Care Modeling: The Care Plan Production and Management of the Future

In 2013, Home Health Providers have been bombarded from all sides with challenges regarding how the homecare Benefit is evolving, and how care will be produced and managed in the near future. The 2014 PPS Proposed Rule, defined by rebasing payment cuts that extend through 2017, is our primary area of concern as the projected reimbursement changes will reduce the funding connected with our care. Meanwhile, we confront the daily and ongoing issues of running a Home Health agency: staffing and recruitment, business marketing and referrals, regulatory demands and updates, costs and cash flow realities, etc. In addition, the looming effects of healthcare reform present us with the challenges of adapting our clinical programs to the demands of the new care approaches and delivery models. Reports of projected loss of Providers, decreased utilization/episode, and the wellness/preventive approaches that will redefine our traditional care vehicles loom in the distance as the reform efforts materialize.

Traditional Home Health care production and delivery protocols may or may not survive the challenging road that lies ahead for us working in homecare. The legacy of the community-care model is one of clinician-led care program development and delivery; this approach may separate us from more progressive care models evident in acute-care DRG management. Prior to the introduction of PPS and DRG-managed length of stay coverage, hospitals existed as fee-for-service Providers. Admissions, clinical programming and care volumes were managed by Physicians and other clinical staff; DRG installation substituted Utilization-managed care that ultimately led to a level of focused delivery resulting in a 77% decrease of acute length of stay statistics since the introduction of DRG care protocols.

The reality of the healthcare reform efforts is that the reduction of the current siloed care continuum effect will identify the entire acute episode in terms of the DRG identity established at acute onset. This is how the care delivery protocol of the future will be rewired in an episodic manner, rather than a group of disparate Providers connecting to create an episode defined by a series of semi-connected clinical programs, as we have today. So much of the Post-Acute care of the future will be administered via a Single Bundled Payment model, with the episode being defined by the acute admission combined with a post-DC period (usually 30 days).

Most informed experts predict the evolution of the Home Health Benefit in terms similar to those seen across the acute care landscape in response to DRGs. Clinically focused programming, assertively managed by Utilization Review (UR) protocols, will be required for success. Home Health programming developed and managed by front-line clinical staff will fail to produce expected results unless managed via these UR protocols developed and employed in acute DRG management. Program expectations will be based on objective assessment findings, full patient/caregiver participation and compliance, standardized but skilled care and progression, and progressive placement and episodic patient movement; all areas that will require significantly different care protocols when compared to today’s standard Home Health procedures.

Care Modeling, the UR-based care production and management of Home Health programming, represents a significant departure from the care protocols developed for homecare throughout the PPS era. By focusing on the historical differences between Home Health and acute care DRG-management, Care Modeling allows for programming to be developed and delivered in a case management model, returning clinical control back to the Provider. By adopting this UR-based control model in lieu of front-line staff managing the bulk of the patient programming, Home Health Providers can re-locate the care currently managed by their clinical staff by relocating clinical control to the administrative office where it can be managed for the episode efficiencies of the future.

Demands of the New Care Models

Accountable Care Organizations (ACOs) will create Integrated Health Systems, a network of affiliated Providers that address all potential patient needs currently managed by today’s care continuum. These integrated networks will include an array of Providers representing the care continuum of today; LTACH, IRF, SNF, and Home Health are the primary care sites included on these Post-Acute rosters. This Integrated Health approach will produce the Single Bundled Payment (SBP) episodes of the future; SBPs that include post-discharge care will be labeled Post-Acute Bundles. The author’s work with Pioneer ACO systems has placed us at the forefront of various pilot programs for the Bundling models currently managed by the CMS Innovation Center – Bundled Payment for Care Improvement (BPCI) program. Those pilot programs employ a case management model whereas the acute patient care manager becomes the Post-Acute “Care Navigator” to manage the post-discharge programming, deciding on placement, clinical programming content control, and Provider-specific care volumes. Post-Acute Providers will be significantly affected by this imposition of a case management influence on their patient programs. The valuation of their care, according to clinical or managed care expectations established by the DRG at admission on an individual patient basis, will alter the basic elements of the silo-based programs of today.

Nearly all aspects of the post-discharge care programming of today will be altered under the ACO Integrated Health System model. From intake to discharge, traditional care structures regarding much of the PPS-era patient programs will be altered to address the goals of the new ACO-derived episodic approach. Start of Care findings will be vetted for reliability and accuracy, and OASIS data will be directly synthesized into patient care plans. Clinical volumes, including frequency and duration aspects, will be authorized according to a safety-based, standardized approach. The presence of a caregiver will decide patient placement in many instances, inferring an expectation of consistent level of caregiver involvement that our experienced clinical staff may fail to elicit. The management of skilled progression and ongoing patient progress will define program volumes and discharge preparations. And finally, clinical programming will be required to deliver clinical outcomes in order to be considered a reasonable and necessary aspect of the episode.

