Healthcare at Home: The Rowan Report

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

Spending a few days with owners and administrators of non-medical home care agencies was an eye-opener. They deal with issues that would cause many entrepreneurs to look for a fast food or vertical blinds franchise to invest in. Here are some of the conversations we overheard this week at the Home Care Association of America Annual Meeting in Austin, Texas. [Rowan provides a list of challenges faced  by employers at non-medical private duty home care agencies–topping the list being: “Turnover among non-skilled employees typically exceeds 100% per year” and, of those who that stay long enough to file for unemployment benefits and file a Worker’s Compensation claim–outcome are typically ruled in the employees’ favor and to the detriment of private duty agency owners. Attempts by private duty agency owners to use employee-tracking software such as an add-on smart phone app  offered by ClearCare to document employees’ work history and help mitigate Worker’s Compensation claims are not successful, as the author shows.]

• Turnover among non-skilled employees typically exceeds 100% per year.
• Missed visits by these employees are often unaccompanied by phone calls, to the patient or the office.
• Sick children and flat tires are the most frequent reasons for missed visits, accompanied by cell phones with dead batteries.
• Many employers have learned to track hours that are refused. Some Private Duty EMR software helps with this tracking effort.
• When an employee files for unemployment, a typical scenario unfolds in this manner:
  • Employer presents a long list of offers of hours that were refused.
  • Unemployment compensation is denied.
  • The former employee is contacted by an attorney out of the blue, who asks, “Were you ever injured on the job?” or “Do you have a sore back because of the work you did?”
  • The employee files a Worker’s Compensation claim.
  • The employer demonstrates that the employee never mentioned an injury, even a broken fingernail, in the past.
  • The judge gives the employee the benefit of the doubt and awards compensation.

A number of attempts have been initiated by software vendors to mitigate this problem. We wrote previously about an add-on smart phone app offered by ClearCare that asks every worker at the end of every shift whether they experienced an injury. One of the agency owners we interviewed for this report said she uses ClearCare and she uses that app. “It doesn’t help,” she said. “The judge says some injuries do not show symptoms for weeks or months. They always side with the employee.”

What sticks in the mind after a conversation like this is that every owner tells a similar story about why they become mystified at this behavior. “I love my employees,” many of them told us. “And they love me. We celebrate their successes and cry with their losses. And we pay them well.”

Ours has never been an easy task. Only those who get into it as a mission more than a business are likely to last.

©2017 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 Tom Moverman, Esq (of the Lipsig Bronx firm since 1989, which focuses on  personal injury,  products liability, and medical malpractice).

Patients put an enormous amount of trust in the hands of healthcare workers. Efforts to avoid breaking this trust must be continuously implemented. Nurses are required, both ethically and legally, to treat patients according to the standards of their profession. Unfortunately medical mistakes are most likely the third leading cause of death in the United States. Furthermore, ten percent of all deaths in America are said to be medical error related. In order to avoid nursing errors, following these standards, as meticulously as possible, is necessary.[Moverman identifies 5 areas of nursing care in which errors are prone and provides suggestions for avoiding these errors and improving patient care delivery.]

Double Check Every Procedure
In a study from the Journal of Nursing Care Quality, 68.3 percent of nurses remember making at least two to five errors over the course of their careers. The majority of these errors occurred when a doctor’s order form was too difficult to read or illegible. The second major cause of nursing mishaps was distractions from patients, coworkers, or events.

Statistically, the highest rate of nursing errors occurs with prescriptions. Dosage errors are committed at an alarmingly high rate. To prevent these types of errors, nurses need to check medications multiple times before they are administered to patients. If a nurse has any questions or notices something out of the ordinary, they must approach a doctor. There is no place for shyness in this profession.

Less than half of all nurses involved in the study indicated that they believe drug errors are only reported 45.6 percent of the time. This reveals that nurses are hesitant to report errors and may fear a medical malpractice lawsuit if they do. Unfortunately, not reporting errors can severely diminish patient care and prevent the improvement of future procedures. Miscommunication and lack of communication in a healthcare environment is highly detrimental to all involved.

