CARE PLANNING AND CASE MANAGEMENT

 
PDGM represents a fundamental change in home health reimbursement, and agencies will feel its effects for years to come.

This new payment structure reimburses services based on quality over quantity, challenging many agencies on how to best market, manage, and deliver services under PDGM.

As a result, , agencies must triage and consolidate their services while also taking advantage of less costly methods of patient contact, such as telehealth or expanded use of assistants and aides.

Initial Start of Care

Identification of ALL comorbidities, functional limitations and anticipated needs at initial start of care is necessary to capture the patient’s primary needs and risks such that essential services can be delivered in a cost-effective way while maintaining patient progress and subsequent Star ratings.

Complete initial identification and documentation enables a more holistic and comprehensive approach to the patient’s care and increases the likelihood that appropriate resources will be provided to maximize the patient’s recovery and resultant satisfaction levels.

Diagnoses

One of the most impactful changes under PDGM is the importance of the patient’s primary diagnosis which determines the payment group and, thus, the bulk of episodic payments. Ultimately, the payment structure has a goal of providing enough funding to support the patient’s essential needs based on a cost average of similarly diagnosed individuals.

Identifying and documenting not only an appropriate primary diagnosis, but all comorbidities and contributory factors, leads to more comprehensive care and rationalizes the utilization of a wider array of therapies.

Integration and collaboration with adjunct therapies, including OT, PT, and SLP have been clinically shown to effectively improve functionality and client satisfaction levels. Historically, these therapies were widely utilized, however they will see a significant reduction under PDGM. Agencies will now have to consider best time and use in absence of the therapy threshold model under PPS.   

Technology

Telehealth resources can also play a key function in plan of care decisions by utilizing technology to reduce unwarranted visits, while managing overall care and maintaining high levels of patient communication.

Customized information and education can be provided directly to a patient’s email via hand-out materials, white papers or even on-line training modules for patient, as well as caregiving family or friends.

Communication of the plan of care to the patient, along with a clear understanding of expectations and goals is the final step in ensuring best outcome and highest satisfaction.

TRAINING AND EDUCATION

 
Changes in Medicare reimbursement style will inevitably lead to changes in the way your field staff must do their work, as well as how your office and billing staff must function. For the transition to be effective and smooth, training and education must be an intricate part of the process.

Field Staff

As already discussed, upfront identification of all comorbidities and a fully identified and documented functionality analysis at start of care will be crucial for your company to be successful under the PDGM program. Training on that program, thorough and appropriate documentation needs, plan of care adjustments and collaboration suggestions are all areas of additional training to consider.

Other steps your organization will need to implement for your field staff include:
 

• Review discharge and hospital notes prior to visit with patient. Have a clear understanding of their status, limitations and anticipated outcomes.
   
• Validate findings with verbal and observational review. Document that validation thoroughly and clearly.
   
• Establish base line status and limitations with front loaded visits. You need a minimum of daily for first three days to fully document the base line.
   
• Consider having dedicated SOC clinicians who open and plan the care and hand off to a case manager. This allows you to have an “expert” in setting up the patient for a PDGM-compliant plan of care.

Office Staff/Billing Staff

There is no question your office or billing staff will need tremendous levels of training on the new requirements and guidelines the CMS will require. However, there are other concerns, less immediately obvious, that you must also consider and address related training and knowledge:
 

• As part of PDGM, CMS added a behavioral adjustment to the new payment system which has the potential of a rate reduction from 6.42% to 8.01%.
   
• If the behavioral adjustments persist, your company’s challenge will be how to operate effectively, efficiently and ethically while remaining profitable.   A unified or consolidating care planning approach will likely yield the best results over time due to efficient utilization while maintaining the appropriate care needs.
   
• RAPs and final claims will need to be submitted twice as often. This means billing and payment activities are effectively doubling for agencies, but not necessarily the revenue. Care plans must integrate this change effectively. Staffing requirements may also need adjustment.
   
• The Home Health Resource Group (HHRG) determinants will become more complex with the introduction of of comorbidities, removal of therapy, and admission source/timing being added. A clear grasp of each area and its application within your organization is critical.  This further highlights the necessity of gathering a complete history and physical.
   
• Finally the change in the RAP will adversely affect the finances and the viability of the agency unless the agency has had managed to secure a line of credit or savings to carry them through the first three months of program change. Smaller agencies are at particularly high risk during the transition time.

With disparate training and education requirements, offering training and education online is an absolute must. Online/remote training not only gives your company the flexibility to customize modules to discipline, it also gives your staff the flexibility to attend those training's within a time most conducive to their schedule.