The Evidence-Based, Best Practice Factor

During a recent CMS Innovation Center webinar for the BPCI Pilot program awardees, the presenter made a statement regarding the historical issues that must be addressed for success in the Bundling era. Relating care value to specific Provider-types, he commented that “Acute care Providers (hospitals) employ evidence-based, best practice care management while Post-Acute Providers (SNF, Home Health) do not.” Continuing, the speaker went on to state that hospitals “manage their physicians, clinicians, and patient programs in a manner not seen across the Post-Acute landscape.” Clearly, the emphasis on evidence-based practices must be addressed by Post-Acute Providers seeking to fit their care programs into the episodic approach of the future, but what specific areas of our care must we address to comply with these expectations? Also, what elements define value when we compare Post-Acute Providers; i.e. how do SNF care programs compare to Home Health episodes for value in the new care models?

First, what differences exist in our care that may define the lack of evidence-based, best practices in the Post-Acute world? At the onset of programming, acute care Providers assure only qualified patients receive services by assertive use of Utilization Review (UR) to manage ALL admissions in a standardized and efficient manner. ER physicians and staff monitor these admissions through UR personnel, assuring that all patients are qualified and classified. Home Health admissions, in comparison, are managed by front-line clinical staff for qualification, care programming and homebound status. Educational and experience levels (regarding OASIS and contemporary Home Health in general) of our staff may adversely affect performance in this area, while the lack of UR-control and accuracy of assessment allows for other external factors to influence performance in this area. In contrast, DRGs prompt the management of acute care content and volumes, including MD interventions and communication, clinical programs at the staff level, and discharge preparation and determination.

Acute hospital in-episode care control is also managed for different results when compared to Post-Acute programming; let’s review how this may affect outcomes. Consider that when a hospital patient suffers a fall during the first day of an acute admission, the hospital staff takes steps intended to eliminate any additional falls during the remainder of the inpatient stay. These steps may include the use of a cane, walker or wheelchair, or even the introduction of an alarm, restraint, or personal attendant to prevent any fall reoccurrence. In contrast, it is not unusual for Home Health patients receiving therapy services in response to falls to continue to record falls during the episode. There may be many reasons for the continued falls; incorrect assistive device use, non-compliance, a therapy program that may fail to address the underlying issues (strength, etc.).

But this scenario raises the question that will define the contrast between acute and Post-Acute care under the ACO model; if, for ANY reason, a therapist placed in the home to eliminate falls is unable to reduce falls, what is the value of the therapist in the home? Likewise, if a nurse is placed in a home to help a CHF patient manage their disease and, for ANY reason is unable to achieve the desired outcome, what is their value in the home? These examples illustrate many cold, hard realities that Home Health Providers and clinicians will encounter as they wade into the ACO era. First, their care programs will be assessed for value by healthcare Providers not in the Home Health industry; the real-time valuation of their interventions will be based on their ability to produce outcomes from clinical programs. Acute care Providers, acting as the ACOs of the future, will require outcomes from Home Health episodes that are measurable and consistent with clinical results they achieve from inpatient programs. Second, the care cornerstones that are commonplace in DRG-managed programming; efficiency, skilled care progression and patient compliance, will be expected from Home Health in a manner not consistently seen in many of today’s care programs.

Care Modeling: How and Why It Works

By controlling specific elements of traditional Home Health care assessment, production, and delivery, progressive Providers can employ Care Modeling to rewire their care programs to meet the challenges and demands of healthcare reform. The ability to standardize admission data and interventions replicates the UR control of the acute care experience; objective admissions absent SOC personnel variations, based on accurate OASIS data and synthesized by experienced UR staff un-related to front-line care delivery. Average SOC HHRG fiscal changes exceed $350/case when OASIS data is vetted for accuracy (seeking defendable patient profile development for optimal rather than maximal results). What Home Health Provider feels that in-accurate OASIS programming serves the patient or the system, or expects to market OASIS under-performance to an ACO seeking progressive and managed care?

Care Modeling also allows Home Health Providers direct control over the clinical rewiring of their care programs to address the requirements of the Post-Acute focus on the 30-day Bundle. By focusing care assignments and staffing levels specifically on the clinical deficits identified during the SOC OASIS findings, homecare programs shed the traditional programming trends that may prove obsolete under the new care requirements. Rather than delivering certification-period programs that may or may not address the 30-day Bundle and readmission concerns, Care Modeling allows for the production and delivery of standardized but targeted care. The net result is decreased visits with elevated clinical outcomes; all produced by the fit and focus of the entire program on the objective clinical concerns derived from the managed SOC OASIS event.