Give Complete Reports
Hastily completed medical documents or documents that lack information are a huge cause of nursing mishaps. To avoid a medical malpractice lawsuit, nurses should be as prepared and concise as they can when talking with a doctor. A patient’s chart, a list of questions, and any suggestions should be available and ready before meeting with a doctor over the care of a patient.

Nursing errors frequently result from treatment miscommunication. In this situation, a nurse must be fully aware of all treatment methods. If multiple tubes need to be drained, if blood needs to be drawn every few hours, etc., a nurse must learn to communicate effectively with doctors to derive all necessary information. This collaborative environment must be reflected in all documentation and during in-person procedures.

Avoid Time Mismanagement
Time mismanagement is common in chaotic healthcare environments. Nurses may become overwhelmed and neglect patients or haphazardly fill out patient charts. To avoid nursing errors nurses must learn how to set priorities. A nurse must also realize the importance of flexibility and patience. Patients are present because they suffer from some sort of ailment. Remaining calm, collected, and level-headed is necessary during dire healthcare situations.

The most important time management skill for nurses is learning when to take a break. Healthcare workers work long, physically demanding shifts. It’s easy to often forget to take care of your own body as a healthcare worker. Fatigue, burnout, and other serious medical issues can all contribute to the productivity breakdown of a nurse. If a break is needed, it must be taken.

Limit Overtime
It is well-known that healthcare professionals work long shifts. Administrators may try to schedule workers for back to back or extended shifts and this is particularly common for nurses. To avoid nursing mishaps, it is important to give nursing staff an adequate amount of downtime.

According to a study in the Journal of Safety Research, all nursing errors were directly related to working more than 40 hours a week. Medication errors had the most consistent relationship to overtime. Ignoring nursing fatigue has been proven to cause nursing errors and, ultimately, a medical malpractice lawsuit. This information should be thoroughly considered when a nurse is scheduled to work overtime.

Do Not Understaff
In a study from the Journal of Clinical Nursing, 82 percent of nursing errors were caused by a hospital administration’s forced understaffing. Understaffing a hospital, or other healthcare environments is destructive to patient access and care. It is also a legal liability that can easily result in a medical malpractice lawsuit. Healthcare entities must schedule the right amount of staff for possible patient intake. They must also avoid treating staff unfavorably. Healthcare professionals work frequent shifts and shouldn’t be performing these shifts alone. To provide the best level of care possible to patients, professionals need to actively collaborate with each other.

In order to avoid nursing errors, nurses must actively take steps to adhere to medical standards ascribed to their professional behavior. Double checking every procedure, limiting overtime, alerting administration to understaffing, checking reports for completeness, and managing time correctly are all methods that will work to prevent nursing mishaps. In a profession where accuracy is key, nurses must be vigilant in maintaining efficient, effective, and error-free patient care.

Tom Moverman established the Lipsig Bronx Firm with Harry Lipsig and his partners in 1989. The firm’s focus is in personal injury, construction accidents, car accidents, products liability, and medical malpractice. Tom’s website is www.lipsigbronx.com.

©2017 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

• Reported Times will no longer be “perfect:” When your not using EVV, your time sheets will generally be “perfect.” Your caregiver will show up right when they’re supposed to and leave right on time. A visit scheduled from 8:00 AM to 10:00 AM will be recorded as arrived at 8:00 AM and departed exactly at 10:00. When EVV is added, these times will no longer be perfect. For example they might arrive at 7:56 AM and leave at 9:53 AM.
• You’ll need to “round” or “truncate” visits in accordance with the rules of your funding source: Most Medicaid programs have you bill personal care visits in 15 minute units. Some programs only pay for completed 15 minute units, while others employ rounding rules. A typical rounding rule is called the “rule of seven eigths,” which means that 7 minutes rounds down and 8 minutes round up.  Other rules apply too. For example labor laws often require you to pay for every minute worked even if you’re not able to bill for those minutes.
• Resistance to Change: In a typical organization, 20% of your workers will love and embrace EVV right away and 60% will be fine with it but the last 20% will be unhappy about it and come along “kicking and screaming.” The best thing you can do to prevent this is to make sure that the EVV system is easy to use and that you provide training and hand-holding in the early days.
• Caregivers will make mistakes: In the early days of your implementation, caregivers will forget to clock in or clock out or make other mistakes. When mistakes are made, it is likely that a time sheet, signed by the client will be required.

