Home Health 60-day Rehospitalizations in the VBP era – MYTH: We can’t prevent them

It should come as no surprise that CMS has made some sharp left turns in Home Health payment and quality areas, directly impacting how our industry delivers care programming. Their goal remains the same; integrating Home Health with care management processes of other care continuums Providers – how do we do it better, more efficiently, and with higher quality care delivery? We currently confront the VBP nationwide expansion after years of discussion, finding ourselves completely submerged in the requirements. And now, many Providers are in a frenzied drive to secure VBP outcomes and Total Performance Scores (TPS) which will result in payment losses or increases.

Goals of Value-Based Purchasing:

  • Improvement of quality care delivery
  • Improvement of efficiency of care delivery
  • Improvement in patient’s experience in their care
  • Improvement of physical function
  • Reduction of ER visits
  • Reduction of rehospitalizations

Objectively, Medicare has reviewed our outcome data over recent years. They recognized inadequate, uncoordinated care for chronic health conditions, and the lack of a standardized path of improvement across the industry. As a result they focused VBP scoring on 3 major areas related to quality care delivery.:

  • OASIS data
  • Claims Based Data
  • HHCAHPS

Let’s break these areas down to objectively look at how we perform, and where we fall short in terms of success under VBP.

  1. OASIS data
    1. Providers across the country still struggle with OASIS accuracy after 23 years. Clinicians don’t understand it, they do not use objectivity from OASIS guidance to answer the questions, and most important – they do it alone. This quality and control silo exists at the Provider level, and that prohibits high level outcomes and single digit rehospitalization rates.
      1. Clinical oversight is much more important than staffing independence at the admission to gain OASIS accuracy. It requires true licensure, and clinical oversight in the form of leaders or departments managing accuracy in real time. Transparent communication in the goal of obtaining OASIS accuracy. We only get one chance to get this right.
        1. Ever wonder why patients stabilize at discharge after multiple visits have been completed? Often, its’ because the clinician got to know the patient during the care VERSUS objective collection of OASIS data at admission.
          1. How does this impact ED use and hospitalization?
      2. Most HH Providers still pay and chase clinicians in terms of admission documentation. The clinician does the admission – then we chase after them days to weeks later to ask questions or verify accuracy. Yet, in many cases, the front-line clinicians’ final answer determines the accuracy of the OASIS, resulting in a national OASIS Case-Mix accuracy rate of 72%. Misguided reasoning for this scenario includes:
          1. They were the one in the home
          2. We are trying to secure long term employment
          3. We don’t want anyone to quit.
            1. Objectively: How is this patient centered??
        2. Includes the lack of use of Guidance for accuracy
          Lacking the objective findings through a comprehensive assessment that includes a functional walk.

          1. Concern: most OASIS are still done by interview alone, without the requirement of an actual functional walk and use of the Medicare guidance manual
          2. This a clinician centered mode – independent of patient centered needs and accuracy. This approach negatively affects the provider in relationship to outcomes and rehospitalizations.
        3. HH Providers CAN NOT improve patient outcomes if they are unable to capture, in real time, the accurate areas of deficit to DRIVE the individualized Plan of Care.
        4. HH Providers CAN NOT reduce rehospitalizations and ED if they do NOT have an accurate profile of deficits, and a global program to treat the patient in prevention of these risk areas.
        5. HH Providers CAN NOT reduce rehospitalizations and ED use based on “high risk” subjective thoughts alone without understanding what the actual deficits are. These areas need to be swiftly dealt with and resolved at the clinical visits.
          1. We often believe that time is on our side to resolve issues. We hear things that suggest not overburdening the patient with too many visits in the first few weeks.
            1. TIP: HH Providers MUST address these issues immediately! How do you prevent falls, ED use, medication errors, functional declines if you are slow walking toward the finish line? This past practice in Home Health resulted in many changes to force quality care delivery and efficiency. This is why Providers, in some situations, are UNABLE to obtain single digit rehospitalization rates as needed for VBP.
              1. Imagine if a hospital slow walked a patient to getting better? Would we be ok if our family member went to the hospital to get better and were told they would take their time, do it slow and see what happened? No – we would not. Is Home Health any different?
  2. Claims Based Measure
    1. Ever look at an agency star rating and think to yourself – I wonder how they got 4 stars when their rehospitalization rate is 23%?
      1. Medicare does
      2. Many Clients do
      3. Prospective referral sources do
      4. Your competitors do and use it to their marketing advantage!!!
      5. Changes in the future with the Post-Acute PPS model will render HH Providers unable to secure referrals with high rehospitalization rates
    2. The focus of reducing ED use and hospitalizations is currently one of the KEY critical areas to focus on for success.
      1. TIPS:
        1. OASIS accuracy and PROVIDER control necessary in all cases
        2. OBJECTIVE Leadership control – versus subjective clinician control
        3. Clear, objective, transparent communication between leaders and clinicians
        4. Patient centered care delivery through weekly – biweekly individualized in episode meetings
          1. No Case Conference – inefficient use of time/labor
          2. Provides little to no value in a patient centered model under PDGM and VBP.
        5. Standardized audit tools for use on each ED visit and hospitalization
          1. Immediate performance improvement on each event
        6. Clinician oversight of clear concise documentation
        7. Driving an objective, factual and accurate plan of care off the accurate OASIS data
          1. VALUE of each visit over VOLUME
  3. HHCAHPS
    1. Real time control of all episodes at leadership level from referral/intake through discharge
    2. Patient/family integrated into care from first admission visit
      1. Full, clear education on right/responsibilities
      2. Involvement in plan of care
      3. Goal setting
    3. Full Provider scheduling control at all turns
    4. Scripting and education of all front-line staff on HHCAHPS
      1. Where the scores come from
      2. How to address all areas on VALUE visits in the home
      3. Most important – what is the providers follow up? Meaning – we do a lot of talking/educating and leaving it with the staff to perform sans tracking, trending or any objective metrics. If you don’t have 4+ HHCAHPS star rating – here’s your rationale for why.

Home Health Strategic management take aways

  • HHSM partners with providers for success
  • HHSM follows a UR based model called SURCH for standardized practice in all areas of clinical/operations/financials
    • SURCH = Service Utilization Review for Care in the Home
      HHSM doesn’t tell you from afar – we join the team in daily responsibility, education, control, and oversight of hard wiring all areas of operational success and longevity

      • Use of daily reporting, objective metrics to hard wire all areas
  • HHSM follows a PATIENT centered model 
    • Driving accuracy of each referral, scheduling, admission, quality review, in episode management at the supervisory level, staff continuous education, documentation requirements through discharge
    • No silos between departments
    • Daily huddles, team operational building in successful oversight of all care delivery
  • Value over Volume model
    • Control and value of each visit through education, documentation requirements, and compliance with regulatory to gain efficiency
    • Measurable goals
    • Real time identification of clinical problems – and same day resolution
  • Immediate focus on rehospitalization/ED use to reduce all controllable situations
  • Client outcomes:
    • 4.5 stars
    • Single digit rehospitalization scores
    • Standardized operation practices with cessation of silos and lack of provider control
    • Improved HHCAHPS
    • Value of documentation
      • Education that is regulatory compliant, measurable, patient focused
    • Scheduling control – no missed visits, follow up and resolutions
    • Improved financials that are accurate based on OASIS accuracy/guidance
    • Quality assurance standardized practices
    • VBP preparation and success

The time is now – do you know your Total Performance Score (TPS) and ranking? What are you waiting for??