack of reliable data on quality and by
technical difficulties in measuring quality. Ongoing efforts in the public and private sectors
aim to improve the quality of data, develop better measures and understanding of the quality
of care, and develop innovative solutions to long-standing challenges. We summarize
priorities and the challenges faced by efforts to improve the quality of care. We also highlight
lessons learned from recent efforts to measure and improve that quality, based on the articles
on quality of care in India that are published in this issue of Health Affairs . The rapidly
changing profile of diseases in India and rising chronic disease burden make it urgent for
state and central governments to collaborate with researchers and agencies that implement
programs to improve health care to further the quality agenda.

The challenge of low quality in health care is not unique to India. Studies from a range of
developed and developing countries have demonstrated widespread problems with providers
who make little effort to ensure that patients receive high-quality care, geographic variations
in the quality of health care services, and high levels of medical errors. Efforts to improve the
quality of health care services in low-resource settings, including India, have typically
focused on structural constraints.  Recent studies in low-income countries have documented
low levels of provider knowledge, in both the public and the private sectors, and have found
evidence of large gaps between providers’ knowledge and the care provided, sometimes
called “know-do gaps.”  In addition to providers’ lack of capacity or knowledge in such
settings, low quality of care could also be due to the lack of incentives in the health system or
information problems in the health care market, combined with a lack of accountability
among providers and poorly functioning governance systems in the health system. It is
important to understand the process of delivering health care services and the factors that can
limit providers’ effectiveness.

A cluster of articles in this issue of Health Affairs focuses on challenges related to the quality
of health care in India. The cluster includes articles that describe challenges in using data
from household surveys and hospital administrative records to measure the quality of care,
examine a delivery model for high-quality surgical care, and evaluate a state-run ambulance
service program designed to improve access to and use of care, as well as a Data Watch
article on trends in state-level maternal and child health indicators. In addition to reviewing
the state of research and evidence on the quality of health care in India, this article discusses
critical challenges related to scaling up promising innovations and governance issues related
to the quality of care.

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CHAPTER 2

Factors Driving Change

Demographic impetus and cost 

Although by some accounts the upcoming Medicare population is healthier than previous
generations—life expectancies are longer and smoking rates have declined—baby boomers
have higher rates of obesity and diabetes compared with previous generations.4 According to
a 2002 study, 88% of people 65 years or older have at least one chronic condition, with a
quarter of these having four or more conditions.5 The effect of these chronic conditions on
spending is massive: Estimates suggest that chronic illness accounts for three quarters of total
national health care expenditures.4 As the number of older beneficiaries with multiple
chronic conditions continues to rise, providing care in the most effective and efficient setting
will become even more critical.

Health care delivery system reform: The Triple Aim and HHS goals 

With demographic trends and spending concerns as a backdrop, the Medicare program began
to emphasize achievement of the “Triple Aim” in 2009. A framework initially conceived by
the Institute for Healthcare Improvement, but now almost universally accepted in health care
policy and delivery, the Triple Aim has focused efforts to innovate in the Medicare program
and has propelled considerable change. The Triple Aim declares that to improve the U.S.
health care system, it is vital to pursue three goals simultaneously:

1. Improving the patient experience of care (including quality and satisfaction);

2. Improving the health of populations; and
3. Reducing the per capita cost of health care.

4. The Triple Aim has been used by policy makers and other leaders in health care delivery
to focus their goals in reforming the health care delivery system.Policy movement
toward achievement of the Triple Aim can be seen in the many initiatives undertaken by
the Center for Medicare and Medicaid Innovation (CMMI), and in the time-specific
goals to move Medicare reimbursements from volume to value that the secretary of the
U.S. Department of Health and Human Services (HHS) announced in early 2015. HHS’s
goals are twofold:

5. To tie 30% of traditional (fee-for-service [FFS]) Medicare payments to quality and value
through alternative payment models (APMs; including bundled payments or Accountable
Care Organizations [ACOs]) by the end of 2016 and 50% by the end of 2018 .
6. To tie 85% of all traditional payments to quality or value by 2016 and 90% by 2018
through programs such as Hospital Value-Based Purchasing Program (HVBP) and
Hospital Readmissions Reduction Program (HRRP).