A Best Practice: The One Day Time Sheet

One best practice that we share is the idea of a one day time sheet. Most agencies who are on paper use a one week time sheet. Continuing with a one-week time sheet makes it too easy for your caregivers who are resistant to the new approach. They’ll just keep doing it the old way.

The idea of a one-day time sheet changes this. If the caregiver makes an error, you ask for them to fill out a time sheet for that one day and have the client sign it. Some agencies even mandate.that the time sheet be brought to the office that same day  This is a bit difficult, but that’s by design. If the caregiver has to fill out a paper time sheet and get it signed each time that they forget to clock in our out, they will quickly learn.

Ken Accardi, MBA, is the Ankota CEO. Sometimes referred to as the “Home Care Software Geek,” Ken founded Ankota to enable the next generation of home care.  Ken was previously a Chief Information Officer at GE Healthcare (NYSE:GE) and VP at Tele Atlas (sold to TomTom (AMS:TOM2)). Ken has also served as CTO for iGetBetter, MedNest, and Veritas Health Solutions (now iHope Network). Ken has been a keynote speaker at numerous national conferences (Medtrade, DecisionHealth), and a lecturer at Harvard, MIT, Bentely, Babson College and UMass. Ken also serves as a mentor for the MassChallenge accelerator. Ken has an MBA in Entrepreneurship from Babson College, an MS in Computer Science from Virginia Tech, and a BS in Engineering from Bucknell.

©2017 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

Many providers have been wondering about the future of Medicaid waiver programs, in light of the efforts by Congress to reduce Medicaid benefits and funding.  However, it appears that most of the waiver programs may be spared the sword this time around, and for some very good reasons.
At the most basic level,  it becomes an issue of cost and resources.  As the 65 million American “baby boomers” age into a health care system that is woefully inadequate to handle their needs, at least one truism is that: lowest cost solutions will win!  Today it’s all about cost reduction (often even at the expense of cost avoidance.)  This is good news for the waiver programs.[Cole provides a brief history of the federal governments creation of rules about seniors’ eligibility for Medicare and Medicaid services and types of services offered by both plans (to recipients known as  “dual eligibles”). The development  of managed care organizations (MCOs) as a means to manage the services provided through both Medicare and Medicaid is described to pay for and service dual eligibles. Additional, needed care services/benefits–known as Consumer directed services (CDS)–provided through Medicaid are also described in this article and in an extensive sidebar.]

When the federal government created rules that can make patients who are eligible for Medicare also eligible to qualify for state Medicaid (known as “dual eligible”), they achieve two huge benefits: 1) the patient becomes eligible for services not provided under Medicare, such as personal care services and homemaking, and 2) the patient is now in a cost split between Medicare and Medicaid (Medicare being 100% federally funded, while Medicaid is a 50-50 split with the states.)

With the groundwork in place for waiver programs and making patients dual eligible, states need a way to manage the waiver programs.  Since most of the waiver programs involve significant federal funding (that could disappear quickly) and are setup as “temporary” waiver programs, states have been reluctant to build out infrastructure and hire new state employees to manage them.  The solution most states are employing is hiring insurance companies to “manage the care.”  This model of course is known as managed care.

Under managed care, the state feeds beneficiary and authorization information to the managed care organization (MCO) that won the bid to run the program.  They in turn refer the beneficiary to an agency in their provider network.  The agency provides the services and bills the MCO.  The MCO adjudicates the claims and sends them to the state’s MMIS system for payment to the agency.

With the passage of the 21st Century Cures Act, by 2019 all of these services will be verified through electronic visit verification (EVV).  Under this funded mandate each state will create its own model for EVV compliance.

The term “managed care” now encompasses all non-medical homecare services.  Even private duty services are managed, but by the consumer rather than the state.

Waiver programs have emerged in many different forms, providing a plethora of different benefits combinations.  Some include skilled services and others don’t.  They are managed in every conceivable way, including consumer directed services, the fastest growing waiver programs nationally.

