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"Staying on that wall".

In 1886, a visionary and bold group of women decided to combine skill, know-how, and compassion and to deliver it into the streets and homes of the Boston waterfront area. If you’ve seen the movie, “Far and Away”, starring Tom Cruise and Nicole Kidman, you’ll recall what that area looked like in the late 1800s. Immigrants lived in crammed and filthy quarters and poverty and malnutrition were rampant. It was an era in dire need of skill, know-how, and compassion and these pioneers responded by launching the visiting nurse movement in America. One hundred and twenty-five years later, we’ve largely conquered many of the public health challenges of that era, but we now face different challenges. On the surface, we experience uncertainty around reimbursement levels and question how broad policy decisions will impact us in an age of consolidation and system formation. Below the surface, organizations such as the Visiting Nurse Association of Boston & Affiliates (VNABA) continue to serve those who remain highly vulnerable within our society. In Boston, the VNABA has historically focused on meeting the needs of all patients within its metropolitan and suburban Boston service area. Over time, competitors have moved into the outer periphery of the city. Inner-city residents, the ones living in poorer communities where security and logistical challenges are greatest, continue to receive care from us. Competitors have been far less inclined to advance into these neighborhoods. But it is exactly in these neighborhoods where our historic mission lives and thrives. Kate Walsh, chief executive officer of Boston Medical Center (BMC), a major academic medical center that serves the greatest proportion of residents in these inner-city neighborhoods, recently described her hospital’s view of the VNABA. She noted that they send their toughest and sickest patients to us. In her description, she referred to the famous testimony of Colonel Jessop, played by Jack Nicholson, in A Few Good Men. Kate was referring to this line: “Deep down in places you don’t talk about at parties, you want me on that wall ... you need me on that wall.” For BMC’s patients, they need us on that wall. But our challenge is staying on that wall. Of our major referral hospital systems, three now own their own home health organizations. Another has a strategic affiliation with an entity that owns a home health agency. In our industry, at one time, referral decisions were made primarily on the basis of geographic coverage. From there we moved to a competitive age where cost and quality were to dictate, but that era, barely now begun, is already giving way to referral decisions being made on the basis of “in system” versus “out of system” affiliate status. Accountable care organizations (ACOs), of which 5 of the 32 pioneer ACOs nationally are located within our service area, seek to foster efforts to coordinate care across populations and to eliminate incentives to partition off components of care. But the ACO movement is also serving as a force to carve up and wall off elements of the system, making it difficult for independent organizations such as ours to continue to serve everyone. Referral decisions are being made less by clinicians in hospital rooms and more by executives in conference rooms. The VNABA has been engaged in an effort to consider these dramatic and impactful shifts in our marketplace, all with an eye toward continuing to respond to the needs of the vulnerable and fulfilling our original and lasting mission. To that end, we have pursued a process with the following three key components: