Healthcare at Home: The Rowan Report

By Tim Rowan, Editor & Publisher of Home Care Technology Report

CMS Administrator Seema Verma’s Open Letter Calling for Rules to Protect the Safety and Health of all Americans.
Despite stringent safeguards, alarming stories continue to be reported about people, including some of our most vulnerable individuals, who have experienced harm in healthcare settings that is devastating to these patients and their families. These include cases of sexual, physical, or mental abuse; neglect and medical mistakes resulting in death; and serious and life-threatening injuries or impairments.
[Details are provided about CMS’s intolerance toward acts that violate quality or safety standards in healthcare settings and, as Verma’s letter continues: ”That is why CMS is issuing new guidance that takes a key step towards making across-the-board improvements in healthcare safety and quality.”
As the letter continues: ”This guidance directly addresses violations of health and safety regulations that cause serious harm or death to a patient and require immediate action to prevent further serious harm. These situations are called immediate jeopardy. The letter continues about ”immediate jeopardy” situations: It is critical that federal and state inspectors accurately identify, thoroughly investigate, and ensure immediate jeopardy situations are resolved decisively and swiftly.”] The remainder of this article talks about handling these situations–identifying them and getting trained to issue penalties for Medicare- and Medicaid-certified healthcare providers, suppliers, and laboratories. CMS has responded to many providers’ concern for a need to clarify handling ”immediate jeopardy” cases and has now issued new guidance that can be found in Appendix Q of the State Operations Manual that federal and state inspectors use.
More opportunities for training is available to the public as well, online at: surveyortraining.cms.hhs.gov.
The revised guidance and administrative tools can be found at: cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions.html, and will be uploaded to the online State Operations Manual within a few weeks.

©2019 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. editor@homecaretechreport.com

WellSky Acquires Health Care Software Inc.
LENEXA, Kan. — Feb. 26, 2019 — WellSky, a leading health and community care technology company backed by TPG Capital, and Health Care Software, Inc., a leading provider of integrated clinical and financial IT software for long-term acute care hospitals, senior living, and in-patient behavioral health providers, today announced that WellSky has acquired HCS.
The HCS Interactant® solution is an enterprise platform, serving patients with complex needs who require longer term hospital stays and highly specialized care. The system serves thousands of client locations across LTACHs, behavioral health facilities, and senior living facilities.
HCS will maintain its office and operations in Wall Township, New Jersey, with CEO Tom Fahey continuing to lead in that location. HCS clients will see no immediate changes to their software and customer service. The company will be gradually integrated into the WellSky brand over time.
About WellSky
WellSky is a technology company offering software and professional services that address the continuum of health and social care. A portfolio company of TPG Capital, WellSky serves more than 10,000 customer sites around the world — including hospital systems, blood banks and labs, home health and hospice franchises, government agencies, and human services organizations.
WellSky.com
About HCS
HCS provides an integrated clinical and financial IT platform to LTACH, senior living, and behavioral health facilities. Since 1969, the HCS Interactant® platform has been delivering enterprise-wide solutions for revenue cycle management, financial reporting, electronic medical records, mobile technology, and business intelligence.
hcsinteractant.com

©2019 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. editor@homecaretechreport.com

Homecare Homebase Signs Virginia Home Health Provider
Homecare Homebase –Dallas, Tx– has announced that Virginia’s Five Star Home Health Care has joined its growing roster of agency clients. Five Star offers “whole-person care” with fully integrated, in-home nursing, therapy and personal care services.
With major regulatory changes fast approaching, Five Star Home Health Care was looking to improve scheduling, streamline workflow and make compliance easier, knowing “defensible documentation” and proven results will be critical under the Medicare PDGM reimbursement system that takes effect in January 2019.
William Harvey, VP of Skilled Care and Administrator for Five Star Home Health Care said his company looked closely at three other software solutions before choosing HCHB. “After seeing the software demo, it was clear that HCHB is right at the forefront of compliance. And for us, that was one of the biggest drivers in our decision.”
Another major attraction for Harvey was the HCHB Analytics tool, which allows fast, easy insight and metrics on staff utilization, clinical outcomes, sales, referral source tracking and conversion rates.
HCHB President Scott Decker also is quoted for his decision to choose Five Star Home Health Care, saying that more complex home healthcare data is now driving more and more clinical and business decisions.
About Five Star Home Health Care
Five Star provides personal care and skilled services in eleven Northern and Northwestern Virginia counties. They accept Medicare and Medicaid, most commercial insurances, long-term care insurance, and can invoice patients directly.
fshhc.com
About Homecare Homebase, LLC
Homecare Homebase (HCHB) is a Dallas-based software company offering hosted, cloud-based solutions to home health, homecare, and hospice agencies. Mobile solutions enable real-time, wireless data exchange and communication between field clinicians, physicians and office staff. Founded by industry veterans in 1999, the company became part of the Hearst Health Network in 2013.
hchb.com
About Hearst Health
The mission of Hearst Health is to help guide the most important care moments by delivering vital information into the hands of everyone who touches a person’s health journey.
©2019 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. editor@homecaretechreport.com

By Tim Rowan, Editor & Publisher of Home Care Technology Report l

At last month’s Home Care 100 conference, post-acute care leaders sat down with health system and managed care executives to describe the benefits of collaboration. As public and private payers move in the direction of value-based payments, they asserted, this level of teamwork is the best way to improve patient outcomes and satisfaction while keeping healthcare costs under control.
[Rowan identifies 5 representatives of post-acute healthcare organizations who participated in a key session at this conference that focused on the need to describe the benefits of collaboration and maintaining a level of teamwork as the best way to improve patient outcomes and satisfaction. Reimbursement, as always, the group said, is the dominant factor. However, key to changes is ”creating true clinical programs that deliver a differentiated experience for their members [and that] requires complete clinical transformation.”]
Panelists agreed that payers today are looking beyond ways to lower unit cost. Of greater concern is finding innovative payment policies that will drive better patient outcomes and experiences. [One panelist confirmed that certain acute care groups’ message to health systems and payers is not that they can reduce short-term costs but that they can lower lengths of stay, readmission rates, and ED utilization over time and keep them lower by achieving better patient outcomes.
The opanelists concluded about partner groups, generally: ”Their goal is to thrive under a Value-Based Reimbursement environment… Health systems and physician groups will need partners that have aligned their incentives and methodologies, creating a standardized approach to value-based care. Post-acute providers must know to what extent their prospective partners value timely initiation of care,total cost of care, per member and per month costs,ED UTILIZATION,3-day return to ED, 30-day all-cause readmissions,3-day return to ED, 30-day all-cause readmissions,and average episode cost of care. A chart is provided that indicates the value of a patient- and cost-benefit “appropriate care setting” rather than “lowest cost care setting.”

©2019 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. editor@homecaretechreport.com

By Darcey Trescone, RN, BSN
To date, we know that PDGM will result in significant changes for agencies and the Electronic Medical Record (EMR) software they use. Quality and compliance with regulations, including how care is provided and what is documented, will become even more critical. If you have attended the webinars and read the numerous articles on PDGM, you understand this. But what does this really mean to you as an agency?
[The author provides a must-do list that all HHAs must complete to be prepared to meet the demands of PDGM. These tasks include identifying internal processes that are not in line with the design of your EMR system, and if you don’t do this first, then you may not benefit from the changes your EMR vendor makes to accommodate PDGM. First must-do– Review current internal processes, and make sure your HHA’s staff is prepared for recertification.]
If internal processes across your organization are labor intensive now, then anticipate that this intensity will likely increase with PDGM, resulting in higher operational costs. In addition, timeliness of care, complete and accurate clinical documentation, and detailed order and claims management will be expected and your time frame for completion of all these areas will be reduced.

[Trescone summarizes important points about the EMR area likely to be impacted by PDGM, as follows:
1.It is imperative that your EMR vendor’s plans be reviewed alongside your present system utilization and internal processes, looking for operational changes that may be required of you. The change to a 30-day episode will require agencies to deliver, document and bill for care in a condensed time frame.

2. Always keep the following activities at the forefront of your planning: Episode and visit management, productivity tracking/management, 30-day periods of care including recertifications, identification and tracking of LUPAs, timely documentation of visits.

