How to make your home care agency an integral part of hospital operations

Even if your CEO sees your agency’s value, you still have to contribute (Second in a series)

Not every hospital-affiliated home health director is as fortunate as Laura Elliott, RN, MS, vice president of North Mississippi Health Services in Tupelo. For unlike some of her peers, Elliott says, she is lucky enough to work with a CEO who believes strongly in the merits and value of home health care. (See related story, p. 3.)

While her job may be a bit easier because of her CEO’s support, it is in no way simple. She may not have to work as hard at convincing hospital management that home health agencies are a benefit to the overall health service system, yet she and her staff work exceptionally hard at making sure the situation stays that way.

Here is a look at what the administrator of Mississippi’s largest hospital-based home health agency has done to ensure that her agency, North Mississippi Medical Center Home Health Agency, remains an indispensable part of the hospital’s system.

A study in justification

Elliott has a lot of resources at her disposal: Her home health agency is part of a hospital system that includes the 650-bed North Mississippi Medical Center (the largest hospital in the state and the largest rural hospital in the country) with which her agency is affiliated, a cancer center, a behavioral health facility, a women’s hospital and family medical clinics, a nursing home, five affiliate hospitals, and a subacute unit. Her agency alone, which covers 17 counties and has 11 branch offices, brought in more than $350,000 last year from a client base of more than 5,000 patients.

Despite this, Elliott knows that she is not exempt from the worries and problems associated with the interim payment system (IPS). Nor is her agency immune to the wave of cost-cutting and downsizing in IPS’s wake. But with more than 23 years of home health industry experience, she also knows a thing or two about keeping her agency up and running.

Perhaps nothing is more important in reaching this goal than communication between hospital and home health agency administrators. "Right now, one of the key things for directors of home care, going through changing reimbursement process from cost to IPS to PPS, is to make sure they understand how they are performing financially under the new system," she says.

Toward that end, she developed an IPS reimbursement sheet that details monthly visits per branch office, both indirect and direct costs associated with these visits, and how "it positioned us with the IPS and per-beneficiary and per-visit costs."

With the numbers in place, she took that information public.

"We communicated it to all management staff so everyone would be knowledgeable of the facts. It has been very beneficial to the president and our CFO. They know we are aware of the changes and that we’re functioning well under the system," she says. Elliott didn’t stop with that, however. She also has developed a mock quarterly cost report "because home care was reimbursed this past fiscal year based on past cost limits which are much greater than what we’ll have this year," she states. "The agency needs to make the president and CFO aware of this so they will see how much money they will need to pay back to Medicare."

Agency in action

Equally important as open communication between agency and hospital administration is taking action, setting out to prove home care’s worth through a series of definitive actions other than cost shifting.

North Mississippi Medical Center Home Health Agency has not limited itself to the confines of its immediate responsibilities. Elliott says she believes, and has been proven right if her agency is any measure, that "it’s important to link your agency up to almost every juncture of the hospital." Such a task, of course, cannot be undertaken at random and requires strategic planning among agency staff and key hospital personnel.

Among the programs Elliott has implemented are the following:

1. Agency-hospital liaison.

To keep the lines of communication open in both directions, Elliott has encouraged her staff to act as liaisons between the two facilities.

"We have a strong psych division and we have utilized some physician clinicians in a liaison role within the hospital to help when a physician needs to make a referral and determine whether that patient should be kept in the hospital or transferred to the behavioral health unit," Elliott notes. "Our liaison evaluates the patient and then coordinates the possible transfer of the patient."

The goal is to unite the aide and the nursing staff so that they work jointly on whatever the DRG losers are. The sooner the patient is out of the hospital the better, she points out, and home health aides are in a perfect position to assist with that. "We want to get the patient into an area where they are best taken care of, whether it’s in home care or in a nursing home. We can help the hospital identify what will work earlier on and work with [hospital staff] toward that goal."

2. Specialization and disease state management.

Elliott and her staff have made themselves a vital part of the hospital "by cross-training and our willingness to hook up with the hospital and complement them in the different areas in which they need staffing," she explains. "All our aides and nurses are specialists in one of our top referring areas — oncology, wound care, cardiac, and so forth. A clinician is assigned to each division and linked with their counterparts in inpatient services."

So integral is her agency’s staff that "they’re visible on the congestive heart failure continuum team and the end-of-life and infection control teams. Home care has linked up with every top DRG category in the hospital that has been identified as being a loser as far as Medicare money. [The teams] meet weekly and collaborate on discharge planning and are involved in meeting the patients’ needs from Day One of admission."

3. Hospital services education.

Some of Elliott’s staff have been trained in nursing home care as well as specific areas, such as caring for ventilator-dependent patients.

"If a patient is ventilator dependent and comes into the system, we can take them in a home setting, or if they need a higher level of care, they can be seen in the nursing home. Our job here is to complement the nursing home with staff," she says. "If their staff [level] gets too low to handle that type of care, we will take some of our staff who’ve been trained in that and switch them over."

Elliott is careful to point out that any time a home health aide or nurse "switches" to the nursing home or any other of the hospital’s units, those hours are not billed to Medicare. "We shift that cost to whatever unit they are supporting," she notes. Some aides have been cross-trained so that they end up performing a double function. For example, several aides have been taught to draw blood. As a consequence, when these aides are making their patient visits, they will also visit other homebound patients to draw blood samples that will later be taken to the hospital’s blood lab for testing.

"They’re already out in areas seeing home care patients," she says, "and so for half a day they float some of their salary time to the lab for patients that are homebound but need lab work done. This helps out the lab and has helped us in home care to shift some hours."

Clinicians also farm out hours to oncology, the diabetes treatment center team, and the women’s hospital, where nurses specialized in pediatrics and newborns shift some hours. The advantage lies in that this relationship "keeps the lines of communication strong between [the hospital] and home health," she says, adding that being visible in the community helps to bring in referrals while reducing her agency’s salary expense.

"If a patient in the community becomes homebound, we might get that referral," she points out. "But if the patient goes into the clinic, then we can still help the clinic by shifting hours to them."

Bringing disease prevention to the community

Another benefit of being a renaissance home health aide is that she is also able to go into the community in a teaching capacity. Some of North Mississippi’s therapists are shifted to the hospital’s family medial centers (FMC) to "train their staff on more specific things, like foot screenings and wound care. It helps in the overall prevention of disease in the community, helps bring more referrals in, and helps the FMCs to have more educational programs," Elliott points out.

4. Care guides.

Through her staff’s specialization has come the development of a series of care guides similar to critical care maps. Working in close conjunction with the inpatient divisions of the nursing services, the guides "are developed so they’re specific to what’s going on. Inpatient and outpatient services are teaching the same thing," Elliott explains, adding that they are all written at a sixth-grade level for clarity and so they will be easily understood by all home health aides.

No matter what course you choose to follow, Elliott can’t overemphasize the importance of showing the hospital administration that you are coping well with the IPS. "In your utilization review," she advises, "you want to make sure the CEO knows all the specializations and high-tech expertise you have. You want to be visible and they know that the value there is in keeping the system and the community well."


Laura Elliott, RN, MS, Vice President, North Mississippi Health Services, 600 W. Main St., Tupelo, MS 38801. Telephone: (601) 841-3611.