The trusted source for
healthcare information and
Know which patients might be outliers
Develop strategies to control cost of care
The easiest way to avoid reaching the 10% outlier cap is to avoid admission of patients most likely to result in an outlier episode. This could mean looking carefully at admission of patients with congestive heart failure, non-healing wounds, and diabetes.
Because patients with these conditions represent a high percentage of home health patients, it is not practical to make a blanket decision to no longer provide care for these patients, so experts interviewed by Hospital Home Health suggest other steps to take.
If your agency typically admits patients whose cost of care is higher than other patients' cost of care, there may be decisions to make about how to handle future admissions, says John M. Reisinger, CPA, principal of Innovative Financial Solutions for Home Health in Tampa, FL. "It is difficult to refuse a referral because you don't have the financial resources to handle the patient's care, because you are not just refusing admission of one patient; you may be alienating a referral source that represents many future referrals," he says. At the same time, you can't continue to accept a large number of patients for care for which HHAs will not be adequately reimbursed if they plan to stay in business, he says.
"One way to address the situation is to determine how many outlier patients you can accept at any one time," Reisinger suggests. "Once you've determined what your agency can handle, educate your referral sources in a non-confrontational manner, and at a time when a specific patient is not being discussed," he says. By emphasizing that your agency wants to provide the best care possible to all of the referral sources' patients and by showing that you can only handle a certain number of complex, high-cost patients at one time, you will reassure the referral source that you are not arbitrarily making decisions about patient admissions, he adds.
Before a decision on how many outlier patients can be handled, a manager needs to predict patient costs, points out Reisinger. "Historically, most home health agencies have been lax about developing budgets down to the patient level," he says. "Now, however, it is important to do some type of patient budgeting using existing information from OASIS, plans of care, [and] admission information to identify potential outlier episodes," he suggests.
Another benefit to identifying types of patients who tend to result in outlier episodes is the opportunity to develop strategies to keep the cost of care within normal parameters. The staff at Advance Care in Richmond, VA, see a lot of wound care patients, because a local wound care center refers many patients to the agency, says Lisa Stroud, RN, administrator of the home health agency.
After other home health agencies in the area began refusing to accept wound care patients that required daily visits, Stroud visited the wound center and provided information about how home health got paid. "I met with the case manager and explained how discharge orders for daily visits impacted us," she says. When a patient is in a hospital, it is not uncommon for wound dressings to be changed daily, she says. Case managers and physicians don't realize the effect that an order for daily dressing changes in home health can have, she adds.
A common misconception is that although some wound care products are described as daily dressings, they can safely go two or three days without changes for different types of wounds, says Stroud. "Our goal is to wean the patient off daily dressing changes," she says. After physicians were educated about the safety of different products and different frequencies of dressing changes, the agency was able to work with patients and physicians to reduce the number of orders for daily dressing changes, she says.