This intimate care programming alleviates a scenario seen all too often in the current Home Health arena; excessive visit totals marked by sub-standard clinical results. Most homecare observers would expect increased visit numbers on a per patient basis to elicit elevated clinical outcomes, but the opposite is observed consistently throughout our industry. The lack of specificity or connection of programming to OASIS findings creates a generic approach to care delivery that addresses visit totals in lieu of clinical interventions. Despite the introduction of face-to-face documentation to identify the clinical focus of the Home Health referral, so many factors promote the continued focus on visits rather than care content (certification history, pay per visit employment packages, lack of UR-managed SOC volumes, etc.). Across the care continuum, decreases in funding or access to patients has prompted more efficient care programs, and, as a result, improved clinical outcomes. Home Health Providers need no specific regulatory changes or CMS prompting to address these issues today; savings produced by decreased visits from managed care can be accompanied by elevated outcomes under the current PPS model. In this manner, homecare agencies can create the care programs of tomorrow today.

Finally, Care Modeling includes the control of rehab services to match the clinical control level of the non-therapy disciplines on the case. Clearly, the historical role of therapy in the PPS Home Health era has distorted the use of rehab in our care model. The recent attempts to separate rehab application from their fiscal identity in the PPS model outlines the CMS level of concern regarding this issue (elimination of 10-visit threshold, reassessment requirements, and regressive therapy reimbursement). ACOs managing Home Health services, either in Post-Acute Bundling or chronic Population Health programs, will expect to view, value, and manage rehab services in a manner identical to all other disciplines on the case. Care Modeling allows for Home Health Providers to manage therapy programming for this level of expectations.

Home Health Providers developing and managing their episodes through a Care Modeling approach elicit significant savings when compared to traditional care programming; changes of up to $1000 per individual Post-Acute patient episode are commonly seen. In addition, the replacement of a generic, one-size-fits-all program with a specific, form fitting clinical intervention delivers improved outcome results despite decreases in utilization (the exact replication of the DRG experience hoisted onto the Home Health model). Clearly, this is the care production and management structure of the future.

Getting Started on the Path to Care Modeling

Home Health Providers seeking to avoid these types of issues as they prepare for the ACO-era realities should focus on care-production aspects that define current programming under the DRG-managed care programs of today. There are many elements to address as we ponder the evolution of our clinical programs to fit the episodic expectations prompted by healthcare reform. From the initial intake process to ultimate discharge outcomes, the Home Health model is rife with opportunities to develop care protocols that offer new levels of value to the ACO-managed episodes of the future. Listed below are examples of areas where Home Health Providers should be assessing their current programming to begin preparations for the episodic future:

  1. Intake Referral Management– The establishment of Integrated Health Systems will reinvent the intake process as the Bundled Episodes of tomorrow connect referral sources and downstream Providers in a manner absent from today’s patient distribution.
  2. UR-managed OASIS Admissions – SOC OASIS performance often suffers regarding accuracy for a number of reasons; staff under-performance, a historical lack of connection between OASIS findings and care plan composition, patient influence on the Plan of Care, etc. As a result, care programs and related outcomes, both clinical and financial, fail to achieve optimal levels. The Rebasing focus on case-mix, outlined in the 2014 PPS Proposed Rule, should make this a priority for all Home Health agencies looking to compete for these patient programs in the future.
  3. UR-managed Care Plan Production– Complete care programs will be reflective of OASIS-based clinical findings. Traditional influences affecting care programs (patient influence & refusal, programming related to care site) will decrease as clinically-based care applications will produce efficiencies and savings.
  4. UR-managed Nursing/Therapy Concession– The history of the PPS era in Home Health has reinforced the connection between care volumes and income; therapy services are directly linked to service volumes, and a lack of recertification controls has prompted clinical volumes from other disciplines. By managing clinical care on a per discipline basis focused entirely on outcomes, volumes will decrease significantly when compared to current programming.
  5. In-episode Clinical Control– Historical PPS-era programs cover the 60-day certification period; the ACO Post-Acute patient will require a 30-day focus, defining clinical interventions un-related to traditional volumes, the need to modify care based on patient response to treatment, and ongoing reassessment, not administered by front-line clinical staff, of care delivered to date.
  6. Discharge Preparation – DC management, controlled by ACO Care Navigators, will manage patient needs as they transition from Post-Acute Bundling episodes to chronic Population Health programming, modifying all current DC influences and volumes.
  7. IT Care Management – Clinical control will be managed by ACO Care Navigators who require regular “reporting” of clinical care data, separate from traditional documentation requirements, as a means of managing care programs. Home Health Providers should assure all clinical staff demonstrates performance with all available IT-related products that contribute to patient care.

Care Modeling assures performance and clinical control in these areas, helping the Home Health Provider prepare their clinical staff and programming for the requirements of the new care models. Nearly all Home Health Providers encountered in our professional practice state they want to participate in the ACO era; this article outlines many areas where agencies and clinicians can start to prepare today. Now is the time to prepare by turning your focus inwards, toward care opportunities that exist in your current caseload. Find elements where your care preparation or management reflects a “business as usual” approach, identify staff that may fail to promote progressive care, and resist the “everyone else does it like this” rationalization for under-performance in areas that affect patient care costs or outcomes. Install Care Modeling in your agency and patient care programs; today is the day to start preparing for tomorrow.

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 (see regarding S.U.R.C.H. and other clinical management protocols for quality outcomes.