Consumer directed services (CDS) is the culmination of tinkering with new benefits until something sticks.  Under CDS, the consumer is the employer of record.  The agency is merely a pay agent for the state.  In some states, the agency has limited oversight and can assist the consumer, but issues of an agency “accidentally” becoming the co-employer by providing services such as training or scheduling for CDS attendants dramatically limit the role of the agency.

CDS is becoming the fastest growing waiver program in the country.  It’s a true win-win for all involved… CMS loves it because it saves a huge amount over skilled care.  The state loves it for the same reason, it’s the least costly program that there is.  The patient loves that their family member is now getting paid to do what they were doing all along, and the attendant loves that they’re finally getting paid for their work.  Even the agencies love the limited responsibility they have and the profits from the differences between bill rate and pay rate.

So, everybody wins.  Well maybe the patient doesn’t get the benefit of more highly trained homecare staff and the outcomes haven’t shown to be great, but it is the cheapest alternative for CMS and the state.  And in this age of lowest cost solutions, CDS certainly fits the bill.

Other managed care programs have similarly shown benefits in excess of their cost.  These are the darlings of the cost cutters and state legislators are finally starting to see that investing in non-medical waiver programs is a cost-cutting strategy for the state.  For all the above reasons, the future of waiver programs is pretty good.  Even the most conservative lawmakers have expressed an interest in “keeping what works” and that means the waiver programs.  Oh sure, the funding is bound to be changed and states will be tightening the Medicaid roles more than ever in an effort to reduce budgets, but it is very unlikely that any state can afford to cut out the waivers once the savings are reviewed.

 David Cole, CCP, is Ankota’s Chief Operating Officer. He is a seasoned veteran of the home care industry with over 25 years of experience. David co-founded StatChek, Inc., a pioneer in home care voice telephony, which was later acquired by Computer Outsourcing Services, Inc. (NASDAQ: COSI), today a part of Wi-Pro (NYSE:WIT). He was a part of the startup team at AccentCare, Inc., has founded and managed homecare agencies and served as the Medicare administrator for Interim Healthcare of Atlanta. He is also one of the principal developers of a novel model for post-discharge patient management.

©2017 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

Ginny Kenyon is one of the industry experts I learn from every time we speak. She is a principal at Kenyon Home Care Consulting, where she helps open home care agencies. Over the years, she has given Ankota valuable inputs on our software.  We at Ankota strongly believe that keeping elderly people healthy and comfortable in their homes (and out of the hospital) is an important step in the evolution of healthcare. Ginny is one of the pioneers driving moves in home health delivery. This is a methodology we learned from her. [Accardi provides 7 key steps that he recommends all persons follow who are initiating healthcare at home or hospice businesses.]

There are well over 12,000 home health and hospice agencies in the US, and the industry grew some 4% annually between 2010 and 2015 due to a rapidly aging population. For someone with an entrepreneurial spirit to meet the population’s healthcare needs, the homecare industry represents a real opportunity. But how does one get started? What is involved in creating a successful homecare agency startup? We have identified seven key areas of concern for every new homecare agency startup:

1. Vision and Business Plan
The first step in starting up your new home health organization is to formulate a clear vision of meeting community needs. A detailed community assessment gives you direction and your own background and focus will play into the decision.

There are many types of home health & hospice agencies, some focused only on non-medical daily living assistance for seniors and disabled persons, others equipped with nurses and therapists to take care of medical needs. To make your vision a reality, you need to think and put into writing a detailed business plan and find effective ways of marketing your vision to the community.

2. Licensing Issues
Step two in getting your home care agency startup off the ground is to obtain all necessary licenses. A good consulting firm will guide you through this complex legal process and use experienced senior consultants to expedite the licensure process.

Your agency will need to be incorporated with a Tax ID. You will also need to obtain a NPI (National Provider Identification) number with Medicare/Medicaid. There are differences in licensing from state to state. Expert guidance helps you properly prepare for your state’s rules.

3. Medicare Accreditation
Next, as a large portion of your reimbursements will come through Medicare (Parts A and B), you must go through the certification process. This involves a three-day Medicare survey in which your policies/procedures, record keeping, and clinical practice will be evaluated. Consulting trains and prepares you to pass the first time.

