The Difference between GOOD and GREAT Home Health Outcomes

What Operational changes produce Improved Clinical and Fiscal Results?

Many Home Health Providers who managed care successfully under PPS have found their traditional care management models fail to produce desired results under PDGM. In addition, VBP Expansion reduces payment totals for Home Health, and most agencies fail to qualify for the VBP Bonus through their standard care processes. There are many reasons why HH Outcomes are more difficult to produce in the Value Era. The long-standing, volume-based, PPS platform has been replaced by PDGM (and VBP), effectively leaving us under a capitated Pay-4-Performance model.

Many HH Providers seek solutions to help improve their programming outcomes in both clinical and financial terms. Working with many of these Providers, we have found that many of Home Health’s PPS-era practices hamper them in terms of improved PDGM outcomes. There are many areas of traditional HH care management that differs from all other Part A Provider practices, and addressing those areas is the first step towards PDGM success and VBP bonus qualification. We will first address CMS Part A practices that may limit our PDGM outcomes, and then review specific HH Operational changes that produce Value-Era success.

Part A Practices for Home Health to Address for Value Success – let’s address and resolve!

  1. Real-time (vs. retroactive) Care Management – ALL Part A Providers manage care processes in real-time, which contrasts with the retro-active manner most HH Providers employ. This practice of retro-active care management began under the Volume-based PPS model and many agencies still utilize this approach. Under the Value-based, capitated PDGM, rapid clinical changes are required for success, and real-time care management is necessary for POC changes prompted by the patient’s response to treatment.
  2. Objective Care Management Platform – ALL Part A Providers manage care through objective reporting (again, in real-time) based on in-episode documentation. In Home Health, verbal reports often drive care, leaving documentation as an under-developed afterthought. For example, “The nurse says she needs more visits” or “PT called, and they want an extension”. In many, or most, cases the agency responds without checking documentation. By assuring that ALL changes to the HH POC occur ONLY after reviewing the documentation, the agency can assure that an extension is appropriate (and CMS-qualified). This approach will ensure all documentation supports the POC in a skilled and ongoing manner.
  3. Documentation for Coverage – ALL Medicare Part A programming is based on patient response to treatment, which is basically acuity management. Inpatient Length of Stay (LOS) is related to patient progress based on real-time treatment notes, creating a “Documentation for Coverage” scenario. Home Health Providers seeking success with PDGM-VBP should develop and manage care episodes and content solely through documentation, which improves the quality of visit notes.

Home Health Operational areas to Address (and rewire) for PDGM – VBP Success

When considering the specifics of the capitated Pay-4-Performance PDGM structure, traditional HH Operations will fail to support the many aspects of value programming required for elite-level outcomes. HH Providers who have rewired crucial areas have increased fiscal margins by >30% while qualifying for the VBP bonus. Most of the areas they focus on relate to efficient programming in a timely manner, basically the elevated performance items identified by the VBP model.

  1. Intake – Intake is the first area requiring a philosophical and operational rewire for PDGM success. ALL other Part A Providers admit all patients within 24 hours, and HH must internalize that timeliness is required for a comparable level of care delivery. In order to achieve 24-hour SOC visits, referral sources must be educated in terms of HH Intake regulations, resolving traditional areas of intake delay. Since HH often has the ability to perform admits within 24 hours (are all clinical staff at full productivity?), the focus on processing referrals and aligning those visits with clinical staff schedules is essential. In addition, timely admits decrease readmissions, most of which occur by Day 10 of the episode.
  2. Scheduling – Agencies should tighten up schedule management and assure full productivity with all clinical staff, which is necessary for timely care delivery and fiscal integrity of the HH Provider. ALL other Part A Providers obtain full productivity for clinical staff, so CMS reimbursement rates are based on that level of staffing costs. When HH fails to manage staff to full productivity, or use PTO to address shortcomings, they fail to achieve the after-cost margins Medicare payments can provide.
  3. Admission (POC Development) – PDGM rewired the HH Payment model, shifting most of the episodic payment to the SOC Clinical Acuity level defined by Case-Mix. As a result, OASIS accuracy is paramount to financial success in the PDGM era. This is a major shift from the PPS era, and all Providers must address this area in terms of increased accuracy during the HH admission. The OASIS Case-Mix questions are answered at a 72% national accuracy rate, and Providers will need to improve to a >95% accuracy rate to optimize PDGM results. In my practice we focus significantly on SOC OASIS Accuracy to achieve a >98% rate. This allows for an elevated POC development based almost entirely on the clinical profile of the patient in PDGM terms. In our experience, neither OASIS scrubbers nor post-SOC reviews achieve this level of accuracy, leaving clinical and fiscal opportunities on the table. Finally, there are no non-admits accepted without agency involvement with the patient, caregiver, and referral source.

