As the year 2008 progresses and agencies have (hopefully) integrated the procedures and lessons of the New Rule Reform, it seems time for the industry to prepare for what lies just over the care horizon. Today, Home Health finds itself moving steadily towards the impending era of Pay for Performance (P4P) and other outcome or quality based reforms. Will industry attention focus on the installation and education of the clinical and programming specifics that will undoubtedly be required to achieve quality levels of the future? How can agencies and their employees prepare for the upcoming alterations in the care delivery model; alterations necessary for both providers and clinicians participating in the Medicare Home health benefit?

   In order to truly grasp the extent of the philosophical and procedural changes that will be required for P4P success, some critical analysis of the current care delivery model is required. Though we are rapidly approaching the end of a decade of the Prospective Payment System (PPS), many remnants of the fee-for-service era mechanisms combine with inadequate PPS understanding to create an unsteady care delivery model. Clinical quality often fluctuates wildly from agency to agency; even from clinical team to clinical team. Certain geographical areas tend to interpret (or abuse) the PPS model for financial gains. Outlier fraud, marketing abuses such as sports tickets or gifts for referrals, compromise of patient choice, over/under-utilization based on misinterpretations of PPS; all common in our industry today. A lack of day to day emphasis on patient care and outcomes as a result of system overload, financially strapped agencies struggling with a dwindling supply of nursing or therapy professionals, patient episodes extended solely to avoid PEPs; also common in our industry today. Medpac-voiced concerns regarding both the costs/returns ratio of the Home Health benefit as well as current OBQI outcome levels will also need to be addressed in the not too distant future.

   Obviously, we in homecare have much ahead to face in terms of the big picture.

Meanwhile, the most prudent course might be to re-focus our care delivery efforts in such a manner as to maximize clinical outcomes in the most efficient way possible. This will require some re-examination of how we, as nurses and therapists, view homecare. Do we disperse our services in a manner that addresses best practices? Are we willing to be managed in order to assure that our services are contemporary and delivered with patient success as the primary area of concern? Or will we fall prey to common homecare mistakes as we cling to the concept of professional autonomy?

   My personal experience while working with multiple agencies and clinicians on a nationwide basis is that these questions are easily answered. The desire to provide meaningful care and outcomes for our patients is present and consistent throughout our industry and personnel. The personality profile of the clinical caregiver supports this reality, particularly in the homecare environment. Most clinicians working in healthcare today honestly and sincerely strive to be the best at what they do. In Home Health, however, nursing and rehab professionals alike often struggle to modify care practices to fit the homecare world.

   Since the introduction of PPS with the emphasis on rehab as a means of acuity based reimbursement, therapists have learned to view their clinical programs in terms of visits. Certainly, this is a symptom of the initial PPS structure and the High Therapy Threshold that prompted so much attention from both agencies and clinicians. The success of this change in programming led to the PPS New Rule, designed to eliminate the gaming aspect of rehab delivery. Nursing seems to avoid the concept of visit based reimbursement that has inadvertently served to distort rehab delivery due to the fact that (beyond LUPAs) the nursing visit total does not directly affect income.

   How should clinicians prompt a change in their care delivery philosophy in order to value the clinical program in terms of care, something other than just a numeric total of visits? Remaining mindful of the fact that the PPS Home Health model is a short-term program designed to restore lost levels of health or function is the first step. We know that as homecare clinicians, our presence in the home will be temporary. How do we best prepare the patient and their caregivers for our inevitable discharge?  First, nursing should strive to make ALL visits skilled and necessary. Many nursing clinicians center their care on a form of task based delivery; taking vitals, managing meds, wound care, etc. A contemporary approach centers on caregiver training and patient teaching. This is realized by embracing the concept of education and striving to teach the patient any and all means of achieving a greater level of independence in the ongoing management of their diagnoses.

   Rehab professionals in the home should center programs around goal achievement in the most efficient manner. The concept of skilled progression should dominate their programming on a visit-by-visit basis. Full compliance with home programs and attempts at expansion or progression of the client performance level EVERY visit will help even the newest rehab clinician to visualize the functional progress path they are attempting to follow. By following this care delivery model, all types of homecare clinicians will find themselves on the road to clinical success, now and in the Pay for Performance era.