Often, agencies will choose accreditation from CHAP, ACHC, or the Joint Commission instead of the Medicare certification every three years. Accrediting bodies hold agencies to all Medicare Conditions of Participation as well as standards of excellence above and beyond those of Medicare/Medicaid.

Today’s healthcare industry requires advanced medical equipment and computerized record-keeping. An existing agency may update software systems as needed, however, a homecare startup agency should carefully select the most effective software program to meet their needs. Senior level consultants help with making sure agencies do not make the costly mistake of choosing the wrong software.

5. Preparation of Manuals
To run your agency smoothly from day one, you will need to develop customized administrative policy and procedure manuals, employee handbooks, forms manuals, and other important organizational tools. Optimizing your manuals can save you valuable time and money

6. Staffing Your Agency
So far, we have defined goals, removed legal barriers, and provided an organizational structure. This is like a naked skeleton. To put flesh and bones on this plan, you next develop effective recruitment and retention strategies. Hiring the well-trained and reputable staff members dedicated to providing top-quality care is key to fulfilling your mission. If you fail to fill your ranks with conscientious staff members, you could retain staff but fail to retain clients. On the other hand, retaining good managers may be a function of your overall policies and standards.

You can hire some staff directly full-time, some part-time, and contract out other specialists as needed. But you must do a thorough background check on anyone who will be working under you agency’s name, to protect patients, to avoid a possible lawsuit, and to protect your agency’s reputation.

<p7. ICD-10 ReadinessFinally, you should realize cash flow and reimbursement rates depend on efficient, accurate, and complete ICD medical coding practices. You need to train in-house coders or use a 3rd-party ICD-10 coding partner. Your clinicians need extensive documentation training to back up coders and keep everyone on the same page.

Do your homework before engaging a consultant. Look at the background of your chosen consulting agency. Do they have expertise in all the items you need to begin your agency? Find the agency that offers specialists in all areas of the process. Are you obtaining access to one individual or a team of individuals working for you?

Ken Accardi, MBA is CEO of Ankota, which he founded to enable the next generation of home care. Ken was previously a Chief Information Officer at GE Healthcare (NYSE:GE) and VP at Tele Atlas (sold to TomTom (AMS:TOM2)). Ken has also served as CTO for iGetBetter, MedNest, and Veritas Health Solutions (now iHope Network). Ken has been a keynote speaker at numerous national conferences (Medtrade, DecisionHealth), and a lecturer at Harvard, MIT, Bentely, Babson College and UMass. Ken also serves as a mentor for the MassChallenge accelerator. Ken has an MBA in Entrepreneurship from Babson College, an MS in Computer Science from Virginia Tech, and a BS in Engineering from Bucknell.

©2017 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 

Last week, in part I, Change Healthcare’s Amy Shellhart presented  important findings by healthcare at home researchers  presented in a  2016 article by Landers et al, titled, “The Future of Home Health Care: A Strategic Framework for Optimizing Value.” In part II of this article, Stellhart f ocuses particularly on two of the four keys to the future of home that the Landers et al article explored.  These key issues are: providing high quality patient care; and using technology-enabled care service delivery tools. 

Key #3: High Quality Patient Care
Above all else, home health organizations must ensure they can consistently deliver high quality care for their patients. Landers et al (2016) outlined several reasons why high-quality patient care matters more today than ever before. The researchers noted that professionals must provide care to an aging population who have limited incomes, and patients often have “multiple chronic conditions and ADL limitations” (p. 273). Home health care firms must be flexible and highly adaptive to the changes in the patient population (Landers et al., 2016).

Home health providers must consistently minimize costs of care while maximizing the quality of care. Home health organizations must focus on the acute and chronic medical conditions, but also on patient safety as it relates to medication safety, fall risk, and disaster preparedness. Organizations that provide efficient and effective care will create a competitive advantage that payers will notice. Payers will pick organizations that can demonstrate consistency in care “that allows patients to get and remain home safely” (p. 273).

Technologists design and develop systems with the functionality to assist you in documenting emergency preparedness information specific to individual patients. There are solutions that provide scrubbing analytics and managerial oversight to help ensure data is captured accurately. Analytics platforms can predict readmission/emergent care scenarios. Accurate data provides insight into a patient’s admission risk factors that can help inform the development of a care plan facilitate the best potential outcomes. Technology platforms for business and clinical intelligence are making it easier than ever for home health organizations to demonstrate to their value to referral partners.

