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Staff productivity, expense reduction more important than ever
Hospital rehab administrators fearful of the impact of the prospective payment system need only look around the corner for a glimpse of things to come. The home health industry has been hit with prospective payment mechanisms for Medicare patients somewhat sooner, thanks to the interim payment system (IPS), the pre-prospective payment, cost-containment initiative from the Health Care Financing Administration (HCFA).
Life under IPS translates into a financial and operational juggling act for home health rehab providers. Agencies are dealing with across-the-board payment reductions, limitations on the number of patient visits, and staff training on how to use a new patient assessment instrument, OASIS (Outcome and Assessment Information Set), while grappling with ways to minimize the impact on quality of patient care. The OASIS instrument is a series of questions therapists must ask patients during an initial evaluation, at interim points, and upon discharge. Its goal is to assess the patient’s health status and monitor improvements.
Agencies have responded in different ways, says David Perry, MS, PT, manager of physical therapy and occupational therapy at the Visiting Nurse Association (VNA) of Southeast Michigan in Oak Park, MI, and treasurer of the American Physical Therapy Association (APTA) in Alexandria, VA.
HCFA statistics released earlier this year state that IPS will reimburse 93% of all home health agencies at less than their costs.
As with hospital rehab, government financing of care underwent a makeover following passage of the Balanced Budget Act of 1997. Traditionally, Medicare-certified home health services were paid based on agencies’ reasonable costs capped at a national per-visit cost calculation. There was no limitation on the number of visits.
Under IPS, these agencies receive the lesser of their reasonable costs, a per-visit limit or a per-beneficiary limit.
Integration leads to efficiency, success
Although the much-publicized techniques of layoffs and salary reductions have prevailed at many agencies, organizations also are employing long-range strategies to increase staff efficiency and productivity.
"We are developing successful approaches," says Karen Crockett Lindstrom, PT, MBA, divisional director of professional support services for SunPlus Home Health Services in Burbank, CA. Lindstrom also is president of APTA’s home health section. "We are spending more time coordinating care but are finding we can be successful under the IPS rates. It’s extremely challenging because it takes constant surveillance of monitoring clinical functions and your business functions. Everything is integrated. It’s critical to focus on good clinical care, but if your office functions are sloppy and you don’t you get your bills out or actively collect [for money owed], you can lose or waste money."
Techniques that have worked well for SunPlus include:
• Focusing even more on patient outcomes during weekly team meetings between clinicians and administrators. Although team meetings have long been a staple of the rehab world, SunPlus managers have kept treatment discussions focused on how these are helping to achieve goals. The key is to have a strong manager leading the meetings who can step back and keep people on track, Lindstrom says.
• Deciding more quickly which caregivers and which treatments to use on patients. "We’re saying, Let’s look right away at what the patient’s impairment is and what they need,’" Lindstrom explains. "We don’t have time to waste on trying a few visits here and there for each discipline. We’ve got to focus much more quickly on meeting the needs of the patient and deciding which interventions will get you to these goals."
• Expanding the involvement of physical therapists when appropriate. This is done in several ways, Lindstrom says. Because Medicare regulations allow physical and speech therapists to open a case, those practitioners may do initial patient assessments, whereas in the past, skilled nurses may have been called in solely to evaluate a patient and open the case. Perry says VNA also has used that approach.
At Optima HomeCare, a division of WakeMed Hospital in Raleigh, NC, cross-training also has been an effective tool, says Dottie Oakes, RN, MS, executive director. "We have examined the scope of service for each discipline to evaluate maximum productivity. For example, if we have the physical therapist there for a visit, we consider whether they can be doing other things. They traditionally have focused on maximizing mobility and muscle strengthening, but there also are other functions they can perform well, such as wound care."
The best thing hospitals can do to prepare for the prospective payment environment is to develop a strategic plan that addresses expense management and monitoring clinical outcomes to assure they are maintaining quality care while operating cost-effectively, Oakes says. A strategic plan that addresses expense management, staff productivity, and clinical outcomes has prepared Optima for the impact of IPS, she says.
All three managers stress the importance of communication between hospital rehab departments and home health facilities they use frequently. "Try to work . . . together as to how the whole continuum of care can operate more efficiently," Perry says.
Because Optima is affiliated with WakeMed Hospital, regular communication takes place between case managers at Optima and case managers at the hospital’s rehab unit, Oakes says. It is important to share common goals and identify problems that affect patient care throughout the continuum. The solutions and the responsibility for patient outcomes are shared, she says.