Regular readers of the HHSM Newsletter are familiar with the Home Health programming tool S.U.R.C.H. – Service Utilization Review for Care in the Home, and the potential for homecare providers to control programming through use of this progressive clinical management methodology. Today, we recount the story of an Iowa Home Health agency who realized considerable gains and success by their integration of this Utilization Review mechanism derived from CMS programming models in other care environments.
Sunnybrook Home Care, with locations in Fairfield and West Point, Iowa, is a Medicare-certified agency serving clients throughout 9 counties in the southeast corner of the state. With a long history of in-home service delivery to an array of clients from a multitude of payer sources (Medicare, Medicaid, Commercial, and Private Pay), Sunnybrook has traditionally posted outstanding clinical scores as it served its Iowa-based clientele. Though their care approach has remained constant, changes in the form of funding cuts to the Iowa Medicaid program, combined with recent Medicare reforms, have led to significant financial under-performances in recent months for this provider.
The agency responded by examining nearly all aspects of their care programming and delivery as it relates to clients of all payer-types, with a decided focus on Medicare episodes. They engaged the services of HHSM to analyze their delivery and utilization models, with specific emphasis on Start of Care program construction and therapy volumes. Initial reviews revealed homecare practices that are common to the industry; unfortunately, many of these traditional programming approaches have outlived their usefulness as they relate to the Home Health benefit of today. Financial losses were based on nursing delivery patterns regularly seen during the PPS era, care plans that failed to assertively address ADL declines, and best practices that took a backseat to physician, patient, and caregiver preference.
Sunnybrook Home Care, utilizing S.U.R.C.H. as the centerpiece, chose to adopt the progressive delivery mechanisms of the future in re-wiring their care approach to address recent Home Health refinements. By embracing and installing all aspects of focused and controlled homecare programming, including central scheduling and clinical staff control, weekly care rounds, and of course the Start of Care QA controls that are the S.U.R.C.H. method, Sunnybrook was able to realize improvements that most providers would covet in today’s uncertain Home Health landscape.
In just over 30 days, Sunnybrook improved case-mix results at nearly double-digit levels (9%), while simultaneously decreasing episode costs (24%). These results led to significant increases in their HHRG/COST ratio (30%) that proved to be the basis of their return to profitability. Most importantly, their clinical scores improved as outcome goals were realized by the inclusion of focused, CMS-mandated care derived from the PPS model. Sunnybrook nursing staff quickly recognized the S.U.R.C.H. process as a clinical quality control vehicle centered on individual patient characteristics identified in the Start of Care OASIS, and steady support by administrative personnel allowed for a rapid and smooth integration. Therapy professionals were immersed in the entire care program through connection to the OASIS-based ADL declines that are the backbone of all rehab programming. Both clinical groups readily embraced the positives of the methodology, and as a result, desired outcomes appeared across the entire caseload of Sunnybrook Home Care.
Uninformed providers often resist S.U.R.C.H.-like QA controls, stating they choose to utilize a “patient advocate” approach instead. When considering that the S.U.R.C.H. protocol was derived from PPS principles that have prompted utilization decreases combined with elevated clinical outcomes across the care continuum, the author is not really sure what the term “patient advocate” references. Would those providers believe that focused and efficient clinical programs, constructed and delivered to obtain outcome goals in the most proficient, rapid, and permanent manner, somehow betray the interests of the homecare client? Or would the care programs of the past, with standard “one size fits all” nursing care plans prompting “social visits with vitals”, supported by therapy-derived profit margins, somehow better serve the beneficiary?
Care and quality controls, such as the S.U.R.C.H. utilization review protocols, are the only responsible response to the CMS and Med Pac refinements. Agencies seeking appropriate strategies to the ever-changing Home Health regulations should take the lead of Sunnybrook and other progressive providers willing to examine care and management practices that may hinder fiscal and clinical outcomes. As Medicare re-defines the benefit to address new healthcare delivery models, homecare programming will undoubtedly evolve to match the outcome goals of the future. Can we truly expect success in the upcoming care environment by reproducing the programs of the past?