3.And more concerns to be kept at the forefront of planning, are: Diagnosis coding – accurate diagnosis coding and sequencing will drive CMS behavioral adjustment assumptions (critical this is reviewed/managed while a patient is on-service.)
And still more of same:
4.Clinical documentation – supports the need for home care, correlates to the diagnosis by body system including complex wound management, care paths based on patient clinical grouping/comorbidity coding, clinical plans demonstrate an effort to improve the patient’s status in line with functional levels/limitations and co-morbidities

5. Order management – orders must be written, signed and received back in a timely manner

6.Enhanced OASIS – scrubbers and quality review practices (including tracking and monitoring tools to ensure care compliance)

7. Real-time tracking and dashboards – high-risk patients including hospitalization risk stratification, visit counts by diagnosis grouping, late episode LUPAs, labor costs–operationally and in the field

8.Billing and claims management – 30-day episodes, timeliness tracking/management of claims, financial reporting and changes to revenue recognition;

[The plate of activities during PDGM is obviously very full. She suggests, therefore, to: “Put a change management team and process in place now.” She continues: Change management and education on internal processes and EMR software changes should be planned for and monitored closely.]

Educate operational and clinical teams on PDGM, and EMR vendor plans and changes to your internal processes that will need to have occur. This will take time and your team will have feedback. Listen to their feedback and incorporate it into your documented processes and education going forward.

Darcey Trescone is a Healthcare IS and Business Development Consultant in the Post-Acute Healthcare Market with a strong background working with both providers and vendors specific to Home Care and Hospice. She has worked as a home health nurse and held senior operational, product management and business development positions with various post-acute software firms, where her responsibilities included new and existing market penetration, customer retention and oversight of teams across the U.S., Canada and Australia. She can be reached at darcey@tresconeconsulting.com.

©2019 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. editor@homecaretechreport.com

By Tim Rowan, Editor & Publisher of the

Home Care Technology Report

Dear Friends and Colleagues,
This special edition marks two anniversaries. I hope you might indulge me while I look back on my 20 years as editor of Home Care Technology Report. Even if you have been around as long as I have, there may be some history you have not heard.[Rowan guides us through highlights of his 20 years of experience with HCTR, his mentor, Tom Williams, and other highlights of his career in home health, home care, and hospice news.]

©2019 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. editor@homecaretechreport.com

by Tim Rowan, Editor and Publisher of The Home Care Technology Report
The most controversial provision in the home health payment system that becomes law on January 1, 2020 needs some unpacking. CMS has decided that lower revenue levels likely to come from PDGM will motivate you to cheat. One fear is that you will elevate a secondary diagnosis code to primary if it comes with a higher payment. The other is the old “case mix creep” argument that your nurses will upcode their OASIS assessments in order to get into a higher pay category.

CMS starts with assumptions about how agency owners think, how they train their nurses, and how closely the clinical and financial thought processes are tied together within a home health agency. [On top of these assumptions, CMS layered historical data – not real-world patient condition data, but claims and OASIS data – and came up with the number 6.42%. This is the deduction they will take from every provider, based on the assumption that all nurses will pad OASIS and each will pad it precisely the same percentage.]
And simply be data-driven. Home health patients really are coming out of the hospital older and sicker and closer to death than they were even a few years ago. The suspicion that nurses are cheating is based on rising average acuity over the years. CMS cites this as evidence of upcoding but the data show OASIS assessments merely reflect a larger reality, one out of the control of home health nurses. Given the choice between blaming the rise on actual patient condition or condition that only exists on paper, CMS chooses to assume the latter. And nobody knows why.
Here is why this is more a revelation of CMS staffers’ opinions of our healthcare sector than of any objective research and analysis. CMS knows that patients are discharged from hospitals in dramatically worse conditions than they were before the introduction of Home Health PPS, certainly before hospital DRGs. In 2007, they commissioned an Abt Associates study that clearly demonstrated that reality. They also know they have saved billions of dollars by demanding hospital stays that used to be 14 days should now be limited to three. Would these early discharges be possible without the availability of in-home care to pick up where hospital care abruptly left off? Of course not. Absent home health, Medicare outlays would soar to cover more hospital days and longer nursing home stays.
Peering into 2020
Back to our first question. Are poor documentation and inaccurate OASIS assessments a problem? Well, yes, unfortunately, they are the number one problem in Medicare Home Health, according to the attorneys and operational consultants we have heard from. CMS data and outside analysts have determined that more than 80% of payment denials result from insufficient, inaccurate, or incomplete clinical documentation – frequently all three. Clinician training across the country, with few exceptions, is either inadequate, ignored, or both. It would be more accurate to describe it as a crisis than a problem.
[What does the near future hold under PDGM? PDGM may not make the crisis worse but it will certainly make it more visible. [Rowan goes on to describe the necessity for HHA owner to be more vigilant in demanding ”believable assessments, thorough visit notes, and justifiable consecutive episodes…[This] will be, starting next year, the characteristics of survivors. An owner who per mits the continued employment of a nurse who cannot – or will not – upgrade the quality of his or her documentation is inviting potentially fatal scrutiny.”
”Nevertheless, CMS is in error thinking that pre-punishment will solve this crisis. This is the reason NAHC president Bill Dombi is currently focusing his meetings with CMS staffers on the so-called “behavioral modification” payment reduction. The rest of PDGM, with its flaws, is better than its proposed predecessor, known as HHGM. Dombi and company were able to reason with CMS about the dangers inherent in that earlier payment proposal. He told us he thinks he has gotten all the improvements he can into the overall plan, but the 6.42% hit based on shaky assumptions has to go.
If, after a year of PDGM, CMS sees that assessments are characterizing patients as sicker than they actually are, then go ahead and put the behavior modification in place, but do it agency by agency. To ignore the reality of the impact early hospital discharges are having on patient condition at the point of home health admission and assume – in spite of evidence to the contrary – that all episodic payment increases are caused by sinister intent is demonstrative of bureaucrat-think, not of concern for the Medicare Trust Fund. Doing the hard work of investigating into the real reason why OASIS assessments show patients are worse at home health admission today than they used to be would have produced a better policy. CMS chose the easier solution.

