Prepare for home care's future: QI cuts admission costs by 10% in 2 years
Prepare for home care’s future: QI cuts admission costs by 10% in 2 years
Agency’s patient satisfaction remains at 100%
Imagine this scenario: You are 10 years old, and each month your parents give you money to spend at the mall. It starts with $5, increasing a little each time, and they ask you to return any cash you haven’t spent.
The trouble is, there is never anything left over. Does this sound familiar? It’s what has happened to many home care agencies because of the way Medicare has traditionally paid for services.
"Medicare set a cap limit that continued to exceed our costs by greater margins each year, and we had the potential to utilize more and more expenses," says Dottie Landry, RN, MSN, division director for home care for Terrebonne General Medical Center of Houma, LA. The hospital-based agency averages 8,000 patient visits per month and serves southeastern Louisiana.
However, Terrebonne resisted the temptation to load the program up with additional expenses to meet the cap limit, Landry says. Instead, she began a quality improvement program aimed at maintaining costs while the agency increased its volume.
As a result, the agency has lowered its total cost per admission per patient by 10% over a two-year period, and more importantly, it has kept admission costs stable for about 10 years, she adds.
In 1987, the agency’s daily census was about 80 to 90 patients, and the agency had 30,000 to 35,000 visits per year. Now the daily census is about 450 patients, and the agency averages 88,000 to 90,000 visits per year.
Landry says the agency’s cost per visit is proprietary information, but it is "far below the Medicare cost limit."
At the same time, the agency’s patient surveys have consistently showed 100% satisfaction among patients.
"A couple of years ago, I thought the cost was going to drive our operation and that the Medicare definition was not going to be the same for home care in the future," Landry says.
"It was always my opinion that the Medicare program set itself up to be overutilized," she adds. The current government furor to save the Medicare program from insolvency suggests she was right.
Here’s how she developed the QI program:
• The agency developed its own clinical practice guidelines.
The agency’s own guidelines encouraged fewer visits than did Medicare, Landry explains.
"The guidelines are very frugal," she says. "There’s not a diagnosis that is authorized for more than five nursing visits within the first week."
Landry says the agency based these guidelines on what managed care companies were using: the Milliman and Robertson visit guidelines for case managers.1
Although these did not apply to the Medicare population and the guidelines were stringent, they provided a good launching pad. So the agency used these guidelines, building some flexibility into them because the Medicare population couldn’t be expected to learn disease management as quickly as younger patients. The result was a goal that still provided fewer visits than did Medicare.
For example, the managed care guidelines allowed a maximum of five visits for any surgical procedure. "Five visits sometimes can be finished in one week, and one week is not enough time for an individual, especially an elderly patient, to absorb everything he needs to know about his diet and lifestyle," Landry says.
"So we put some flexibility into it based on the nurses’ assessment of patients and how fast they could learn," she adds.
The resulting guidelines were still shockingly different from the way the agency had handled visits under Medicare’s fee-for-service system.
"This caused us to rethink the content of each visit," Landry says. "We know we have to teach more, and the nurses have to organize their work so no part of the visit is wasted."
In seven or eight months, the agency achieved its goals of cutting visits to the new recommended levels.
Education was crucial because the staff had to change a mindset, Landry says. "We recognize that we’re being asked to think of home care not as a long-term solution for people, but as a recovery period."
• Nurses make critical assessments of patients’ needs.
Landry says the nurses are taught to assess the patients’ needs by asking themselves the following questions:
What does the patient need to get him or her back to health?
How well can the patient learn to take care of him- or herself?
What is this person’s barrier to recovery?
The last question is the most crucial, Landry says, because if a nurse identifies a patient’s barrier to recovery and neutralizes it, then theoretically the patient can get well.
"That’s the most inclusive question we ask: to have them identify barriers to recovery, which might include the family, resources, lack of information, health problems, or anything that keeps the patient from getting well," Landry adds.
The patients’ barriers sometimes are formidable because the agency serves a southern Louisiana area where the average education is at a sixth-grade level, and many speak in Cajun French and broken English, says Tina Samaha, RN, assessment nurse for Terrebonne.
"The biggest barrier is assessing their level of understanding; a lot of them just nod their heads yes’ to everything," Samaha notes.
So nurses use whatever teaching methods work best with each patient, including showing them pictures, reading the material to patients, or having the patients read the material. "We have to remember to speak slowly and reduce outside distractions," Samaha adds.
Another method that works is for the nurse to tell the patient at the beginning of the visit what the goals are that day.
"We say, this is what I want you to learn. Today I want you to identify what precipitates congestive heart failure, and at the end of the visit I want you to be able to do this,’" Samaha explains.
"We set simple goals, and if we find that the patient is going to have trouble with the goals then we find a family member or friend to teach," she says, adding that most people in that part of the state have close-knit extended families, so there is usually enough caregiver support.
• Nurses ask patients for input.
"This is a frequent question from our nurses to the patients: How many times do you think I need to come to see you before you will learn this?’" Landry explains.
What often happens is patients say they can learn in less time than the agency typically would have allowed for the instruction. For instance, a patient may say he could learn to take care of his own insulin in two visits, which is considerably less time than the nine or more visits the agency might have planned "to make sure he learned it," she says.
If a patient still doesn’t understand how to use insulin at the end of the week, then the nurse will return to provide reinforcement. "But that’s a whole lot different situation than assuming a patient is going to need six weeks to teach them something," Landry says.
Nurses also ask patients and their families, "How many times a week do you think you need an aide to help you?"
Again, Landry says, the patients and family usually say they need fewer visits than what are allowed by Medicare. And while the patients sometimes underestimate how many visits they need, this process still results in fewer overall visits.
"They’ve been much more realistic with what they needed than they were before, because before we never asked them," Landry says.
Reference
1. Doyle RL, Schibanoff JM. Healthcare Management Guidelines: Home Care and Case Management. Seattle: Milliman & Robertson; 1994, vol. 4.
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