Psychiatric services may be just what the doctor ordered for your business

Specially trained aides are key to running a cost-effective program

Home care agencies have two big choices when they receive referrals for psychiatric patients: They can seize the day, or they can continue the same old practice of treating these patients as if they were medical-surgical clients. Two large home care companies have chosen to meet the challenge and even seek more referrals for psychiatric patient services.

"We decided this was a window of opportunity for us," says Carolyn Scott, RN, MS, national coordinator of the behavioral health program for Staff Builders Home Health Care in Chicago. Staff Builders is a for-profit company that has about 200 home care agencies from coast to coast.

Scott and Verna Benner Carson, PhD, RN, CSP, developed comprehensive psychiatric training programs for aides and nurses. Staff Builders agencies use the programs to build their employees’ expertise in dealing with patients who have psychiatric diagnoses. (See story on Staff Builders’ aide education program, p. 181.) Some Staff Builders branches have quadrupled their psychiatric census since going through the training, Scott adds.

Atlanta-based Norrell Health Care also has a psychiatric training program for aides who work at the company’s 11 offices in New York, Pennsylvania, and New Jersey. (See story on Norrell’s aide training program, p. 179.) "We are starting to get referrals for caregivers with expertise in psychiatric patients," says Cathy Kelly, RN, BS, Norrell quality improvement manager. "Before, these patients were lumped into the general population of home care patients."

Psychiatric diagnoses are becoming more important in home care referrals for a variety of reasons:

• Reimbursement changes. "One of the things driving people to consider psych services is the home care industry’s move from fee for service to the interim payment system [IPS]," says Gary Hoover, PhD, a psychologist with Healthcare Documentation Systems in Winston-Salem, NC. Healthcare Documentation Systems specializes in designing and producing a computer-assisted documentation system for psychiatric care.

"Instead of focusing on increased visits as being responsible for increased revenues, agencies are having to focus more on increasing patient census," Hoover explains.

This is a big change for home care agencies, and it’s forcing agencies to take a closer look at their patient mix, Scott adds. "It’s becoming more and more difficult to squeeze out any kind of profit," she says

Psych services might help bottom line

Providing specialized psychiatric services can help the bottom line because psychiatric patients often require fewer visits than an agency’s Medicare beneficiary cap allows under IPS, Scott says. That often surprises home care administrators because they think of psychiatric services as a black hole of need that could result in years of visits, she explains.

That view is dated, however. Agencies such as Staff Builders do not provide therapy to these patients. They use a medical model of solving problems to get patients stabilized and perhaps help them make a transition to long-term care. Such services might take 12 to 15 visits, which leaves plenty of cushion in the beneficiary cap for other cases, such as diabetic patients, who might be high users, Scott says.

With the current managed care mentality, home care agencies need to find the most cost-effective way to care for psychiatric patients. And one way to do that is to use specially trained mental health aides under the supervision of a nurse, Scott says.

"If you are able to justify the need for further mental health services, many of the behavioral health case managers with commercial payers are willing to extend visits much longer than they would have under Medicare because they don’t have to deal with homebound issues," she adds.

Psychiatric hospitals see declining LOS

• Reduced inpatient stay. Another trend driving the growth in psychiatric home care is that managed care is causing the same drops in length of stay at psychiatric hospitals as in acute care hospitals. This, in turn, is creating a need for alternative providers for psychiatric patients, and home care is a natural choice, says Anthony Sciara, PhD, a psychologist with the Grove Clinic in Asheville, NC.

Hospitals still treat psychiatric patients who need acute care, but the ongoing care has to be provided elsewhere, Sciara says.

Plus, some psychiatric hospitals and programs have closed in recent years, and their patients are being mainstreamed into communities, Kelly says. "People are not getting as much institutional care as they would have in the days gone by, and now they are being treated at home."

Hoover notes that managed care organizations [MCOs] already have cut much of the fat from inpatient services and now view home care psych services as a way to reduce psychiatric care costs by helping patients remain stable and preventing returns to the hospital.

• Reduced outpatient services. MCOs are not approving many visits to outpatient psychiatric clinics, either, Sciara says. "The managed care outpatient psychiatric care has suffered significantly because of fewer visits being approved. And there is significant oversight of what therapists are doing. This actually makes it more difficult to treat patients because of the amount of paperwork that goes along with the visits."

• Reduced service from community agencies. Mental health community centers have shifted their focus from a direct service model to a case management model, Hoover says, "so they’re looking externally for service providers."

Sciara predicts psychiatric patients’ shift to home care services will continue. And he says home care agencies might begin to consult with psychologists and other mental health professionals to assist with emergencies.

In addition to serving the needs of patients with psychiatric illnesses as their primary diagnoses, home care agencies increasingly are asked to recognize and address the psychiatric needs of medical-surgical patients, Sciara adds. "It’s been my experience in over 20 years of practice that even a patient who has only a medical problem, such as an amputation due to diabetes, often has significant psychological issues that go along with that. And these people just have not been getting the mental health services they need."

The growth of home care psychiatric services carries one danger, however. Medicare intermediaries have observed an increase in psychiatric services and are taking a hard look at how they are being delivered, Hoover says. That means agencies must be careful about how they document psychiatric services to prevent accusations of fraud and abuse, he explains. His company has developed a computer software program called Mental Health Studio, which provides documentation for psychiatric home care services.

What these trends boil down to is a greater need for psychiatric education in home care agencies, all four experts agree. Both aides and nurses need training to understand the finer points of psychiatric illnesses and medications. Otherwise, home care staff could make mistakes in interpreting these patients’ behaviors and in treating them.

"It takes a uniquely trained aide to work with that type of patient," Hoover says. "Home care aides tend to be nurturing caregivers, but with psychiatric patients you need to be aware of boundary issues and be firm, but kind, in implementing behavior change."