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The Health Care Financing Administration’s (HCFA) new prospective payment system (PPS) for home health represents a challenge to hospital case managers as well as the home health industry itself. With funding reduced and documentation increased, many home health agencies find themselves scrambling to serve patients and break even financially. Meanwhile, hospital-based case managers have had to worry about whether agencies will be able to accept the patients that hospitals send their way. It’s been a tough adjustment with a long learning curve, and things are still in flux.
When PPS became effective in October 2000, home health professionals found there was plenty of culture shock to deal with. There were time- consuming but critically important OASIS (Out-come and Assessment Standardized Information Set) assessments to be completed with each admission. There were the home health resource groups (HHRGs), which categorize each case and determine utilization and cost. There were new coding issues and utilization factors.
"And it’s affected case managers in all areas," says Sandra Lowry, RN, BSN, BRRN, CCM, president of the Case Management Society of America in Little Rock, AR. "Home care has suddenly realized the impact of PPS, and the anxiety level is becoming quite high. Agencies are now scrambling to develop strategies to deal with the new system. And I see some real opportunity there to make this work and to bring down costs."
Fazzi Associates Inc., a Northampton, MA-based planning, training, and management consulting firm, was selected by the National Association for Home Health Care in Washington, DC, to help develop strategies to deal with PPS before it became law.
In its report to the industry titled "Ground Point Zero," Fazzi emphasized the importance of developing strategies that serve the agency and the patient rather than those built around individual departments and turf protection. The report stressed the need for utilization guidelines for each HHRG. Agencies were urged to educate their staff on the OASIS assessments and the necessity of consistency and follow-through "since it will determine the reimbursement amount that the agency will receive for a patient."
But getting ready for all that wasn’t easy. "The agencies were hit with a double whammy," says Lowry, "because they had to increase staff productivity at a time when the staff were expected to fill out lengthy OASIS forms. It takes an experienced health care staff person 20 minutes to complete a form, and they have to do them for every admission and every readmission. It’s Medicare’s way of facilitating the reporting of outcomes, then add to that the PPS requirements for looking at the cost per case. It’s very demanding time-wise."
Linda Samia, RN, MSN, CNAA, is the chief clinical officer for the Visiting Nurse Service in Saco, ME, and she agrees that staff time is an issue. "It requires more staffing for different functions," she says. "The administrative burden of getting started was a nightmare, and that continues. There was a lot of cost involved in educating staff. We reduced productivity so we could supply visits. For September [the month before the PPS became effective], we had to double up on plans of care. We had to add staff and have them work overtime.
As with most bureaucratic regulations, documentation is crucial. The OASIS assessment is filled out for each admission, and the patient’s care must be carefully monitored and documented thereafter to be sure it is consistent with that assessment. Coding also is very important and has a major impact on the level of reimbursement. Once again, the documentation that follows the patient’s path of care must support the codes assigned.
Agencies also were warned to be alert for utilization patterns, assuring the government with still more documentation that patient care is not being compromised in the interest of cost. In addition, they were advised that HCFA would be on the lookout for "cherry picking," or choosing patients who could produce the most desirable reimbursement.
"A major issue was the resources that could offer us support," says Samia. "First we had to understand the rules and make sure every claim was properly filed. And, of course, there’s an exception to everything. All of that detail created a lot of confusion we didn’t anticipate." But she did give HCFA points for coming to the rescue. "They were good about providing clarification and communication." Still, there were frustrations on many fronts. "Some agencies couldn’t submit their requests for payment because their software systems weren’t in sync with HCFA’s," Samia recalls. "Then HCFA changed the rules at the 11th hour, throwing us another curve. But HCFA pretty much suspended medical review for the first 45 days and that gave us a reprieve."
The industry’s struggles have had trickle-down effects, as well. "From the case managers’ perspective," says Lowry, "they are more concerned about whether [the agency] will take the patient than if they can budget for the care. For example, will someone with a brain injury who needs long-term care even be accepted? Home care agencies in some of these cases are reporting that they don’t have the staff to handle it. It’s a level of concern that hospital case managers didn’t used to have."
"There are problems with providing care," Samia adds. "We [the Visiting Nurse Service] are in a good position, but there are certain populations industrywide not being reimbursed based on the amount of care that’s necessary, especially the wound population. Some of it depends on the case-mix factors. The majority of home care agencies are losing money on patients who have complex wounds." She says that although Visiting Nurse Service hasn’t had to alter its practice, "some have had to limit accepting patients who require twice-a-day visits because it’s very costly. Some patients can be very complex with many comorbidities, and there are complicating factors for coding.
"Another thing that has impacted our patients is the consolidated billing of supplies and outpatient services," she says. "We hoped to get relief through legislation, but that’s not happening. It’s affecting patient care and overall cost and administration. "That’s because when patients choose a home health agency, they have to purchase their supplies through that agency. This might be a patient with a long-standing colostomy who is used to buying ostomy supplies at one particular place. But now there’s been a different injury, and this person requires wound care. With home health in the picture, he has to change the place where he buys his ostomy supplies as well. This makes patients anxious and makes it important for home health agencies to work with suppliers."
Then there’s the shortage of nurses and health care aides. "We’ll see a definite shortage in home care nurses," Lowry predicts. The existing nurse shortage is a nationwide problem, and we already face a tremendous shortage of home health aides and homemakers. It’s entry-level work for entry-level pay, and people can earn the same money at McDonald’s without having to consider the toileting or the heavy lifting. Add to this that the individuals who do this are mostly women, and now mostly women who are older. These jobs require strong backs and younger bodies."
As with any huge bureaucratic reconstruction, things seem chaotic right now. "We are currently revising our case management model because there are select populations who are at risk," Samia says.
"A lot of the crisis is anxiety," says Lowry. "But some see this is a step to the future, as learning how to manage costs and ultimately come out with a positive result."
Samia’s Visiting Nurse Service may be one of those. "We’re looking at where we can improve our practice with the PPS. For us, PPS may be a better solution, but that’s not the case with every agency."
"It’s possible," Lowry concedes "that we’ll end up with consolidations of home health agencies. Small ones could go out of business. Larger ones could end up merging. But home health agencies can’t just go away. They’re too necessary, too well-regarded. We have to have them. I’m convinced it will all settle down eventually."
[For information, contact:
Sandra Lowry, RN, BSN, BRRN, CCM, President, Case Management Society of America, Little Rock, AR. Telephone: (501) 225-2229.
Linda Samia, RN, MSN, CNAA, Chief Clinical Office, Visiting Nurse Service, Saco, ME. Telephone: (207) 284-4566.]