The Bold New World of Healthcare at Home

The metrics of healthcare reform are well documented: episodic approach, integrating healthcare professionals for improved care transitions, cost management, value-based reimbursement, insurance reform, an emphasis on population health and a new focus on wellness-based healthcare vs. deficit-based care.

Put it all together, and it points to an unprecedented opportunity for home healthcare, says Arnie Cisneros, PT, longtime physical therapist and president of Home Health Strategic Management, a Lansing, MI-based consulting company. “You are the desired care provider here,” Cisneros recently told a roomful of home healthcare providers at the Homecare Association of Washington’s 2014 annual conference. However, that opportunity can only be realized if home health providers adjust their delivery of care in specific ways.

His first recommendation is to get to know your accountable care organization (ACO). “There are 500 ACOs in America now. There are going to be 1,000,” he says. “You can destroy Obamacare tomorrow, and the ACOs will still be coming.” He notes that the ACO concept and bundled payments have been in the works for years but only became reality through passage of healthcare reform.

Currently ACOs are looking for solutions with regards to managing care transitions. ”You have to let hospitals know you’re already here in this space, or they will create a program without you,” Cisneros says. “Let them know you’re there and willing to partner.”

Cisneros defines care transition as the movement patients make between healthcare settings as their condition and care needs change during the course of a chronic or acute illness. Each shift from care providers and settings is defined as a care transition. The key to this concept is that the focus is on the patient, not the provider.

Under the current model, healthcare providers must see more patients in order to increase revenues. The new system pays more if the patient improves faster. While this is an improvement for both the patient and the provider, the new model also involves a reimbursement strategy called bundled payment for all of the patient’s providers based on 30-day episodic care, instead of the current fee-for-service method. It includes coverage for post-acute care services such as home health. This is where home health can prove its value, says Cisneros: The faster hospitals can discharge a patient to home health, the more significant the savings. Although if the patient is readmitted within the first 30 days post discharge, the entire provider group, including home health, is penalized.

That also means costs are more transparent. “When home health runs up a bill in the bundle, everyone knows about it,” he says. “They will replace you for a more cost-effective substitute.” Beyond that, there is an incentive for home health to become more efficient: gain sharing. If the patient outcome is successful, home health will share in the profits.

Barring Congressional changes, every hospital visit will be bundled beginning January 1, 2018. “Maybe politics will take over and it won’t be until 2019 or 2020, but it’s coming,” Cisneros says.

Unlike the years of working in separate silos, healthcare in the new model requires extensive communication and coordination among all providers. That means real changes in how home healthcare operates. Clinical accuracy, staff control and care insight are crucial.

Cisneros notes that home health can develop strategies to improve its value to ACOs. “Find savings and efficiencies,” he says. “Clinical care elements do not equal time elements. Don’t grade those out. That’s a step you can take today.” Other strategies include:

• Intake management—Data must be timely and accurate. “Nobody thinks it’s OK to wait two or three days,” Cisneros says. “It’s important that care starts within 24 hours or less.” The problem, he says, is that often the home health clinicians are concerned about offending the patient. He recommends scripting the start of care control. “We are not going to let the patient dictate their care program. [Home healthcare] is not a buffet for the patient,” he says. Hospitals don’t operate that way, and neither should home health.

• OASIS accuracy—“Clinical case accuracy is paramount. Case management is everything,” he says. “The F-score relates to our S-score, and that affects our reimbursement.” He suggests doing OASIS training with just the case-mix questions. “Stop thinking of it as a 22-page questionnaire and start thinking of it as a 20-question questionnaire,” he says.

• Plan of care development—For some home health clinicians, patient contacts have become little more than social visits with vitals. “Nobody is going to be paying for that,” Cisneros says. Clinicians must stop thinking in terms of visits and start thinking about delivering care programs. With a defined schedule, patients will feel more in control and have an incentive to stay home instead of being sent to an SNIF (skilled nursing inpatient facility).

The duration and frequency of a care plan must be considered. Typically, home healthcare plans are for 60 days. “We take 60 days because we had 60 days. Some patients may only need 30 days,” Cisneros says. Rather than giving all patients seven visits, clinicians must determine the appropriate frequency. Some patients will need four visits, while others need 12. The plan of care should fit the patient’s clinical care, rather than a specific time element. “Patients improve on their own timetable,” he says.