©2019 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. editor@homecaretechreport.com

by Roger McManus, MBA

Over the last 24 months, we have seen significant changes in consumer behavior with regard to online consumer research. This particularly impacts home care, an industry years behind in using this free resource of business.[McManus recounts the brief history of an ”online review craze” which Amazon started a dozen years ago, ”when they encouraged people who read books they had purchased on the site to critique them. A few loquacious readers, perhaps joined by wannabe writers, would craft long, involved essays about the books they had read. Amazon did not need lots of reviews to make their strategy work, but those they did get were highly impactful on sales.McManus goes on to describe 2 new types of websites developed:”sites created specifically for reviews like Yelp and Trip Advisor and sites created for social expression like Facebook and eventually Google.”Google,” he notes soon dominated ”the market for consumer opinions,” and according to a 2019 study by ”ReviewTrackers, it captured this review market by 58 % to Facebook’s 19 %.”

Google’s growth was cannibalized from all other sites, allowing it to soar far beyond the second place site where people go to research products and services before they buy (63% vs. 37% for all other sources combined). Search results for every local business include reviews right within the product and service data delivered in their search, making it small wonder that Google dominates both the collection and dissemination of consumer opinions.

Further, because Google delivers reviews right in the search results, it tends to preempt people looking at other sites for reviews, further bolstering Google’s preeminence in the reviews delivery game. The key point, however, is that this change has occurred quickly, faster than owners of home care agencies appear to realize. This enhanced access consumers have to reviews is of huge marketing importance.]

JUNE 23, 2019 By Tim Rowan, Editor and Publisher of Home Care Technology Report

The Hospice Quality Reporting Program (HQRP) currently consists of two reporting requirements: the Hospice Item Set (HIS) and the Hospice Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey. HIS and Hospice CAHPS® data are used to calculate performance on quality measures.
HIS data can be used to calculate eight National Quality Forum (NQF)-endorsed measures and one non-NQF-endorsed measure. Descriptions of the nine HIS-based measures are provided below. Additional details about the measures can be found in the QM User’s Manual located in the Downloads section at the bottom this web page.
The CAHPS® Hospice Survey was considered as a single measure by NQF and endorsed as NQF #2651; CAHPS® data can be used to calculate eight patient experience measures. Additional details about the CAHPS® quality measures can be found below, and on the CAHPS® survey webpage at: http://www.hospicecahpssurvey.org/globalassets/hospice-cahps/scoring-and-analysis/steps-for-scoring-cahps-hospice-survey-measures–2017q1-_nov-2017.pdf.
Information on this webpage is specific to the quality measures that are calculated using HIS and CAHPS® data. For item-level information on the HIS (e.g., coding instructions, HIS Manual), please visit the Hospice Item Set (HIS) portion of this webpage. For information on the CAHPS® survey itself (e.g., survey questions, data collection timelines), please see the Hospice CAHPS® portion of this webpage.
Version 3.00 of the HQRP QM User’s Manual is now available for download in PDF format. The measure specifications for Hospice Visits when Death is Imminent Measure 1 and Measure 2 are included in this new version. Please refer to the “HQRP QM Users Manual v3.00” document in the Downloads section of the Current Measures web page to download the QM User’s Manual v3.00….

