Resolved: 1999 will be a good year for home health improvements

Experts nationwide give advice on how to make that happen

It’s the beginning of a new year when all things seem fresh and possible. You’ve made a resolution to make the coming year a good one. What should your agency do to make sure it thrives in turbulent times and still delivers the best possible care?

Experts interviewed by Homecare Quality Management say your focus should be on patient care. Agencies should measure outcomes and communicate the results to payers, patients, and staff, yet stay within the confines of all the new rules and regulations that govern home care.

Beth Henn, MS, RN, director of quality management at SNI Companies in Langhorne, PA, thinks agencies need to concentrate on the basics.

"In the hubbub of constantly evolving regulations and mandates from regulatory bodies, we have to look at what are the basics of home care," says Henn, noting that agencies are spending more time concentrating on administrative requirements and less paying attention to issues like quality improvement.

However, Henn understands the need to balance fiscal and patient care goals. "The thing you have to do is balance the financial aspect with care, looking at the basic needs of the patient, and making sure the organization stays viable."

Prioritize your projects

The key, says Cathy Neilsen, RN, CPHQ, vice president of clinical services at In-Home Health’s Minnetonka, MN headquarters, is to prioritize your projects.

"There are so many issues to deal with from trying to cut and control costs to maintaining efficiency and keeping quality high. You have to prioritize," she says.

Now, Neilsen adds, rather than blindly implementing projects, In-Home Health is spending more time determining "where we get the biggest bang for our buck. For instance, we know we want to revise our written competency tests for nurses. But the time it would take in human resources terms doesn’t give us as much benefit implementing another program, like providing nonskilled personal care providers to patients."

Once you have programs in place, you need to measure how well you meet the needs of your patients. According to Patrice Spath, a health care quality consultant based in Forest Grove, OR, you should resolve to incorporate patient preferences into your outcomes measurements this year.

Measure your success

"A good example is to establish a mechanism for obtaining patient and/or family goals for treatment and then measure to see if these goals are met," Spath says. "Patients and their families want to be more involved in their care and setting/measuring patient defined goals is an important part of this collaboration."

Karen Carney, editor of The Home Advantage newsletter in Andover, MA, thinks agencies should put together a report card of their agency.

"You have to be able to articulate what information makes your organization different and be able to share that with providers and referral sources," she says.

Once you have that information, don’t just share it with physicians and payers, but share it with your staff. "Home care organizations and hospices have such a hard time articulating what they do and how they are different," says Carney. "They say they have good quality, but they can’t tell you if that means there are fewer visits, or fewer hospital or emergency room visits. Pull the information together. Define what you mean by quality and share it with your staff. When they talk to patients, family, and physicians, they can explain just how you are different."

Part of successfully sharing information is determining what information different parties want to know, says Carney. For instance, social workers want to know how fast you are in the home after discharge. "They want to know they can hand a patient off to you and not be called again. They want to know you have less incidence of rehospitalization and emergent care. Other agencies might not be able to articulate this, but you can." Ask your customers, "What information do you want to know about us?"

That kind of communication with customer and referral sources also tops the resolution list of Elizabeth E. Hogue, an attorney in private practice in the Washington, DC, suburb of Burtonsville, MD.

"You should resolve to communicate effectively with physicians to offset whatever perceptions have caused them to reduce referrals to home care," says Hogue. She says part of the reason they may be reducing referrals is fear of falling foul of fraud and abuse regulators. But, Hogue adds, there are also fraud implications of not referring, and home care agencies should make physicians aware of this.

"Sure referring brings risk," she says. "But if you don’t refer, there is a risk of liability for negligent premature discharge of patients from hospitals, or fraud in the form of underutilization of services. We have focused so much on overuse, but if you look at the fraud and abuse compliance guidelines from the Office of the Inspector General from July, underutilization has already been applied to managed care organizations and health maintenance organizations. If they are targeting them for underutilization, then it applies to doctors, too."

Hogue says you can find an effective way to communicate this to physicians, but it will take a one-on-one meeting between a home care executive, preferably the medical director, and the physician. "They need to explain — without it being refer or else’ — the ramifications of failing to refer."

