The discussion in the mainstream media regarding the Home Health industry often focuses on the overpayment, over-utilization, inefficiencies, and fraud or abuse that have been present in recent times. The specific and debate-based exchanges that have defined the legislative healthcare dialogue often reference these concerns as evidence of potential savings in the Medicare program that may help fund the universal coverage bill. Though many industry leaders, consultants, and speakers describe their individual weariness with these recurring characterizations, the gaming and lack of care evolution is, in fact, present in the recent homecare history.
Whatever the eventual outcome and effects on the Home Health model the final healthcare bill presents; the issues above will be addressed and eliminated, or at least minimized, as a result of the increased exposure the debate has brought. Audits, whether implemented by Fiscal Intermediaries (FI) or Recovery Audit Contractors (RAC), are certainly here to stay. Furthermore, funding reductions may hasten the implementation of proposed refinements such as Pay for Performance (P4P) or Post-Acute Bundling. The increased scrutiny of episode claims will cause all service delivery to be re-examined to assure reimbursable care. It seems certain that the net result for Home Health will be a smaller client base combined with decreased utilization.
Though much of the Home Health industry is comprised of honest, caring providers that attempt to deliver quality and sincere care, their services will also be affected. Already experienced by agencies in states where FI audits have been seen this year, scrutiny results in “deliberate care” delivery. Elevated levels of focus on skilled progression, patient compliance and education, and efficient delivery combine to produce improved clinical outcomes despite decreased utilization. The reasons for this scenario have been exhaustively discussed in this column, and the changes seen in our clinical approaches have been long overdue. Though different agencies adopt different methods to address concerns in light of audit exposure, all successful responses involve the willingness to MANAGE their care.
Also examined previously in this column, the lack of care management experience is prevalent in all our clinicians. DRGs and RUGs require Utilization Review-based care in hospitals and Skilled Nursing facilities respectively, and in many cases, Home Health clients are similar, if not identical, to those patient populations. The Prospective Payment System (PPS), though extremely effective in transposing our fee-for-service identity to a more acuity conscious version, fell short in regards to the level of care management required under audits. The establishment, management, and delivery of care plans has remained in the hands of front-line clinicians in nearly all cases examined today. With few concerns regarding reimbursement, the Home Health agency had little incentive to progress care. The OBQI program, with outcome based quality scores posted on the internet since its introduction, failed to connect with many providers due to the lack of direct effect on agency success. Only the proposed P4P refinement marks the functional use of the OBQI scores as a direct care factor through the use of bonus payments for best clinical outcomes.
As a result, few providers and clinicians have been able to independently evolve care to the level required for the audits seen recently. Agencies that have experienced the audits and denials have been forced to re-wire care to produce programs inclusive of the factors requisite in the outcomes/utilization results mentioned above. Their newfound “deliberate care” delivery has resulted from an increased attention to both the care provided and clinicians involved. Any approaches that don’t include these items have the net effect of decreasing visits without improving outcomes. Sadly, having failed to modify care to the level required by audit scrutiny, those programs will suffer in both clinical outcomes and audit results.
The key to successful care, today and in the future, is based on an approach that values and includes care management at all points of the program. Quality clinicians, best suited to address the many subjective elements of the homecare client and environmental concerns, are managed on an ongoing basis regarding all aspects of objective care delivery. Utilization Review procedures are established to assure all Start of Care (SOC) programming is PPS-compliant, the first and most crucial step in episode development. Most Home Health agencies fail to perform this task and the resultant care programs reflect the practice patterns of the SOC clinician.
Ongoing case conferences with individual clinicians are employed to manage care on an in-episode basis. These weekly care rounds help keep the program skilled via reinforcement of best practices, compliance, skilled progression, and discharge management. Clinicians who fall victim to substandard care programs, non-compliance, and inadequate documentation are re-wired and assisted in their care delivery. A financial officer from a large, hospital based Home Health agency recently commented that he knows when their schedule of weekly conferences is not maintained: the visit totals increase on a per episode basis.
The bottom line is the willingness and ability to MANAGE your care, the simplest and easiest path to quality Home Health programs. This timely response to the recent industry challenges solves a myriad of programming and delivery problems by integrating so many of the philosophies and care advances of the PPS era. The result is contemporary care that works for providers, clinicians, physicians, and patients.