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7. HHS has made strides toward achieving these goals. While quality programs in the
Affordable Care Act (ACA) primarily focused on hospitals, recent legislation and
regulatory actions have expanded quality and value programs to post–acute care with
the skilled nursing facility (SNF) value-based purchasing program and the home health
value-based purchasing demonstration. In addition, post–acute care providers are
increasingly finding themselves affected “downstream” by programs directed at other
entities, such as bundled payments and hospital value-based purchasing.

Consumers driving care 

As patients become increasingly engaged with their care and the health care system strives to
empower patients in their care, patient preference and satisfaction are increasingly becoming
key measures of performance. When asked about their care preferences, older Americans
overwhelmingly articulate a desire to age in place and receive care at home rather than in
institutional settings. A 2010 AARP (formerly the American Association of Retired Persons)
survey found that nearly three quarters of a survey population of those age 45+ strongly
agreed with the statement, “what I’d really like to do is stay in my current residence for as
long as possible.”15 This is echoed in the last stages of life, where the Dartmouth Atlas
researchers found that more than 80% of patients say that they “wish to avoid hospitalization
and intensive care during the terminal phase of life.

Recognizing these preferences and the potential for home-based care to reduce care delivery
costs system-wide, policies have begun to prioritize noninstitutional care settings. State
Medicaid offices have led this trend toward consumer-based care. In 2013, in the context of
Medicaid long-term services and supports, there were more home- and community-based
service providers than institutional providers, an 18% increase since 1995.17 Medicaid
expenditures for home- and community-based services have also grown significantly,
reflecting the rise in use of home-based services as opposed to institutional care, more than
doubling from $25.1 billion in 2002 to $55 billion in 2012.

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According to the Urban Institute’s “The Retirement Project,” in 2000, approximately 2.2
million individuals received “formal personal care services,” defined as personal care
services that are paid for by various means; this increased to 2.5 million in 2010 and is
projected to increase to 2.9 million in 2020.19 Some patients may be eligible for Medicaid or
other state programs that provide coverage for such services; however, there is considerable
variation in such programs and their scope. Some may have private long-term care insurance
that enables coverage. Still other patients may have no private or public insurance coverage
for formal personal care services and may need to pay out of pocket for such services.

Approximately 3.4 million people receive Medicare skilled home health care, which supports
homebound patients by providing coverage for intermittent skilled nursing and therapy
services that are provided by Medicare-certified home health agencies subject to a
physician’s plan of care. In 2014, Medicare spent $17.7 billion on home health care.20

Home-based primary care and hospital-at-home are models of care that serve patients with
conditions that are more acute or severe are less commonly used. The skill needed to provide
the services increases accordingly. Home-based primary care is a model that makes use of
home care physicians and nurse practitioners, in connection with an interdisciplinary team of
professionals, including skilled home health professionals. The hospital-at-home model
serves to supplant hospital admission for certain patients with intensive, hospital-level care in
the home. Those receiving this highest acuity level of home-based care have been shown to
experience 19% lower costs, higher satisfaction, and equal-to-better care outcomes when
compared with similar inpatients.21

In addition to these varied services along the spectrum of home-based care, it is also critical
to include mention of the role of palliative care and end-of-life care. For patients that have
been diagnosed with severe or serious illness, palliative care is often a core element of
treatment of the patient in a holistic fashion that emphasizes function.22 Palliative care may
be delivered outside of the Medicare hospice benefit in various settings, including at home by
home health agencies, or in facilities including hospitals. For many patients who use
palliative care, the Medicare hospice benefit may eventually be used at home or in a facility-
based setting as well. Including palliative care and hospice in the spectrum of home-based
care services enables a full understanding of how care may be shifted toward the community
and the home from birth to death.

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Strategy for innovation.
Source. Eric Dishman, Intel Corporation (presented October 1, 2014, IOM-NRC Workshop
on “The Future of Home Health Care”).
Note. IOM = Institute of Medicine; NRC = National Research Council; ICU = intensive care
unit.

