Home health branches into outpatient services

HHA nurse-staffed clinic extends care to patients

(Editor's note: This is the second of a two-part series that looks at how disease management programs within home health agencies can better position agencies to be successful under a pay-for-performance program. Last month, we discussed the components of a disease management program, staffing, and education. This month, we look at how the program can be expanded to serve patients who are not homebound.)

When Celina, OH-based Mercer Community Hospital's Home Nursing Care department implemented a cardiac disease management program, the service was not limited to home care patients.

"We opened an outpatient clinic at the same time we implemented our cardiac disease management program within our home care agency," explains Laurie Bladen, RN, BSN, MBA, director of community health at Mercer Health. Her reasons for implementing disease management programs within home care included the need for standards of practice and an emphasis on improving outcomes. "We worked with hospital staff to develop standards for treatment of congestive heart failure patients, as well as diabetic and wound care patients," she says.

While working with hospital experts in these diseases, Bladen realized the benefit of offering certain types of outpatient care to home health patients once they were discharged. "We want to reduce readmissions to both home care and the hospital, and one way to do so is to offer patients a way to continue care after they are no longer eligible for home care benefits," she explains.

"We might be seeing a patient for orthopedic care, maybe a surgical patient who needs wound care, but the patient might also have a secondary diagnosis of diabetes," Bladen points out. As the patient improves and is discharged from home care, the patient still may need assistance with or monitoring of the diabetes.

"Although our home care nurses educate the patient about nutrition and how to choose groceries, it is different when the patient actually goes into the real world," she says. "At the clinic, the patient can not only meet with a dietitian, but the dietitian will go to the store with the patient as part of the teaching."

In addition to providing follow-up care to diabetic patients, Bladen's wound care clinic has proved to be successful. "Wound care in home health is very costly but if we can get the patient ambulatory, we can then see the patient in the outpatient clinic," she says.

Although the clinic is staffed with home care personnel, the actual revenue from the clinic is counted as "hospital" revenue because of the way it is billed, says Bladen. "Medicare regulations require that we bill visits to the outpatient clinic through the hospital as outpatient hospital visits rather than home care visits; but both the hospital and the home health agency benefit financially from this approach to patient care because we are able to better manage the patients' care and reduce hospitalizations and readmissions," she explains.

Home health nurses staff the outpatient clinic, Bladen says. Not only does this improve the continuity of care for patients discharged from home care to the outpatient clinic, but it also enables nurses to continue following their patients, she points out. "Nurses in the clinic follow the same treatment protocols used in home care," she says. Because the clinic nurses are home care nurses who have cross-trained to work in the clinic, the transition to working with patients in a clinic setting is very smooth," she says.

"Nurses who work in the clinic volunteer to do so," says Bladen. Nurses like to work in the clinic for a variety of reasons, she says. "It is a change of pace and enables the nurse to see a variety of patients throughout the day and, at the same time, enables them to see home care patients they may have provided care to previously," she explains. "Home care nurses do get attached to some patients and they always enjoy seeing them as they recover."

The outpatient clinic staff consists of three RNs, a dietitian, a social worker, a medical assistant who helps with clinical and administrative tasks, and several physicians. Infectious disease, podiatry, interventional radiology, and vascular surgery all are specialties included in the medical staff of the clinic, says Bladen. "Although our patients have family physicians, many of them see the clinic physicians as their specialists," she explains.

Transportation to the clinic is an important issue to address, advises Bladen. "We work with the local Council on Aging to ensure transportation for patients from their homes to the clinic," she reports.

The outpatient clinic does not just see patients discharged from home care. "Some patients come directly from the hospital and some may come directly from a physician's office," says Bladen. Most, however, do come from home care with the original referral to home care from the hospital or a physician, she adds.

Billing and proper documentation to support billing are the biggest challenges when developing an outpatient clinic as an extension of home care service, Bladen admits. "Documentation required for home care services is slightly different than documentation required for outpatient services in some cases," she says. For example, home care infusion documentation requires only the starting time for infusion, and outpatient services documentation must include both the starting and ending times for infusion, she points out. The differences are minor but nurses do need to keep the differences in mind, especially if they are working in both the clinic and the home health agency, she explains.

Bladen is pleased with the success of both the home health agency's disease management programs and the outpatient clinic. She says, "Our industry is changing dramatically, with more emphasis on outcomes and quality of care as well as an efficient use of health care dollars. The combination of disease management programs and outpatient clinics gives home health agencies a way to meet all of these goals."


For more information about home health-run outpatient clinics, contact:

  • Laurie Bladen, RN, BSN, MBA, Director of Community Health, Mercer Health, 1107 N. Main Street, Suite 8, Celina, OH 45822. Telephone: (419) 584-0143. E-mail: lbladen@mercer-health.com.