©2019 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This CMS article was reprinted in Tim Rowan’s Home Care Technology Report. homecaretechreport.com It may be freely copied. editor@homecaretechreport.com

Studies have found that early technology adopters are more likely to experience better business outcomes, including increased revenue growth and market position. The same studies have shown that health and home care are the least likely to be early adopters among industry verticals. Artificial Intelligence is widely used in all kinds of health related aspects, to note the largest concentrated usage is cardiology, neurology and oncology.
So how can Artificial Intelligence be utilized in home care?
First, let’s start with what is Artificial Intelligence.
Artificial intelligence (AI) makes it possible for machines to learn from experience, adjust to new inputs and perform human-like tasks. Most AI examples that you hear about today – from chess-playing computers to self-driving cars – rely heavily on deep learning and machine learning. When using these technologies, computers can be trained to accomplish specific tasks by processing large amounts of data and recognizing patterns in the data.
Patricia W. Tulloch RN, BSN, MSN, HCS-D, Senior Consultant of RBC Limited of Healthcare & Management Consultants suggests that, “Home Care is really at the beginning of integrating AI into care services. The use of AI to analyze critical clinical data is currently used to perform acuity risks and support clinical practices that address patient risks to reduce emergent care and hospitalization. The updated HomeCare CoPs requires providers to determine emergent care & re-hospitalization risks and address patient specific diversion strategies and interventions in their Plan of Care. The goal here is proactive early identification to reduce unnecessary emergent care.”
What are some successful applications in AI with homecare?
IBM’s Watson—an AI platform famous for beating human Jeopardy! has been piloted by a home care provider to gather and analyze patients’ data in order to ensure that they are in the most appropriate care setting, whether in a skilled nursing facility or at home. The home care provider believes that home-based artificial intelligence has a significant role to play in driving down health care costs. The algorithms capture a myriad of metrics which in turn generate a variety of predictions to create better health and economic outcomes.
Formal caregivers are the backbone and front-line workforce in the homecare industry. Artificial Intelligence has been successfully utilized in the education sector in several ways. AI will also provide personalized tutoring for learner’s outside of the classroom. When learner’s, such as the caregiver workforce, need to reinforce skills or master ideas before a case, AI will be able to provide them with the additional tools they need for success. AI will also work in identifying the learner’s weaknesses. For instance, AI will identify if and when groups of caregivers miss certain questions letting the home care agencies know which material needs to be retaught. In the same manner, AI will also hold the individuals who designed the courses accountable and strengthen best teaching practices and instructional design.
The Challenges of AI in Homecare
There is ample data available in the healthcare field, the issue lies that the data is many times in different databases. As well, to be effective, the data should be accurate, uniform, and complete, which is not always the case in the healthcare field. In a world where reimbursements are tight, budget constraints become a barrier. It is costly to maintain current technologies, let alone invest in new technologies.
Finding the right equilibrium between human touch and machine learning is a big ethical issue. Will machines ever replace humans? To what extent will machine learning replace medical practitioners?
In healthcare, human judgment is said to be a lot more valuable than any insights Artificial Intelligence can derive, regardless of technological advances.
Getting Truth from Machine Learning
Jonathan Conaghan, Vice President with J.N. Savasta Corp., an employee benefit consulting firm in New York, believes that “Data driven decision making is revolutionizing the way those in the homecare space are approaching their HR function. In an industry whose workforce is its greatest asset, it is critically important to understand how to leverage data to improve areas such as recruitment and retention. Data definitively shows homecare operators that make an investment in employee benefit offerings see improved employee satisfaction. Turnover is consistently high across the industry, and data supports that companies who offer high value benefits see significant improvement in their employee retention metrics.”
There are emerging technologies in the home and health care field which will assist in providing better unit economics along with better health outcomes. The early adopters to these technologies will reap benefits. As the saying goes–the numbers don’t lie!

James Cohen is the Co-founder and CEO of Nevvon, a software developer of mobile learning solutions for caregivers. He is a homecare expert who has dedicated the last 10 years of his career to serving the fastest growing–and most vulnerable–segment within the healthcare industry. A former financial engineer, James has held a variety of executive leadership positions in healthcare administration, strategic development and operations. He sits on a National Brain Injury Board and is often speaking at health events.

This article was reprinted in Tim Rowan’s Home Care Technology Report by permission of the author. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. editor@homecaretechreport.com