Cisneros estimates the costs of unfocused care at approximately $1,000 per case. “We are not going to be able to waste that money anymore,” he says. The added bonus is that once a plan of care and frequency have been determined, supervisors can staff more appropriately.

He recommends supervisors work more closely with those in the field. “Clinicians can’t do it on their own,” he says. “What’s really happened in home healthcare is that it is clinician-driven. The era when the front-line clinician can determine the frequency of care is over.” He assures supervisors that clinicians will eventually come to appreciate the assistance. “The care burden is relieved when they stop manipulating it for their own benefit,” he says.

• Safety-based care content—Patients who are in danger of readmission must be identified early and given additional attention. “If you can’t eliminate the setbacks, the ACO will find someone who can,” Cisneros warns. It means clinicians must initiate care in a timely fashion and eliminate setbacks by identifying potential issues (falls, etc.) and conducting medication reconciliation.

• Productivity—Cisneros says missed visits are crippling home healthcare. Changes must be made to improve scheduling. He admits those changes will not be easy, especially for clinicians used to working independently. Everyone else in the healthcare system tells clinicians what to do and how often; “Why are home healthcare clinicians any different?” Cisneros asks.

Expect pushback. “Pushback is a phase,” he says. “It lasts 2–3 weeks. You have to outlive them. Eventually their care and competency kicks in, and they are on board. If you can hold the line, they will adapt.” The first step is to establish clearly defined goals. For Cisneros, it comes down to a simple question: “Ask yourself what you would do if the patient were your aunt and you weren’t getting paid [to care for her]. Then do that,” he says.

• Episodic care delivery—The key is to focus on the primary diagnosis. In the cases where a comorbidity affects the post-acute diagnosis, the care plan may have to be adjusted.       

The Roadblocks Ahead

• The noncompliant patient—An oft-heard complaint from home health clinicians is that they cannot complete their assignment because the patient is noncompliant. The SNIFs and hospitals know how to deal with noncompliant patients, says Cisneros: They discharge them. “Find ways to make them compliant. Demonstrate compliance on the first visit,” he says. If they do not comply, discharge them. “In the ACO world, they are not going to tolerate noncompliant patients,” he says.

• Documentation—“We all hate documentation. Noted. Now let’s do it correctly,” Cisneros says. Incorrect documentation can lead to poor patient outcomes, scheduling issues and reimbursement challenges.

• Nonproductive clinicians—“There are not going to be the margins to tolerate nonproductive clinicians,” he says. “Take patients away from clinicians who won’t [follow rules] and give them to clinicians who will. That’s a shot to the heart of a healthcare clinician, but don’t hospitals do that?” He recommends removing obstacles for things they are expected to do and putting obstacles in the way of things they should avoid.

He estimates a home healthcare business may lose up to 15% of its clinicians this way but notes, “Are these really the clinicians who will be missed?” If you want to keep them, help them understand these changes are about improving patient care. “Ask them, ‘How does it help the patient?’” he says.

• Missed visits—This is a huge productivity problem, says Cisneros. To obtain patient buy-in, he recommends clinicians review goals with patients early on. Tell them how this works. Providing a script for the start-care approach is helpful.

Clinicians can make it difficult to miss visits. Instead of calling patients the day of a visit, call the day before. Track reasons why visits were missed. He also recommends avoiding overscheduling. “Eight to 10 visits a day is bad care,” he says. It shouldn’t take 10 visits to get seven.

• LUPAs (low-utilization payment adjustments)—“Stop worrying about LUPAs!” Cisneros says. “Do OASIS correctly, deal with it, then move on.” LUPAs are an issue for home health because they’re not considered full episodes and are reimbursed significantly below the standard episode rate.

Summary

Cisneros believes the evolution of home healthcare a good thing. The payoff is great for patients, clinicians and businesses. “You win the cost race by a mile, but you have to prove your value,” he says. In order to compete in the brave new world of healthcare, home health must learn to manage patient care more effectively and efficiently. He believes it can. “We are going to become the heroes of the healthcare system again,” he adds.

Arnie Cisneros, PT, is the owner of Home Health Strategic Management. He can be contacted at 517/337-8500 or through his website, www.homehealthstrategicmanagment.com.

Teresa McCallion, EMT-B, is the managing editor of Integrated Healthcare Delivery.