Today we continue to address areas of Home Health that may be cause for concern regarding care and service delivery as the industry moves forward into a future defined by reforms or refinements such as OASIS-C, P4P, and Recovery Audit Contractors (RACs). Attention to these items was raised during our analysis of audits and denials seen from Fiscal Intermediary reviews in various corners of the country. Many of these topics discussed today are exemplary of some of the care quality and delivery lapses that plague nearly all agencies. The historical perspective of the Home Health benefit, previously discussed at length in this column, has contributed in no small part to some of the troubling topics discussed below.

           

Aspects of care that may need to be addressed in the not too distant future often extend to the core components of our business.

 

Safety (as a basis for programming) – Examination of this care concern reveals alarming levels of misunderstanding regarding how to identify safety concerns as part of the OASIS Start of Care visit. Resultantly, inappropriate and inadequate programming leaves many Home Health patients in unsafe environments, particularly those who live alone. Seen and discussed by this author in multiple agencies with clinicians of all designation (nurses, therapists, etc), this issue centers primarily around the answer to the ambulation question of the ADL/IADL section of the OASIS; M0 700. Routinely, clinicians (again, both nurses and therapists) state that they feel unable to declare a patient unsafe when the patient lives alone. When questioned, these clinicians recount that they feel they may create a liability concern if they label such a patient unsafe. It seems they feel that by labeling a client (who lives alone) unsafe, the safety becomes the medico-legal concern of the Start of Care clinician. They relate the idea that the concern regarding a client’s safety becomes their responsibility.

           

In addressing this issue, it is important that all Start of Care clinicians achieve competence in answering this important question (see Home Health Forum, 7/13/08). Recent audit activity seems to identify this question as the prime indicator regarding the need for, and intensity of, physical therapy services. Clients whose SOC data reveal that they are safe ambulating independently with an assistive device, #1 under M0700, certainly present milder levels of deficit than those that need a device AND assistance for safe mobility. Those clients who exhibit unsafe ambulation, # 2 under M0 700, particularly those with a decline of recent onset, should receive PT programs of a higher level of intensity to address this lack of safety. Caregiver and physician notification are necessary, frequency of treatment should be higher based on fall concerns, and appropriate clinical interventions are necessary. The correct assistive device, progressive therapeutic exercise programs with full compliance as HEPs, and skilled and progressive gait training that includes caregiver education and participation, are the required elements here.

 

OBQI-based care – Most agencies and their clinicians focus on a number of indicators that they feel define success; patient or physician satisfaction, state or other accreditation surveys, staff retention, census, case-mix, fiscal earnings, etc. Relatively few embrace the OBQI results that serve as the clinical DNA for Home Health providers. Clinicians profess ignorance when questioned about their agencies’ outcomes, supervisory staff recounts a myriad of management concerns that prevent them from embracing OBQI, and administrative staff describes feelings of helplessness when seeking to improve their scores. Commonly heard is the belief that agencies have good clinicians and provide excellent care despite lackluster OBQI scores. This approach dismisses the evidence-based indicators employed by the OBQI scale. The areas highlighted by OBQI are more than just randomly chosen care outcomes used as a means of quality provider identification. They are the result of OASIS-based data that identify commonly seen clinical concerns that have been statistically determined to be those most closely linked to the desired outcome. Good agencies have good OBQI scores.

 

In order to improve OBQI scores, the agency in question must first embrace their outcome numbers and internalize that the indicators are, in fact, directly related to quality of care. In determining how to begin, we suggest that a random sample of 10 charts should be screened regarding areas of care highlighted by OBQI. Find the specific questions relating to each indicator (available in many previous columns) and compare OASIS data from the Start of Care to Discharge. Did you improve the client in these areas? Did you record credit for all improvements? Was the clinical program centered on these specific items (and why not)? Did the clinician recognize the value of these items and address them in each visit? Answering these simple questions will put you on the road to the clinical success required in the audit-defined future.