Medicare Home Health nears the completion of a decade since the reforms prompted by the Balanced Budget Act of 1997 were installed. Moving forward, we are confronted by the many challenges the future presents that will undoubtedly alter our care mission. The obvious need for clinical advancement, quality outcomes, and financial review will test all homecare providers. In the quest for successful agencies, efficient caregivers and acceptable fiscal returns, Home Health providers would be well served to mine the current care model. Deliberate and conscious use of the Prospective Payment System (PPS) produces a level of performance success traditionally seen only in elite agencies. By embracing the sort of philosophical changes PPS has introduced, all providers will find new levels of efficiency and outcomes. In addition, they will discover the path to the next care horizon, Pay for Performance (P4P). The gains achieved will not only result in happy patients and physicians, but will also develop successful agencies that realize both clinical and financial health. Most of the techniques we will discuss are derived from the basic philosophies of the PPS; in fact, they are well-founded best practices common to our industry. But they are employed in a pro-active manner that focuses solely on use of the PPS model as a programming and clinical delivery guide.
In keeping with the theme of joint disease, we will present today on the topic of efficient therapy utilization and its relationship to homecare success. Employing the episode of an 85 y/o hip fracture and subsequent ORIF surgical intervention, we will demonstrate how use of the PPS model can lead to desired outcomes. Prior to the description of our fracture patient’s episode management, we must review the history of reforms as installed by the Center for Medicare Services (CMS). In addition, we must also examine the goals and evolution of our industry in the ever-changing healthcare environment in America.
Over the last decade, Medicare reforms have moved steadily down the continuum of care; in 1997, Congress passed the Balanced Budget Act. The resulting PPS reform was developed around the concept of an acuity-based, capitated payment mechanism, and served as a replacement for the previously employed fee-for-service structure. The 2008 PPS refinement, known as the New Rule, emphasized correct therapy utilization as a primary reimbursement driver by the elimination of the 10-visit, high therapy designation. Proposed refinements, such as the Pay-for-Performance model currently in the demonstration phase, go one step further. By its inclusion of clinical outcome levels (as defined by agency specific OBQI scores) in the payment equation, this reform places a premium squarely on the “improvement” of the client. Clearly, as our industry evolves, we must re-wire our delivery in terms of accurate programming and management of clinical services. New ideas, and new ways of thinking about how we do what we do, will be the order of the day. Many of the lingering habits of the fee-for-service era will be abandoned as agencies focus on P4P relevant strategies. OBQI-based programming will be the cornerstone of clinical services, and the premiums placed on patient improvement, especially in areas of safety and function, will dictate all staff performance.
The New Rule installed significant changes in payment based on therapy utilization as measured in terms of visits. The original PPS high-therapy designation (10 visits) was replaced by a reimbursement structure reflective of a more specific, graded approach to the process of using rehab visit utilization to determine payment. The New Rule, however, continued the use of the Home Health Resource Group (HHRG) score to identify acuity, and therefore, payment. The graph exhibited in Table 1 (e-mail HHSM for Table 1) shows the raw effect of therapy visits on reimbursement. By neutralizing both the Clinical (C) and Functional (F) scores, the relationship of therapy utilization to specific payment levels becomes clear. The fiscal results derived from variations in the rehab visit based Service (S) score, are graded and consistent as evidenced in the graph. 2008 data reports that identify clustering of visits around 6, 14, and 20 levels confuse this author. They seem to be reflective of the visit “gaming” that many agencies and clinicians unconsciously employed in response to previous high-therapy payment rates. Hopefully, as we move forward with PPS and subsequent reforms, the distribution of rehab services will mimic the “smoothing” of payment levels installed by The 2008 New Rule refinement.
Before addressing our patient example, we must discuss a few additional realities that will affect our approach to programming, and ultimately, outcomes. As the continuum of care evolved over the last 25 years, many healthcare changes occurred that are relevant in our daily practice as homecare clinicians. Ignorance of these changes produce care plans and programs that fail to address many of the realities of today’s homecare client. First, the 2007 length of stay statistics for acute hospital beds reveal inpatient stays of less than 4 days (3.9), as compared to nearly 18 days in 1984. Home Health patients are clearly more complex and present higher levels of acuity and care needs as a result. Failure to program these clients appropriately will surely hinder clinical outcomes.
Second, continuum of care comparisons must also be considered in the development of a successful homecare program. The case of our hip fracture patient provides an insightful example of these realities and their connection to programming. If this patient, for any reason, were unable to be discharged home after the acute hospital stay, they would surely be admitted to either an inpatient rehab unit or a Skilled Nursing Facility (SNF). Rehab frequencies in these programs would be 5-7 days/week in all cases. In many instances such as this, the presence of caregivers, rather than acuity, serve to determine discharge placements. Many agencies fail to consider these continuum of care realities when creating homecare programming for this type of client. As a result, many of these programs fall prey to rehab staff shortages or habits and are created with frequencies of 2x/wk for PT and OT. The care disparities for this debilitated and needy patient are substantial and require further examination. How can a homecare program at 2x/wk provide a level of care comparable to that received in a SNF at 5x/wk? And why wouldn’t the Medicare beneficiary, having pre-paid for coverage for up to 45 years of their working life, expect quality healthcare services now that they meet qualification requirement levels? These questions must be addressed, and answered in a patient-centered manner, for the types of outcome success that will be required in the P4P era.
