Is your hospital afraid of referring patients to its own home care agency?

How to dispatch the referral message in your system

Hard as it may be to believe, some hospital-affiliated home health agencies have trouble getting referrals - from their own hospitals. How can that be? After all, the hospital is filled with patients, and here your agency is - ready, willing, and able to take them on as home care patients. But while you might not be struggling to find new cases, you might be struggling to understand why most of the referrals are from outside health care providers. What gives?

According to Susan Schulmerich, RN, MS, MBA, executive director of the Montefiore Medical Center Home Health in Bronx, NY, "Physicians, in particular, have been made very fearful of steering patients to the hospital's own agency."

She is speaking, of course, about the effects of the Stark II law which prohibits physicians from owning more than a significant interest in a facility to which they refer patients. The Stark II law was the brainchild of U.S. Rep. Fortney (Pete) Stark (D-CA). Stark II created some exceptions, and confusion, to the stipulations in 43 CFR 424.22, a 1983 federal regulation that disqualifies physicians from certifying care plans of Medicare patients at home care agencies where doctors have a significant financial interest. The regulation defines significant interest as doctors having 5% ownership or payment transactions exceeding a total of $25,000 a year. (See related story, Hospital Home Health, July 1997, p. 77.)

Dangerous liaison: Fear and ignorance

"The Office of the Inspector General [OIG] has gone out with a vengeance after what they think is fraud and abuse - and to them that includes steering patients to an organization that the physician owns," she continues. "So now, if a physician is employed by a hospital and refers patients to its home health agency [the physicians] feel they will be in violation of the regulations. This simply isn't true."

But doctors' fears of going up against the OIG isn't the only reason some hospital-affiliated home health agencies are finding that their referrals are coming from outside their network. Plain and simple, says Schulmerich, "physicians may not be aware that the hospital has its own home health agency." And even those who are, she adds, may be more comfortable referring patients to a community agency, "especially if they suddenly found themselves affiliated with a hospital, they have done business with for a number of years."

Of course, it's not just physicians who are referring patients. Hospital discharge planners shoulder that responsibility as well. And it's discharge planners who in many cases see to it that the OIG ruling is administered correctly. "The new rulings say patients must have a choice of home care agencies, and when it comes to how the choice is given to them, it's really the discharge planners that are enacting the whole thing," says Kathryn Christiansen, DNSc, RN, executive director of the Chicago-based Rush Home Care Network. "The problem is that some discharge planners have really gone over backward giving patients long lists of everyone and their brother with the hospital agency buried deep in the list."

Because discharge planners represent a variety of health care industry professionals, notes Schulmerich, they bring to the job a wide variety of experiences and beliefs. "First and foremost is concern for the patient and patient choice," she says, "but in some instances, planners may have more allegiance to the competition's hospital agency than their own hospital's."

There are several reasons for this, she says. "Some of the competition is extremely aggressive in marketing to discharge planners, and the other thing is some planners may not even know their hospital has an agency. That may not be anyone's fault, really, maybe the person is new and came from a place where there wasn't a hospital home health agency so they just continue working as they did in the past," Schulmerich explains.

"Then, some discharge planners see in-house agencies as being more difficult to work with because the health assessment is more expensive," she adds. "Generally, hospital-based coordinators are on site so when the agency reviews a case, they will find all the pitfalls in it that heretofore hadn't been identified and need to be corrected before the patient is released home."

Knowledge is power

It's interesting, notes Schulmerich, "how the hospital home health agency isn't in front of everyone's mind in referring." If you're finding this to be the case at your agency, there are ways to remedy the situation. (See list, above right.)

The No. 1 way is education. "There needs to be a formal vehicle," she says. But formal doesn't mean your efforts should be restricted to dry classroom-like lectures. Schulmerich and her staff are actively involved in every nursing orientation that goes on in the medical center, and the agency also has become one of the first stops for physicians in training. She makes sure her agency is visible to the hospital community, she says, adding that "during Home Care Week, we're in the lobby of the hospital every day."

Montefiore Home Health has its own newsletter that's distributed to everyone from the hospital's own physicians and discharge planners to other agencies. But the agency doesn't restrict its efforts to the medical center. Instead, Montefiore has an outward-looking approach. The agency and its staff "get involved in community activities and other disciplines so people get to know us in a casual way," says Schulmerich. "We participate in any number of types and levels of meetings on issues like length of stay, disease management programs, and care maps so we have a lot of face-to-face interaction. The formal work is being done but you're also building an informal, personal relationship."

Being in the forefront is a critical step toward making yourself known to the hospital, but it's not the only one by far. In addition, the power of the hospital administration's backing cannot be underestimated. "One of the most important parts of our success has been that the medical center president is wholeheartedly behind us," says Schulmerich. "He sees the value of the organization and is supportive of it. He was a catalyst to developing the agency into what it is."

While other agencies may not experience such full-fledged enthusiasm, support from the higher-ups is a must. In order to cultivate that, hospital home health agency administrators must make sure that the hospital administration has more than a passing understanding of home care and its value, says Schulmerich. To accomplish this goal, talk money, she advises.

"If you're trying to get the attention of the CEOs and administrators, the best thing is to talk about how much money home care saves them," she continues. "The home health executive needs to show it to them in black and white - 'This is what we did for you. We were the impetus in shortening hospital stays for you. So since we reduced every stay by an average of one day and we had 2,000 admissions, we saved the hospital 2,000 days which translates into however many dollars.'"

Include the legal team

Don't forget to get the hospital's legal team in on the action. Christiansen recommends having the lawyers address the physicians and discharge planners, letting them know that it's OK for them to recommend the hospital's own home care agency. Moreover, although patients must be presented with a choice of home health agencies, Christiansen points out that there is nothing in the language to say that list must be in alphabetical order or that the hospital's own agency can't be the first one listed and in larger type. "You don't want to push the agency on patients, but you can tell them what you know," she says.

For smaller hospitals and their home health agencies, such suggestions may not be feasible. If that's the case, Schulmerich recommends that these agencies "get out and market to more than the discharge planner. There are lots of additional referral sources - senior citizen groups, other physicians, even the schools. Have your nurses go out to local schools and talk about home health - it's amazing what kids will bring home to their parents."

If after all this you still aren't seeing the results you'd like, have patience. Explains Schulmerich, "This doesn't happen over night. It takes a long time to build trust because what you're really doing with all this is building a relationship. It took six or seven years of 'in-your-face, we're here to help' attitude to get them to think of us first. You can't just sit in your office and get the exposure you need. I was out there all the time. It's definitely not a build it and they will come thing."