You must integrate testing and skill checks with your training program, to verify comprehension and retention of the new materials being presented.

DIGITAL WORKFLOWS

 
There are so many ways in which utilization of a digital workflow system will make your organization more profitable during and after the transition, while still maintain quality of care and improving staff efficiency. Here are just a few:
 

• Obtain physician’s signed order authorizing care prior to or during admission to establish start of care.
   
• Obtain signed orders and protocols for medications, DME, oxygen support, and/or therapeutic interventions.
   
• Reduction of errors, by always getting signatures, never miss a checkbox, ensuring all potential coding is identified during start of care.
   
• HHA staff onboard the new patient: During the admission process, HHA staff can visit the patient’s home to handle the complex onboarding process. That process is burden-ridden with forms that must be prepared and signed. Paperwork with illegible or incorrect information complicates the process and forces nurses to manually rekey data back at the office. By digitizing these form packages, HHA providers save time and eliminates costly errors .
   
• Submit forms to CMS for reimbursement: After providing care, HHAs must submit required forms and patient information to CMS within the new 30-day window to get reimbursed. Transitioning to digital forms simplifies the submission process for agency staff and patients.
   
• Replace paper-based tasks with faster solutions, which increases your staff’s time for direct patient care, improves patient interaction and maximizes therapeutic value of treatments each and every session.
   
• Enables your HHA to transmit ongoing documentation faster to patients, physicians, intake personnel, schedulers, billing and so forth. It also reduces “pending” files and improves cash flow.
   
• When utilizing a telemedicine or telehealth program, digital workflow systems will expedite signature collection requirements.

This is in no way an exhaustive list of opportunities for your digital workflow system to improve your bottom line. Those opportunities are limited only by your own creativity.

sales and referral processes

 
As a result of changes under the PDGM, your agency must prioritize forming closer relationships with hospitals and skilled nursing facilities. While local doctors’ offices or other community-based referral sources remain important—their referrals will be weighted differently. However, MDs, ALFs and other community partners can be excellent “bird dogs” to acute care stays as they may alert you to an inpatient stay and can help you navigate directing a discharge onto your services. In many cases, a community referral source can bring about an “institutional” referral. MDs remain essential as following physicians—critically necessary to bill according to CMS regulations.

PDGM will change case mix weight calculations related to referrals and introduce a 14-day look-back mechanism to determine patient source. Your reimbursement is directly tied to that source.

A case mix weight for a community episode is 0.8782 compared to an institutional referral that has a case mix weight of 1.1855, according to a technical report from Abt Associates, with projections and estimates based on 2015 numbers. That means someone that is referred via a community-based setting will receive less of a bump in their case mix weight adjustment.

The breakdown of referral sources is different from state to state, but a large portion of patients are typically referred from community-based settings.

Key Takeaways

 
Under the Medicare PDGM guidelines, it is possible to achieve both quality patient outcomes and profitability. But it will take some reinvention of operations to make this work for most home-based healthcare agencies.  Key areas that should be reviewed and addressed as needed include:
 

• Care Planning and Case Management. Comprehensive, complete and accurate identification of all diagnoses, comorbidities and limitations. Identification for appropriate collaboration opportunities, and the use of appropriate technologies sets your agency in an optimal position during the transitional phase.
   
• Training and Education. Training of your field, office and sales staff independently, with a focus on their unique roles within the next paradigm must be accomplished. To do so effectively will require the use of remote or online training, ongoing skill checks and intermittent testing capabilities. Ideally, your system will allow for reporting capabilities that identify areas of weakness to allow for remedial training.
   
• Remote Solutions. The use of remote technologies like telehealth and telemedicine integrated with ongoing direct patient care will maximize patient satisfaction and quality of care, while reducing unnecessary visits and associated loss of time.
   
• Digital Workflow. Implementation of cloud based online forms and workflows eliminates potential errors and ensures swift transmission of documents and signatures. Ensuring you can quickly receive orders matching all identified patient conditions is critical to optimal care delivery and episode reimbursement.
   
• Sales and Referral Processes. Reevaluation of referral sources and a renewed focus on hospitals, SNFs, and LTACs as strong potential referral partners.
   
• Staffing Optimization. Your staff, whether field, office or sales, is your greatest resource. Good staff is the foundation of a strong, profitable, and high quality HHA. It is incumbent on your organization or retain, train and support this resource.

ClinicalHQ provides free, no-obligation, strategy sessions to assess the needs of any healthcare business to balance quality and profitability. Contact us to schedule a session today.