Finally, we must examine forms of Utilization Review (UR) employed as a mechanism of care management in various healthcare environments. Traditionally, the homecare industry has lagged behind other types of providers in this area. When Medicare introduced DRGs over 20 years ago to hospitals as a form of capitated payment, UR personnel were established as gatekeepers of clinical delivery in order to focus care without compromising quality. When Home Health installed PPS, no such attempts to introduce a well-defined, consistent form of UR were undertaken. As a result, homecare efficiency has been placed squarely on the clinical shoulders of our front-line clinicians. Despite obvious differences in educational background, experience, or rates of clinical success, the front-line caregiver is expected to perform at a level of proficiency that is relevant under PPS. In reality, many clinicians working today still lack an insightful, working knowledge of PPS and the New Rule modifications. UR management of Start of Care (SOC) programming, subsequent clinical delivery, and discharge planning, are crucial for future homecare success.
As we describe programming and episode management of our hip fracture patient, we will reference many of the ideas and procedures described above. This protocol is standard operating procedure for all Home Health patients we serve: we utilize these principles as our roadmap to clinical success. If SOC goals prove to be unattainable, these practices help us lead our clients to their highest functional performance level.
Our client is an 85 y/o male who lives in a small home with his 80 y/o spouse. Both have arthritis and use assistive devices to ambulate (he had a cane, she uses a rolling walker) independently throughout their house. He had fallen approximately 8 days prior fracturing his R femur, was hospitalized and received an ORIF surgical procedure. He was discharged home as a result of the involvement of his children who live nearby and their desire to participate in his care as a means of avoiding SNF placement. A hospital bed and commode were delivered to the home, and a Home Health referral for Nursing, Physical Therapy, and a bath aide was made. The client has a rolling walker and a RLE toe-touch weight-bearing limitation. Upon discharge from the hospital, the client was able to walk 15-20 feet with a walker and moderate assist for safety and maintenance of RLE weight-bearing restrictions. Please refer to Table 3 (email HHSM for Table 3) for ADL declines noted on the SOC OASIS. Multiple family members live nearby the client’s home and are eager to participate in the initial visit as well as the entire homecare program.
The Start of Care OASIS visit was performed by nursing, and a Plan of Care (485) was created that included orders as follows:
Nursing ————————–2 x 8 weeks
Physical Therapy ————– PT Eval -1 x 1, 2 x 7 week order
Home Health Aide————–2 x 8 weeks
Upon performance of a post-SOC utilization review completed in a pre-RAP routine by Quality Assurance staff, many PPS programming concerns were identified. Why were nursing orders that spanned the entire certification period necessary? Do these levels of nursing needs exist, or are orders created solely for the purpose of completing the 60-day episode? Many agencies still program as if nursing is required to monitor therapy in the home for the entire program duration. Why is the PT frequency 2 x week? And why is the duration for 7 weeks? Regarding frequency, this same patient would receive 5 x week services if sent to a SNF for sub-acute rehab for up to 100 days of coverage. Is the patient only requiring 2 x week service levels, or is this the result of an over-taxed rehab staff delivery protocol? And does the PT feel a seven week program is required to achieve safety and function in the home, or are they also programming to complete the 60-day episode? Our experience is that this sort of patient, in most instances, needs intensive rehab services for shorter time periods.
Finally, why write an order for a bath aide that also spans the entire episode? Bath aides are not reimbursable under PPS, and they tend to foster dependence because they don’t help solve the ADL limitation that is identified in the SOC OASIS. The PPS model advocates the placement of skilled services, as defined in this instance by Occupational Therapy, to address and resolve strengthening, caregiver training, or equipment needs. All of these may be required to assure a restoration of independent function in the home after discharge. In our practice, we follow a simple rule: No aide placement without an accompanying OT eval order. When OT completes their program in cases such as this, they discharge and the aide is DC’d simultaneously.
The pre-RAP UR routine we advocate helps determine appropriate answers to these questions beyond the scope of the SOC clinician. The SOC nurse would be asked to create a nursing frequency that fits the obvious and objective clinical needs that a nurse alone must address. UR would also help PT identify frequency approaches that are more in line with how this patient would be programmed at other points of care. In addition, the SOC nurse would be asked to modify the POC to include the OT services identified by the PPS model to address ADL deficits. Lastly, the UR routine would encourage the SOC nurse to create a more progressive bath aide order to limit agency expenditures and prompt patient and caregiver use of the OT expertise.
It is easy to see how this approach can foster efficient care that is accompanied by improved fiscal results due to the adherence to PPS reimbursement principles. Though OT was not on the original referral, the Home Health model requires that despite the initial order, the multi-discipline OASIS assessment must be performed to identify areas that should be included in the homecare program in order to maximize the level of successful outcomes. Clearly, the ability to demonstrate OBQI outcomes in areas such as gait, transfers, bathing, and shortness of breath, is enhanced by the prudent application of the correct disciplines at the right intensities. Efficient providers embrace the UR-based opportunities to educate their staff and referral sources in an ongoing manner as their care programs achieve desired outcomes.
Post-SOC program delivery should also be managed in a UR-type manner. The changing homecare environment requires agencies to assist the clinician so they can experience success in our industry. As many frontline clinicians complain of burnout and over-stressed work experiences, we as agency supervisors can aide them in their delivery. Clinicians should be conferenced on an individual and weekly basis to assure focused, skilled care progression When is nursing ready to discharge? Should PT complete their original frequency, or should they achieve goals as rapidly as possible and discharge? What is the effect of not fulfilling the M0826 projection from the SOC OASIS? If the OT improved bathing to a level maintainable by the client or the family, why is the aide still going?
These are some of the programming concerns or opportunities that we, as homecare providers, confront today and in the immediate future. Clearly, there exists many care solutions and methods of helping our patients return to safe, independent lives in their homes. By the performance of a UR review for ALL SOC OASIS documents, and definitive management of the therapy service mechanism, agencies can learn how to make appropriate clinical decisions for their entire caseload. As demonstrated above, progressive embrace of the PPS model, particularly through refinement of the Therapy Utilization system, can serve to help all agencies illuminate the care pathway of the future.