During workshops with clinicians, providers, and state Home Health Associations, the author has observed a general disconnect regarding the concept of skilled progression and the role it plays in the area of clinical outcomes. When both clinical and managerial staffs confront the prospect of the audit-based programming requirements that will define efficient care in the Recovery Audit Contractor (RAC) era, the lack of understanding of how to employ skilled progression quickly becomes evident. Though even the novice homecare clinician is familiar with the concept, the nurse or therapist that is able to fluently deliver and successfully document skilled progression remains in the minority of caregivers at most Home Health agencies.
As mentioned many times in this column, the recent history of the Home Health benefit has provided little incentive to refine the skilled component of our care delivery.
Reimbursement levels of greater than 90 %, competitive business practices, shortages of clinicians, and the lack of a consistent audit/denial mechanism have also contributed.
Supervisory staff has become fairly well versed in the concept since the installation of PPS and the subsequent refinements, and they consistently stress the need to demonstrate this approach to professional field staff. Most front-line clinicians understand that skilled care is required in homecare, and these clinicians often modify their care programs to provide some level of skill in their clinical episodes. The difficulty encountered seems to be when care programs have to be modified and documented accordingly in order to assure that skilled progression remains evident throughout the entire episode.
Experienced Home Health clinicians often struggle with the specific thought processes that are necessary to visualize the skilled progression-based path they are obliged to create and maintain in their care programs. Their legacy as successful homecare professionals often obstructs their ability to re-wire care approaches to fit the skilled progression delivery mandate. The common response is not to dismiss the need to address requirement in all care programs, but rather to view the topic as just the latest in a long line of topical and fleeting quality initiatives that have no real-time connection to what they do on a day to day, or visit to visit, basis. The implicit belief that their care programs are beyond review and improvement appears to be common in all of these situations. Usually preceded by experiences in which their reputation as quality and successful Home Health caregivers has been established, these clinicians are often markedly un-approachable on the topic of care modifications. They are often dismissive of attempts to orient and educate on this subject, and as a result, fail to experience or experiment with the “new solutions to old problems” approach. These clinicians often respond by stating that they plan to continue to employ their current delivery techniques; they will just document differently. Lack of insight into the underlying healthcare advancements and care philosophies at work here is nearly always present in these instances.
The basic resistance to improved care techniques that translate to better outcomes or decreased utilization always puzzles this author. Though we understand and acknowledge that human behavior resists change, the culture we live in would appear to make it possible for educated, caring professionals to see the value of care advancements. In an era where we use the Blackberry, document on Point of Care technology, download music on MP3 players, and have I-Phones (or at least our kids do), the need to evolve our basic care techniques seems necessary and obvious.
Along this line of thought, the requirement to demonstrate skilled progression seems like the first step in the re-wiring of care that will be required to produce audit-proof Home Health episodes in the future. The practicing clinician often complains of the emotional effects of denied care; these types of experiences and emotions can be reduced or even avoided by assertively embracing the clinical advancements that skilled progression represents. After doing this, the clinical discussions about their specific care delivery approaches no longer prompt defensive reactions from front-line clinicians. Instead, the discussion is viewed as an opportunity to improve the value of their quality care delivery. New solutions are identified and integrated into care programs, clinicians see the value and communicate that to patients, outcomes improve while utilization decreases. The reward is better patient outcomes, progressive programs, increased professionalism, and successful clinicians providing contemporary care.
The next article will address specific examples of skilled progression, and how it defines care that differs in both delivery and outcomes.