The four organizations used different approaches to the delivery of home health care. Aspen and Kaiser Colorado were similar, in the sense of concentrating delivery of home health care to their members in a single agency. Aspen used its agency to deliver home care services, with the exception of some specialized care such as occupational therapy and IV therapy. Kaiser Colorado relied exclusively on the Visiting Nurse Corporation of Colorado, for which Kaiser represents 40 percent of patient volume. The concentration of responsibility with one agency at Aspen and Kaiser Colorado appears consistent with their general philosophy of fostering close working relationships with a limited number of providers and facilities. For example, Kaiser Colorado and the Visiting Nurses Corporation were jointly developing a new home health referral form, to ease the paperwork burden and ensure the transmission of all relevant information about patients. They were also developing a computerized home health information system that will link with the Kaiser Colorado data system. In contrast, Keystone East contracted with more than 150 agencies, including the agency owned by its parent company, to deliver home care in its five-county service area. This approach gives Keystone East physicians and members more choice, but it does not permit much close planning between the agencies and the MCO.
The case study organizations generally did not exceed Medicare home health coverage guidelines, the major exceptions being for home IV therapy and, in the case of Kaiser Colorado, blood transfusions for patients who did not meet the Medicare homebound requirements. The organizations also arranged for home health nurses to assess the living environment in terms of personal safety and caregiver availability for people who did not meet the homebound requirement. Finally, Kaiser Colorado patients who were discharged from a skilled nursing facility routinely received at least one home visit regardless of this homebound status.