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Medicare value-based programs and authorizing legislation.
Source. Avalere Health, 2016.
Note. HHRP=Hospital Readmissions Reduction Program; HH-VBP = Home Health Value
Based Purchasing model.

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CHAPTER 3
Efforts in the formal care sector
In addition to improving the quality of care provided in rural areas by informal-sector
providers, there are several major ongoing quality improvement efforts in both public and
private institutions in the formal sector.

Public Sector:

Several state governments in India have undertaken quality improvement initiatives (mostly
focused on maternal and child health), combined with independent evaluations of the
performance and impact of these initiatives. For example, the states of Bihar and Uttar
Pradesh, two of the largest states in India that also have some of the worst health indicators,
are collaborating with external donors and researchers to implement strategies such as nurse
mentoring and direct observation of deliveries—where trained observers watch and document
the quality of services provided during delivery. With more than eight thousand deliveries
observed since 2012, these efforts are currently being evaluated. The Uttar Pradesh
government is also conducting a large-scale randomized implementation and evaluation of
social accountability interventions to monitor and improve the delivery of health care services
at the village level. Efforts such as these signal increasing interest from state governments in
improving the quality of care and, importantly, increasing openness to adopting innovative
methods to improve quality and evaluating them rigorously. Finally, efforts to invest in better
data, support evaluations, and promote accountability also reflect governance improvements
in the health sector.

Private Sector:

Similarly, innovations in the formal private sector can make major contributions to improving
the quality of health care. The experience of innovators such as the Aravind Eye Care System
has several lessons for the management of health systems in the public and private sector. As
Hong-Gam Le and coauthors report in this issue of Health Affairs , 1 the system adopted
widespread task shifting, using paraprofessionals to conduct most pre- and perioperative tasks
to deliver high-quality cataract surgery at low cost. However, efficiency-enhancing strategies
such as having paraprofessionals discuss surgical options with patients and not requiring
surgeons to change gloves or operating gowns between patients are not without peril. While
they might have been implemented successfully in the highly controlled environment of the
Aravind Eye Care System, expanding these methods broadly to other settings could pose
significant risks to patients and patient satisfaction. Empirical evidence is critical for policy
makers to decide whether models such as that used by the system can be replicated in other

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settings, applied to other health care services, or scaled up nationally to meet population
health care needs in India.

Given that the majority of health care in India is obtained not in the public sector but in the
private sector, engaging with private providers is strategically important for health policy.
While public-private partnerships in health care have received considerable attention,
previous large-scale efforts have not yielded significant improvements in targeted health
outcomes or out-of-pocket spending. 

Performance incentive contracts for health care providers are another promising option to
improve quality through engagement with the private sector. Although governments in
developing countries have been eager to experiment with performance-based contracts in
health care delivery, most performance incentive programs do not reward health
improvements directly. 

Furthermore, evidence on the impact on health outcomes of programs that reward the
provision of inputs has been mixed. A field experiment in the state of Karnataka randomly
assigned obstetric care providers to receive contracts with performance incentives based on
either inputs (adherence to best-practice guidelines for obstetric care issued jointly by the
Government of India and the World Health Organization) or health outcomes, and
researchers found that both types of contracts reduced rates of postpartum hemorrhage by
20 percent, relative to the control arm. The study also found that input-based contracts
required smaller incentive payments to achieve these reductions than output-based contracts
did, but implementing input-based contracts required reliable administrative data on the
inputs provided that are not routinely available. These data were collected with intensive
fieldwork as part of this experiment. A significant area of investment for state and central
governments in coming years will be to improve the quality of administrative data, as Morton
and coauthors point out. Ongoing efforts in various states in India to strengthen their health
management information systems are promising steps in this direction.

Scaling Up

A related and equally important issue in quality improvement concerns scaling up quality
initiatives that are often developed in small-scale controlled settings. This is especially
pertinent for innovations with demonstrated efficacy, but not effectiveness, in real-world
settings. Successfully scaling up such innovations requires a careful assessment of underlying
market demand, an understanding of how the innovations might evolve or need to evolve
during implementation, and an understanding of how the key market actors (providers and
patients) respond to changing market conditions during the scaling up. Examples such as the
Assess, Innovate, Develop, Engage, Devolve (AIDED) model of scaling up family health
programs could be adapted for use in India to help policy makers as they prepare to

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implement large innovative programs that require implementing agencies to adapt
dynamically in a complex environment.

A more cautious approach to scaling up successful pilot programs, given the scarcity of
resources in countries such as India, would be to require evidence of effectiveness before
scaling up a program—insofar as that is possible. Even when innovative programs have
evidence of effectiveness, it would be prudent to rigorously evaluate the impact of their
scaled-up implementation. Another critical reason to invest in generating robust empirical
evidence on program effectiveness is that such evidence could prevent successful innovative
programs from being discontinued for reasons of political economy or because of evolving
trends in global health priorities.

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CHAPTER 4
THE FUTURE OF PAYMENT AND

DELIVERY REFORM

Payment and delivery reform is here to stay.

The interviewees emphasized that payment reform will continue in the direction of
emphasizing value-based longitudinal payments where an entity—such as a hospital,
physician group, or post–acute care provider—is financially responsible for services provided
beyond their immediate care setting. There was consensus among interviewees that CMS will
meet its goal of 50% of traditional Medicare payments through APMs by 2018. One
interviewee stated that “these models are here to stay.”

No dominant model is emerging. Continued heterogeneity across markets is expected.

Key thought leaders interviewed were in consensus that no single payment and delivery
model is emerging as the dominant model. There was consensus that bundling and ACOs, for
example, will have an increasing role over the next 3 to 5 years; however, one model will not
dominate across all markets. In general, payment reform will continue in the direction of
emphasizing value-based episodic payments where an entity, such as an ACO, is financially
responsible for services provided.

Greater momentum around bundling and Medicare Advantage than ACOs.

While some strongly supported bundled payment arrangements as a model for future payment
and delivery reform, others noted that bundling currently represents a relatively small fraction
of Medicare expenditures, which will likely remain the case for the next 3 to 5 years. For
example, the Comprehensive Care for Joint Replacement (CJR) model is an expansive use of

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bundling for Medicare relative to the Bundled Payments for Care Improvement Initiative
(BPCI), but CJR accounts for a small proportion of payments. The movement toward bundled
payments suggests that CMS will be growing the base of a small percentage of payments.
The interviewees also noted that continued growth of Medicare Advantage plans is expected,
potentially with increased provider (i.e., hospital)-owned plans.

Locus of control (physician vs. hospital) unclear.

Key thought leaders varied in their perspectives about whether the locus of control for
payment and delivery will lie with hospitals or physicians. Several key thought leaders noted
that markets will likely be a hybrid of control, in which hospitals will predominate in most
locations because they have more resources and market power, but other markets will have
multispecialty physician practices that are sophisticated enough to succeed. For example, the
CMMI was very intentional when giving hospitals control of the CJR bundles, but it is
foreseeable that different entities would be in control in other clinical episodes or models.

Other key thought leaders stated that absent policy support to buttress physician practice
capacity to be the convener of ACOs, hospitals will likely retain and grow control. One
interviewee noted that early evidence indicates that physician-led services may lead to better
outcomes, but there is not sufficient evidence to have clarity on this issue. Several
interviewees also acknowledged that as hospitals increasingly acquire physician practices, the
distinction may be moot.

Payment and delivery will continue to rely on FFS systems with retrospective reconciliation.
No large-scale movement toward prospective, capitated models for bundling and ACOs.

Currently, almost all of the APMs involve continued FFS payment with a retrospective
reconciliation. While capitation and prospective payment offers more opportunity to
experiment with services covered and service delivery, key thought leaders agreed that the
original Medicare payment system will not move to prospective payment system in the near
future. Ultimately, the system is moving toward capitated payment, but the time frame to get
there is unclear. It will be important to continue watching CMS to see how quickly the
system evolves. Within 3 to 5 years, the Medicare system will still largely emphasize a
retrospective shared savings model.

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Flexibility greater with shared risk but limitations on innovation persist within existing FFS
structure.

When providers are operating in an at-risk environment (with both upside and downside risk)
and bear the consequences, then policy makers (e.g., Congress and CMS) may be more
amenable to expanding or altering the home health benefit.

For example, CMS has offered waivers of certain home health benefit requirements for
providers participating in APMs where they take on downside risk. CMS is willing to provide
additional flexibility, including toward the home health benefit, where providers take on risk.
However, providers are currently bound by the existing home health FFS payment structure,
limiting potential innovation.

The Future of Home Health Care

Home health “big winner” in payment and delivery reforms.

All key thought leaders interviewed stated that home health stands to be a “big winner” with
a substantial increase in utilization as a result of payment and delivery reforms. Payment
reforms create incentives for upstream referral partners to utilize home health more
substantially because it is a lower cost setting of post–acute care. In addition, patients prefer
to receive care at home. The economic trend more generally is toward personalized, on-
demand, direct-to-consumer services; the health care industry will similarly see shifts in
consumer demand for how people consume health services.

The timing of the shift toward home health is a big question, as it is currently unclear when
more services will be covered in the home. However, ultimately, the system is moving
toward a broader use of home health.

Lack of consensus around modifying the home health benefit.

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Stakeholders and key thought leaders were not in consensus about whether to revise the
Medicare home health benefit, and if so, how to redefine the benefit. A majority of
interviewees thought that the Medicare home health benefit needed to be more flexible, to be
provided based on patients’ care need, and more integrated with a patient’s care, that is, more
integrated with the primary care physician.

Several noted that it was not politically viable to expand the Medicare home health benefit to
cover more services, and others went further to suggest it was unnecessary to alter the
eligibility for services covered by the benefit because payments are increasingly going to
shift to bundling, ACOs, and Medicare Advantage, where entities taking on risk will have
more flexibility to define home health care coverage.

Some suggested removing the homebound requirement and instead focusing on whether
beneficiaries have a certain number of ADL limitations or chronic conditions. One key
thought leader noted the Medicare benefit should be more “nimble,” rather than being defined
by a 60-day episode.

A variety of stakeholders discussed the need for home health care that is more responsive to
patients’ needs and preferences, particularly as it relates to significant unmet need for long-
term care. Some acknowledged that Medicare does not provide a long-term care benefit.
Others asserted that the Medicare benefit must evolve to respond to the needs of the Medicare
population, which increasingly live for a period of time with a variety of ADL limitations and
chronic conditions.

Key thought leaders did not identify a single emerging model for managing post–acute care
patients, high-risk patients, or patients with chronic conditions and long-term care needs.
Some noted that there is not enough evidence in post–acute care around exactly what clinical
care pathways are most effective. There is not one single post–acute care model, and it will
be impossible to establish a single post–acute care model for Medicare patients because their
needs and socioeconomic status are so varied.

ACO providers and hospitals in bundled payments will increasingly give attention to
evidence regarding efficient, high-quality care for determining clinical care pathways and
post-acute care (PAC) utilization. ACOs are concerned about the lack of evidence-based
protocols for different patient populations. Managed care plans generally report having a
more firm understanding of post–acute care, which they manage through selective contracting
and prior authorization. However, one health plan representative stated that they are
struggling to address their home health network because the industry is so fragmented.

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CHAPTER 5
Conclusion

Improving the quality of health care at the system level requires a focus on governance
issues, including improving public-sector management, building institutional capacity, and
promoting a culture of data-driven policies. Ideally, state and local governments and local
health facilities would use data from administrative sources and household surveys for quality
improvement efforts and for accountability in health care delivery. This use of evidence in
making policy decisions would require institutional incentives and targeted capacity building
in addition to investments in creating standardized and more reliable data sets. It is critical for
governments, implementing agencies, and researchers working in India to collaborate on
evidence-based approaches to improve the quality of health care and health outcomes.

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