CoPs: Just the beginning for most hospices

Changes boost need for electronic records

[Editor's Note: This is the first of a two-part series examining the impact of some regulatory and financial changes faced by hospices during recent years. This month's article looks at the increased need for technology to manage hospice billing and data collection. Next month we look at how agencies have met the challenge of physician notes in records, staff training, and management of increased administrative tasks.]

All segments of health care have watched the debate over reform closely for several years, but hospice managers have not had to wait for reform to undergo significant changes to billing and cost report requirements.

Starting with Conditions of Participation (CoPs) that became effective December 2008 and continuing with requirements to collect more detailed visit data and to document certifications and re-certifications more closely, hospices have been in a constant state of change.

"Our staff members have laptops and our records are computerized, so we have the capability to collect data, but we are constantly updating our system to handle each new wave of requirements," says Carla Braveman, BSN, RN, MEd, CHCE, president and chief executive officer at Big Bend Hospice in Tallahassee, FL. "The changes are good because we are collecting better information," Braveman says.

Hospice cost reports have not included enough data for the Centers for Medicaid and Medicare Services (CMS) to obtain an accurate picture of the services provided by hospice, she says. "I know that payment model changes are on the way, so we need to provide the best information we can, or we hurt ourselves," Braveman says.

Renee Hahn, chief financial officer for Harry Hynes Memorial Hospice in Wichita, KS, says, "Luckily, we've been ahead of the game with technology that has made it possible to collect the information required. I can't imagine what hospices that use paper records are going through in order to meet requirements."

As more changes come along, it might be necessary for all hospices to use electronic records to capture and report required information, Hahn adds.

The good news for smaller hospices is that there are more web-based systems available, Braveman says. "The technology is less expensive, and some of the systems allow you to pay per patient record, which keeps costs down for smaller hospices and doesn't require the agency to have an information technology staff," she says. "We saw the first indication that technology would be necessary in the CoP language that stated that CMS was not telling hospices that they had to be computerized, but a computer system would be helpful in collecting and reporting data," Braveman adds.

Pay attention to rural challenges

There is more involved in obtaining a computerized system than simply purchasing it, Hahn says.

"Once you invest in a system, be prepared to continue updating and investing in upgrades," she says. For this reason, be sure that the vendor you select is capable of managing continuous CMS updates and that your system has the capability to grow, Hahn adds.

There are special challenges for hospices that serve rural areas, warns Hahn. "We serve 25 counties in the state of Kansas, and only four of the counties are urban areas," she says. With an average daily census of 230 to 240 patients, Hahn's staff members often find themselves in rural, remote areas in which there is no Internet service, she says. "Our constant challenge is finding ways to synchronize staff members' laptops with our server," Hahn says.

"Our goal is to ensure our clinicians have access to our VPN [Virtual Private Network]," says Hahn. The VPN is an encrypted computer network tunnel that allows staff to access the agency's servers and vice versa via the Internet, she explains. Access may be through a dial-up, wired, or wireless connection. "If the connection is wireless, IT staff members may have to go to the clinician's home to set up the wireless router encryption code into their agency laptop," she explains.

Cellular internet air cards are used by some clinicians, and when there is no way to access the Internet in the clinician's home, nurses can go to the nearest agency office location, she adds.

Despite the investment required for computerized records, Hahn believes that the technology is necessary to enable hospices to collect and report data CMS needs to accurately evaluate hospice services. "This is an opportunity to ensure cost-effective, quality patient care," she says.

Braveman agrees and adds, "Many hospices are collecting data because CMS has told them they have to in order to be paid. That is the wrong mindset. We should all be working to ensure that future changes to our reimbursement system are based on accurate, complete data, not a partial picture of hospice care."