In Part Four of our series on the 2011 Final PPS Rule, we will continue to address changes confronting our industry that will re-tool how we service patients. Having identified and analyzed the refinements of the 2011 Rule from programming, financial, and therapy perspectives, we will examine how the reform offers challenges to the development and delivery of nursing care to Home Health clients. Though nursing has had the benefit of exclusion from the direct reimbursement formula under the PPS Home Health model, the sweeping changes seen this year will undoubtedly alter how agencies view and provide this type of care in the future.
Most of the refinements experienced by Medicare Home Health since the introduction of Prospective Payment System (PPS) mimic similar reforms successfully introduced to other healthcare sites over the last quarter century. Home Health providers, confounded by the goals of some of the more recent reforms, are poorly served by their homecare experiences when seeking to understand and integrate required changes into their management and care protocols. Lessons learned from the experiences of acute (Hospital) and sub-acute (Skilled Nursing Facilities) Medicare providers can offer valuable insight into the goals of CMS and Med Pac reforms while identifying progressive solutions for required homecare changes. The first step is to accept and understand the latest (and future) reforms as the cost and quality controls they represent. The changes aren’t about homecare; they’re about Medicare, or rather: healthcare as a whole.
Nursing services, as mentioned earlier, have been an indirect factor in the Home Health Resource Group (HHRG) reimbursement structure first introduced as the payment methodology for PPS in 2000. The HHRG score, an OASIS-based, acuity profile of the patient, is comprised of Clinical, Functional, and Service components that address nursing and therapy characteristics of the patient and clinical program. The “C”, or clinical score, identifies nursing needs on an acuity rating similar to the method employed for acute hospital inpatients under the Diagnosis Related Group (DRG) system established in 1984. A “C1” patient has relatively mild clinical nursing needs, while the “C3” patient has the highest clinical acuity nursing rating possible. The “C” score includes diagnoses, medications, disease processes, wounds, and other factors in determining the acuity of the patient based on OASIS answers.
In contrast, the “F”, or functional score, derived from answers to OASIS ADL/IADL questions, relates directly to the “S”, or service score, which correlates to the number of therapy visits in the episode. The “S” factor is one of the prime clinical factors in Home Health reimbursement under the PPS model. As a result, therapy delivery has been associated with over-utilization and gaming concerns, and the 2011 Rule addresses this in a not so subtle manner. Since the volume of nursing visits or care have not been factors in the establishment of the HHRG score, the link between the HHRG and nursing services has been less direct than the HHRG-therapy relationship. Consequently, this indirect connection has led providers to scrutinize and modify nursing visits significantly less than therapy volumes during the PPS era.
The use of certification periods in Home Health have also contributed to the lack of specificity of nursing volumes since the introduction of PPS. The establishment and use of full certification period nursing orders has continued throughout PPS, despite reforms and funding cuts that may have prompted a more progressive nursing delivery model. Unlike Home Health, other Medicare providers (Hospital, SNF, and Outpatient) tend to discharge their patients when clinical goals (or at least stabilization) are achieved. The majority of Home Health providers, at least until recent years, have found other things to address in continuing until the end of the certification period. This approach has often resulted in programs that, by spanning the entirety of the nine-week period, prompt the three word question on week eight; “Should we re-cert?” In this aspect, when compared to other care continuum providers, Home Health is certainly obvious in its exclusion. In fact, a quick review of re-certification rates of some national homecare chains show how variable an approach this can become.
Home Health nursing programs, based on certification period orders, speak to the very heart of some of the reforms currently seen or proposed for our industry. When nursing orders are tiered (2 x 2, 1 x 7 or 3 x 2, 2 x 2, 1 x 5), it is clear that the bulk of the nursing care will occur at the front of the episode. How do we answer the charge that the patient will still require the same nursing volume on week 9 as they did on week 3 (in the first example above)? Or that the patient will require the same nursing volume on week 9 as in week 5 (in the second example above)? Considering that the length of stay statistics from both acute and sub-acute care providers have steadily decreased, providing much of the patient population currently served by Home Health, it seems odd at best that we have adapted such a “one size fits all” approach to our nursing orders and length of stays. The staffing and delivery cost of such a care model speaks to the Home Health profit margins that are the focus of any CMS or Med Pac reform discussions.
Nursing visit orders, patterns and volumes must be managed in order to successfully navigate the 2011 changes, as well as some of the proposed reforms for the future. Do triage nurses make Utilization decisions for Medicare patients admitted to acute care hospitals through the emergency room? Do acute care staff floor nurses determine length of stay or make discharge decisions? In the case of Home Health, the triage (Start of Care) and front-line clinicians often make these decisions. What real-time differences may result from the homecare approach that may present obstacles to success in the future?
Other traditional nursing habits may require updating when attempting to restrict program costs to those necessary for safe and desired clinical programming. Wound care, care plans that parrot referral orders (in lieu of OASIS-based programs), over-utilization of home health aides, programs that are based on subjective findings rather than objective items; all pose concerns in the Home Health era we now confront. Progressive and successful providers will achieve clinical and business goals only if they can “manage” to help their nurse clinicians evolve to obtain the delivery efficiency of the future.