If you listen closely, you can almost hear a collective sigh of relief from Home Health agencies and clinicians as they complete preparations and modifications in response to the 2011 PPS Rule. The gradual introduction and confusion initially surrounding the rule, combined with delays of the face-to-face and therapy requirements, have presented homecare providers and clinicians with an emotionally unsettling winter. Refinement fatigue results from confusing therapy questions (separate or combined count?), coding changes, and face to face documentation struggles; all present under the pressure of declining reimbursement. These most recent of homecare experiences are common for all providers in our industry; in fact, three of the four publicly traded Home Health companies have reported significantly reduced 2011 first quarter earnings (Home Health Line 5/23/11).
So as we move forward into an uncertain future, yet to be defined by the numerous CMS and Med Pac reforms proposed for 2012 and beyond, it is important to assure that we have integrated both lessons and requirements of the 2011 Rule. Though initial implementation of the new procedures required Herculean efforts from even the most progressive providers, the ongoing task of continued compliance and performance regarding the latest standards will present an even bigger challenge. Of primary concern is the achievement of desired qualification requirements involving face to face certification and therapy documentation. Next, we must address the vigilance required to assure a standardized and contemporary level of clinical delivery in a Home Health model. Finally, we must support both clinical and office personnel as we mine management, supervisory, and back office protocols for future efficiencies.
Much work has been done in assimilating the new protocols in response to the face to face and therapy program changes. Despite a 90-day delay in enforcement of the face to face requirement, the resultant struggles, resistance, and protest from all involved parties has been well documented. 2011 therapy changes, also delayed until an April implementation, received an unprecedented level of differential analysis regarding the Assessment/Reassessment rules and visit count management. Providers have re-wired QA and therapy supervisory efforts to address face to face and visit count concerns. Various approaches may or may not be sufficient in the objective test and care plan production areas.
During recent consulting events in multiple agencies, the author has noted a troubling lack of compliance with therapy care plan production regarding to objective tests and measures. Despite the extensive efforts on the part of Home Health educators, professional organizations, and homecare providers to investigate and educate therapists regarding the objective tests and measures that must be established, much of the ongoing compliance is left up to the front-line clinician. Production of care plans, re-assessment content, and care continuation rationale are the areas often lost in the shuffle as we resume a normal care schedule under the new rules.
In order to assure that your agency is compliant with all the new changes, establish routine rounds to address primary areas of concern. Weekly spot checks of face to face documentation, performed by personnel un-related to the day to day performance of this requirement, are required. CMS contractors will be auditing for compliance with the face to face requirements; losing claims in the upcoming years when previous cases are audited will be an unsuccessful business strategy in the homecare landscape of the future.
Therapy care plan production should be based on objective tests and measures performed at the initial therapy evaluation, and baselines should be established in this manner for all clinical program goals. When auditing for compliance with this requirement, find the clinical outcome goals (both short and long) on the therapy care plan, and work backwards to the corresponding therapy evaluation to find the tests employed to identify the baseline for this goal. If you can’t find the standardized test that produces your goal: you are out of compliance. Reassessments should receive the same level of ongoing weekly scrutiny for compliance and agreement with content to date in its relation to continuation.
Regular reviews for compliance establish a standardized baseline for care quality for your agency, not unlike how hospitals or large health systems manage clinical content. Remember, the CMS auditor is unlikely to be a licensed nurse or therapist, so these professionals are not required for these self-audits. In addition, you are able to positively control clinical care evolution as a means of keeping your staff current and progressive. For example, caregivers are important, compliance is necessary, home programs are essential, and long distance endurance doesn’t require skilled therapy services. Don’t be left out in the cold; producing outdated care and clinical programs that fail to rise to 2011 PPS standards.
Arnie Cisneros, P.T., is renowned for his adaptation of traditional care philosophies to address current and future healthcare initiatives. His status as a practicing clinician provides a working level insight into program development and care consultation needs for Home Health providers. He authors “Home Health Forum”, a bi-weekly column addressing contemporary homecare issues and is a contributor to “The Remington Report”, CARING, and Decision Health publications. He presents nationally on homecare topics including S.U.R.C.H. – UR for Home Health, OBQI Case Conference, and PPS/P4P strategies. He is President of Home Health Strategic Management, a homecare consulting firm in Lansing, MI.