2015: A Time for Change in Home Health

As we in Home Health move into the calendar year 2015, we confront what is a rapidly changing care landscape, focused on reform efforts that challenge us from many angles. Though payment cuts represent business as usual in the homecare industry, those rate reductions now materialize in rebasing and Case-Mix scoring changes that result in decreased reimbursement evident once the episode is billed. In addition, F2F updates imply that this requirement is here to stay, despite implementation issues that affect compliance. The Affordable Care Act (ACA) also affects our daily Home Health routines, addressing readmissions in an assertive, take no prisoners approach. In addition, the ACA prompts intimidating discussions about preferred Providers, ACO vendor rosters, Bundling programs, IT challenges, and documentation requirements. None of these topics were anywhere to be found on the Home Health horizon as recently as five years ago.

Other aspects of healthcare reform are slowly eroding the Home Health Provider’s traditional business model; cost centers, referral bases, and financial structures are shifting as we speak. Previous census, episode, and LOS stats no longer apply in today’s care environment. Recertification rates, once a sign of a healthy agency, are viewed negatively today, as ACA episodic pilot programs rewire our focus into a Post-Acute (30-60 day) bundle. The impending changes of the ACA have also had an effect on daily business; reports of decreased referral volumes are heard across the country. Further complicating matters are the ongoing discussions between health systems and the MDs that serve them regarding patient management under the ACA. At stake is the eventual ownership of the patient; as a result, MDs are partnering together or directly with a health system as a means of leveraging their influence on patient control. The net result is that patient referrals are increasingly changing, becoming about much more than the MD and his choice of Providers.

If all of that weren’t enough, the care we regularly produce may no longer fit the needs of the new care models. First, we certainly might expect some changes to be in order if we hoped to contribute positively to a decreased readmission rate. In addition, we noted that the increased focus on the 30 day readmit seems to effect the ability of Home Health to manage the length of the total episode. MD attention to this Post-Acute phase can increase their insight into how the patient is doing, and in some cases this has served to limit the length of the homecare program.

Finally, in keeping with the Triple Aim of the ACA, the 2015 Home Health Proposed Rule installs a Value-Based Purchasing (VBP) Model Pilot Program. Designed to address the general value concerns in healthcare, the Home Health VBP plan would prompt value on the basis of clinical outcomes. In the 2015 VBP Pilot proposal, Home Health rates would be modified 5-8% in either direction based on whether clinical goals were achieved. In this manner, value would be addressed in an ongoing fashion, clearly at the forefront of every agency’s and clinician’s care mission. Regardless of what form the VBP Home Health program takes when it becomes policy in 4 years, its’ clear that Post-Acute episodes will look quite different when we are competing for value on a per patient basis. And combined with the ongoing rebasing and ACA-related factors, it’s clear that a remodeling of our agencies and care programs must occur.

THE Solution for Home Health Providers – UR Control

Most Providers are seeking a long-term solution to the challenges and changes ahead for homecare, firm in the knowledge that healthcare as a whole is changing. Since homecare will be on episodic programs along with other Medicare Providers, a prudent approach would be to look to those care sites for quality and efficiency protocols they employ to develop and deliver care. While sharing programs with these other Providers, we should expect our care to be valued in identical terms to those used for their care valuations. Along those lines, Home Health cannot reasonably expect their clinical delivery staff to deliver programs comparable to those managed by Utilization Review (UR) processes that control acute care admissions. These are the same UR processes that CMS employed to cut hospital stays by more than 75%, reduce IRF admits to less than 14 days, and decrease SNF rehab stats to approximately 3 weeks. None of these best-practice based changes would have occurred if left to front-line staff in these respective care sites: that is EXACTLY the quandary that Home Health faces. Without adopting UR care management, they will fail to compete in the future with other UR-based Providers, employing efficient management protocols to assure efficient, best practice care programs that are managed on an in-episode basis for patient-centered goals.

Installing a UR program for care production and management represents a culture change in your agency, replicating the culture change that is currently occurring all across healthcare. The rewards are apparent immediately, and agencies who are installing this quality protocol are realizing the following types of changes in program financial outcomes:

UR-BASED HHRG INCREASE ———————– 23-31%
UR-BASED CASE-MIX INCREASE —————— 29-36%

These changes reflect the efficient level of PPS care that is achievable under the Home Health model if managed in a comparable manner to other Medicare Providers. Inefficiencies that we confront daily involve nearly all aspects of homecare programming, including intake, OASIS accuracy, nursing/rehab evals, clinical frequency/duration orders, scheduling/productivity, skilled progression, clinical outcomes and patient satisfaction. UR-managed programming alleviates all these concerns, while creating and delivering care episodes that are totally PPS-compliant and audit proof.

These changes are not easy to produce, and they involve clinical program and staff management and accountability never before seen in Home Health. Agencies seeking to adopt the UR-managed approach will need to rewire over a decade of care practices that became routine under the PPS model. Emotions run high during these changes, as loyalties, habits, nuances, and traditional homecare programming is challenged, all in the name of efficiency and healthcare evolution. Many hospital-based agencies find this path to UR-rewiring easier to internalize than free-standing Providers. Certainly, health systems confront ACA-related discussions daily in the hospital environment, and they understand changes are in order for their homecare agencies, whose primary function until recently was to assist in DRG management. In addition, the management of clinical staff for productivity, clinical content, acuity management, and scheduling is second nature to the hospitals; they already perform these duties for their in-house clinical staff and don’t understand why this would be difficult in homecare. As a Home Health clinician, contractor, consultant, or speaker for 35 years, I’m not sure why it’s so difficult either.

So for Home Health Providers seeking help regarding the issues of today that also solve the homecare problems of tomorrow, Utilization Review is the answer. By installing this clinical management protocol, you will regain control over your care programs, your clinical staff, your patient outcomes, and your financial results, all while establishing truly patient-centered care that addresses the needs of an evolving healthcare model. Other agencies are already on this path. When will you begin your journey?


Arnie Cisneros, P.T., President of Home Health Strategic Management, is the most progressive speaker in homecare today. He provides coaching and consulting services to providers on a national basis regarding S.U.R.C.H. and other clinical management protocols for quality outcomes.

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