Communicate IPS strategies

Hogue also thinks agencies should resolve to communicate to skilled nursing and hospital discharge planners what the interim payment system (IPS) means for them.

"They need to make it clear to the planners that they can no longer just dial an agency, but really have to plan the discharges," she explains, "The advantage of this is that you not only can work on preserving important relationships by this communication, but you can insure with better discharge planning that you have fewer non-billable visits, or fewer times where you go out to admit a patient and find you can’t."

Lillia Rosenheimer, RN, MPA, associate director of nursing at Community Home Health in San Pablo, CA, says communication is one way to keep employee morale up. That’s her No. 1 resolution for 1999.

"We have been forced to do more and more with fewer and fewer people," says Rosenheimer. "That makes morale a bigger issue."

Recently, an internal audit by her company brought a score in the low 90s. "We want to tell staff about the audit results during a meeting, but they always complain that we concentrate on the things we didn’t score well on," says Rosenheimer. This time, she wanted to emphasize the positive in the meeting, but save the problem areas for a later, in-depth discussion. This lets the staff savor the good news.

Veronica McCabe, RN, RNC, a quality management specialist at SNI Companies, says the increasing requirements put on home care agencies are the basis of her resolution.

Stand up and be heard

"Lobby the legislature about the impact of IPS and OASIS [Outcome and Assessment Information Set]," says McCabe. "The data collection requirements of OASIS impact how many patients we can see. We have to let the legislators know that isn’t acceptable."

McCabe’s colleague Henn agrees. "Turning up the gas and getting people to make noise will help. If they want home care to continue to exist, then they can’t keep going the way they are," she says.

Rosenheimer also says making your voice heard about the realities of doing business is another good resolution. She advises starting with the upper management of your company.

"If someone is asking more of you than you can deliver, say so. Pipe up," she says. Her company recently asked her to gather productivity data daily. "It would have taken me hours every day to do that. I told them twice a month was more realistic, and they said fine. If something is too much, raise your voice and complain."

Hogue says the whole issue of IPS and PPS also has an impact on one of her suggested resolutions.

"You have to resolve to manage your patient mix without incurring legal liability. You have to be willing to control who you admit and who you provide services to without incurring liability for abandonment. I find agencies all over the country that either don’t believe it can be done, or are unwilling to make the internal changes they have to make it work successfully, such as screening admissions, making sure patients meet Medicare criteria, or ensuring that they are generally clinically appropriate for home care."

Once you do that, you have to continue to monitor your patient load and make sure you remain under cost caps and aggregate per beneficiary limits.

Another resolution that fits under the general legal heading, says Hogue, is to implement or continue to implement a fraud and abuse compliance plan.

"We hear providers say, I can’t afford to do this,’ all the time," Hogue says. "I understand that perspective when they are talking to consultants who tell them they need a six-month internal audit that will cost $50,000. But they can skip the internal audit, develop a plan, implement it, and then do an audit. If you can’t afford to have a fraud and abuse compliance plan, then you can’t afford to be in business. There are very few issues I put at the top of my list, but these are up there. These are things that must happen."


Beth Henn, MS, RN, director of quality management; Jane Elliott, RN, quality improvement specialist; Veronica McCabe, RN, RNC, quality management specialist, SNI Companies, 880 Town Center Drive, Langhorne, PA 19047. Telephone: (215) 752-6562.

Cathy Neilsen, RN, CPHQ, vice president of clinical services, In-Home Health, 610 Carleton Pkwy, Minnetonka, MN 55305-5214. Telephone: (612) 449-7654.

Karen Carney, editor, The Home Advantage, 12 Burnham Road, Andover, MA 01810. Telephone: (978) 475-2096.

Elizabeth E. Hogue, Esq., attorney, 15118 Liberty Grove, Burtonsville, MD 20866. Telephone: (301) 421-0143.

Patrice Spath, Healthcare Quality Consultants, 2314 19th Ave., Forest Grove, OR 97116. Telephone: (503) 357-9185.

Lillia Rosenheimer, MPA, RN, associate director of nursing, Community Home Health, 13201 San Pablo, San Pablo, CA 94806. Telephone: (510) 235-1821.