Readers of the HHSM Newsletter, and attendees at educational presentations given by HHSM personnel, are familiar with the S.U.R.C.H. protocol that has been promoted as the centerpiece of care plan production and delivery. Over the past five years, HHSM has introduced the S.U.R.C.H. method to multiple providers in dozens of states to address compliance and quality concerns; all report the positives of this progressive Utilization Review (UR) mechanism. Many providers described significant improvements in clinical outcomes; others experienced elevated patient and clinician satisfaction scores. Some agencies realized un-expected levels of financial outcomes and posted the first profitable fiscal results in their 20 year existence. Most importantly, providers under Focus Review scrutiny have had plans of correction approved based on the establishment of a S.U.R.C.H.-like UR protocol for clinical programming. These providers subsequently employed the S.U.R.C.H. process to reduce audit results from levels > 32% to 11% or lower.
Developed over the past decade in response to the Prospective Payment System (PPS), S.U.R.C.H. is an acronym for Service Utilization Review for Care in the Home. This progressive mechanism identifies clinical care needs of Medicare homecare clients as defined by the PPS model established in 1999 after the passing of the Balanced Budget Act of 1997. Based on lessons Medicare had learned during the past quarter century while reforming other aspects of the care continuum, the Home Health PPS model based clinical programming and related payments on the acuity profiles of the patient, derived from the newly(at that time) introduced Outcome and Assessment Information Set, referred to as the OASIS. By aligning programming with the philosophical mandates of the PPS model, focused care delivery became possible and care pathways to desired clinical outcomes became apparent.
Mimicking the UR process that had become standard operating procedure in other Medicare venues, the S.U.R.C.H. protocol established clinical baselines identified in the programming questions of the OASIS, and employed those clinical results to create a QA/UR approved care plan culled from the clinical findings of the Start of Care clinician. Just as triage clinicians don’t make utilization determinations regarding clinical care content and length of stay in other CMS care sites (acute care, SNF, etc), the S.U.R.C.H. process allows for UR control of Home Health care programs. In light of the ever-evolving CMS Home Health model, with proposed changes slated to continue for the next 5-7 years, the days when front-line clinicians can create PPS-compliant care claims are over. Factor in the litany of CMS contractors poised to audit your episodes and claims for denial concerns, and the stakes become quite real. Why wouldn’t homecare providers seek the answers that helped hospitals and Skilled Nursing Facilities navigate the introduction of these type of cost and quality controls designed to protect the integrity of the benefit?
HHSM created the S.U.R.C.H. protocol with answers and approaches discovered and developed by these other Medicare providers. With a history of service delivery across the care continuum, our clinicians employed the approach hospitals used to control DRG statistics since their introduction in 1984. In addition, the care control concepts established by the Functional Independence Measure (FIM) scale, employed to manage acuity and length of stay stats for inpatient rehab service since 1996, were integrated for their assessment value of therapy delivery. Lessons from the ADL section of the Minimal Data Set (MDS), developed as the SNF version of the OASIS and introduced in 1998, were incorporated with care and programming drivers from the OASIS itself to create the S.U.R.C.H. worksheet. This shorthand approach separates these programming drivers from parts of the OASIS that are primarily data collection, and crystallizes this information into an efficient care delivery program.
New care control approaches have evolved from the S.U.R.C.H. mechanism. Care plans called into the agency from the SOC clinician during the actual visit will help providers assure their care content rises to the desired levels of compliance while simultaneously reducing misinformed patient expectations. Just as UR control defines care plan production and utilization in hospitals and SNFs, this approach will return clinical content control back to your agency, where it belongs.
An HHSM client, Residential Home Health Care of Troy, MI, has developed a post-hospitalization CHF program designed to decrease re-admissions of this difficult to manage clinical profile (25% re-admission rates nationally). Since the establishment of this program nearly 12 months ago, Residential has posted re-admission rates of approximately 3% of CHF patients in the first 30 days post-acute discharge. To quote Residential President David Curtis, “It all begins with S.U.R.C.H.”