A quick review of healthcare changes seen over the last quarter century offers insight into how proposed refinements of the Home Health benefit will alter many of the day to day practices common to our industry. The establishment of homecare, as an alternative to costly inpatient treatment, has redefined the care continuum through the delivery of care in the patient’s residence. As acute inpatient length of stays shortened (down from 17 to 3.8 days since DRGs were instituted), much of the care previously provided in institutional settings is now delivered in the home. Though inpatient care remains necessary for emergency, triage, stabilization, and other acute medical needs, the establishment and use of Home Health is essential for a successful return to previous levels of function. The proposed refinements for homecare, enacted via audit scrutiny, funding reductions, and clinical advances, will combine to elevate the acuity of Home Health patients and services over the next ten years. As a result, many of the care practices and approaches that are commonplace in homecare will be viewed as ineffective and obsolete under the Home Health model of the future.

            The hospital-discharged Home Health patients of the 1980’s had received inpatient care for nearly two weeks prior to admission to homecare. Likewise, the 1990’s client had received care for up to seven days prior to discharge transition to Home Health. Under today’s care model, the average Medicare client is opened to homecare after inpatient hospital stays of less than four days. There is no debate that contemporary Home Health services replace care previously provided during hospital inpatient admissions.

            So as we redefine our care model over the next decade, we must examine what aspects of our care, and care delivery, have become obsolete. Many of our agencies are managed and staffed by clinicians that have extensive experience in Home Health. They have delivered care to the ever-evolving client under a delivery model that has shifted wildly in structure and clinical direction. Prior to PPS, much of our focus was on keeping the client in the home in lieu of expensive admissions to hospitals or residential nursing care. Today, the emphasis is on short-term programs; education based approaches that involve both patients and caregivers, resulting in a rapid return to previous functional levels. The stark contrast of these Home Health approaches renders many traditional aspects of homecare delivery obsolete. These practices, with their lack of contemporary, PPS-based philosophies, have outlived their usefulness and, in fact, identify programs that fail to deliver modern-day value to Medicare beneficiaries. Some common areas of concern are;

 

1)      “Are you up for a visit today?” Commonly heard in homecare agencies, this approach creates the impression of a program that is optional for the patient rather than the acuity-based care vehicle identified by the PPS model. Can you think of anywhere else in the Medicare Part A healthcare world where patients are addressed and programmed in this manner? Tales of homecare clients canceling scheduled nursing visits because they don’t feel well that day result from this type of approach. As Home Health programs become shorter in duration and less frequently covered (as a result of audit scrutiny), clients will deserve a more contemporary delivery approach so as to obtain needed outcomes from their pre-paid homecare benefit.

2)      Missed visits are expectable – Audit scrutiny has identified the importance of achieving ordered frequencies in order to assure the program rises to the level of “reasonable and necessary”. Many Home Health clinicians are reluctant to insist that frequency/duration orders are maintained, in fact, they are quick to point out that the patient has a right to refuse. It is important that all clinical providers understand and inform their patients that missed visits, especially those that are not based on valid medical reasons, may jeopardize their care programs. Clinicians must attempt to reschedule visits to maintain frequency at any cost as a means of demonstrating the validity of their programs and claims.

3)      Patients on hold awaiting MD orders – Speaks to the heart of “reasonable and necessary”. Auditors are certainly correct when they question the validity of care that is held hostage to the agency’s inability to communicate effectively with the physician of note on the case. Agencies and clinicians must advocate for their patients and care programs; historically, we have been reluctant to press the MD for needed and timely responses to order requests. Many providers are concerned with angering the referral source; this concern may be reconsidered when the delayed communication results in episode denials and un-resolved care concerns that represent medical liabilities for the agency.

 

            Agencies and clinicians will need to address each of these areas in a pro-active manner or they risk claim and care denials. In not doing so, they will have failed to help their patients obtain value from the Home Health commodity they have purchased through pre-paid FICA deductions during their working life. Further complicating this new approach to Home Health care delivery, our clinicians are creatures of habit, and though understanding all the underlying philosophies described above, they often leave the agency and engage in a “business as usual” approach to services. So, we have our work cut out for us as we face the brave new world of Home Health in the audit era.