    When addressing HH POC development, it is essential to adopt the Value-based care approach, which is based on timely, rapid response to care concerns and resolution. This is a MAJOR change area when compared to the PPS era, where care volumes often resulted in increased payment levels. Under PPS, most HH POCs were developed under the philosophy of “It might take us this long” to resolve clinical concerns. Under PDGM, POCs should be developed under a “Maybe we can do it this fast” approach, with an expectation that previous HH volumes would decrease under PDGM. This prompts timely care responses and realigns HH programming in Value-era terms.

    Finally, Scripting for Success at admission informs the client of how contemporary Home Health works and their rights as patients. Also essential is the discussion of patient responsibilities in terms of their participation and compliance with the HH POC to assure the episode remains skilled.

  4. In-Episode Management – under the capitated PDGM, POC modification should occur in real-time based on documentation for coverage. This occurs in an ongoing manner with ALL Part A Providers outside of HH and cannot be managed successfully under the HH Case Conference method. We employ weekly clinical rounds and move programming forward based on care to date with the Value model in mind. This also allows us to manage per visit care content for best practices as we continue to evolve our care delivery.
  5. DC Management – There are no independent HH Discharges performed without agency pre-approval. This allow the Provider to control all DCs and address clinical gains, stabilizations, or declines prior to the discharge. This is essential when working in today’s HH era where VBP qualification is based on patient improvement.
  6. HHCAHPS – Successful Scripting is required for hi-level HHCAHPS scores, specifically regarding communication with the patient and caregiver, how HH will get them better, noting improvements or lack thereof and why they are happening, and assuring expectations were met prior to DC. Specific levels of attention are required here as frontline HH clinical staff are not comfortable with scripting this approach.
  7. Employing Key Performance Indicators (KPI) for Ongoing Improvement – Success requires transparency regarding care and outcome improvements. Ongoing maintenance of Key Performance Indicators (KPIs) are tracked daily and reviewed with all administrative, managerial, and supervisory staff weekly. This ensures standardized care throughout the agency, tracks data in real-time for improvements (or to address any regression) or opportunities to further improve care delivery and outcomes. KPIs we track and report on weekly include:
    • Financials – related to earnings or costs
      • HHRG Payments
      • LUPAs – Non-Admits
      • Nursing Visits per Episode
      • FIL Percentage
    • Clinical Programs
      • Missed Visits
      • Productivity Report
      • Readmission – w readmit audit findings to ID preventable readmits
      • VBP Clinical scores – including TNC and TPS tracking scores
      • Potentially Avoidable Events – focus on falls & med management
      • CMS-required documentation compliance for best practice care
  8. Closing Summary – It is evident that the HH Operational Platform outlined above is anything but a “Business as Usual” approach to Home Health. What is important is that this Value-Based Operational Model mimics the manner in which Inpatient Part A Providers have managed care for decades under their version of capitated programming. It assures a comprehensive, objective care development and delivery approach based on what Medicare regs outline as success in Home Health.

Hopefully, the specific areas identified in this article give you a starting point to improve your operations and change your clinical and financial outcomes from Good to GREAT!!