Key #4: Technology-Enabled 
Technology-enabled refers to using technological platforms to gain new efficiencies that are not possible with traditional health care processes. The challenge with becoming technology-enabled is that it is a double-edged sword. Technology can improve health care coordination, improve quality of care, and make health care professionals more efficient, but Medicare does not typically reimburse for such technology (Landers et al., 2016).

If we know that technology can provide unique benefits that can create competitive advantage, then that same technology must deliver high value to make the investments worthwhile.

Recent industry analyses indicated that home health technology use is increasing. Analysts expect the number of consumers engaging in some form of home health technology to increase from 14.3 million worldwide in 2014 to approximately 78.5 million by 2020 (Tractica, 2015). Technology product categories include medical monitoring and management, remote consultations, eldercare, and health and wellness.

Deloitte analysts found that caregiver scenarios were most popular for consumers for remote patient monitoring (Korenda, Cruse, & Reh, 2016). Korenda et al. (2016) found that 40% of respondents said they likely would approve of sensor use for two caregiver scenarios: (1) location tracking; and (2) fall detection. One primary takeaway from these industry analysts is that companies implementing home care technologies must safeguard patient and caregiver information.

Remote monitoring has struggled to take a significant foothold in home health care. The reason for this struggle is the lack of financial incentives. If remote monitoring and other technological solutions in home health care are to become more ubiquitous, home health companies need to see a greater return in value from their technology investments. If Medicare will not reimburse for these efficiencies, then technologists must deliver technical solutions that make home health care processes more efficient while simultaneously lowering the barriers of entry for implementing such solutions.

Home health care agencies should focus on adopting technologies that exceed expectations. The goal of any such technology implementation should increase efficiencies, improve effectiveness, secure patient and provider data, and integrate with existing business processes. A goal should be to locate tools that are easy for clinicians to use while enabling better patient care. Time spent analyzing reports is inefficient and wastes resources. Technology tools should empower clerical staff and management to easily identify exceptions where intervention is needed. Directors and executives need technical solutions that tie key metrics to business processes so they can manage their enterprises and focus on strategy and building new business opportunities.

References
Korenda, L., Cruse, C. B., & Reh, G. (2016). “Will patients and caregivers embrace technology-enabled health care?” Deloitte. Insights. Retrieved from https://dupress.deloitte.com

Landers, S., Madigan, E., Leff, B., Rosati, R. J., McCann, B. A., Hornbake, R., . . . Breese, E. (2016). “The future of home health care: A strategic framework for optimizing value.” Home Health Care Management & Practice, 28(4), 262-278. doi:10.1177/1084822316666368

Tractica. (2015). “Home health technologies: Research report.” Retrieved from https://www.tractica.com/

Amy Shellhart is Vice President of Product Management, Change Healthcare. She can be contacted at Amy.Shellhart@McKesson.com 

©2017 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

Few businesses like the government telling them what to do or how to do it. That’s true in health care, as much as anywhere else. [Nonetheless,]  the new electronic visit verification (EVV) mandate is here and it’s not going away. Consequently, home care agency executives have three choices: 1. Fight it; 2. Embrace it; or 3. Move to a Caribbean island. Unless the flight has already been booked, we at Sandata believe EVV should be embraced, and by doing so, home care providers can drive incremental and quantifiable business value. And we’re willing to give readers six tips – which either maximize revenue or reduce costs – and therefore make it easier to love your EVV system.

Maximizing Revenue

Tip 1: Filling Missed Visits

Even if the federal government didn’t require EVV, it’s valuable for home care agencies to know when your caregivers are arriving and leaving – and more importantly, when you might be missing a visit entirely.  Even the best employees have issues from time to time, and the best patient schedulers make mistakes. EVV systems allow office managers an opportunity to catch issues via real-time alerts and to fill the missed visit quickly.

Tip 2: Be ready for the future: Capture Health Status Changes

Managed Care Organizations (MCOs) are increasingly expecting home care providers to capture and communicate health status changes of their members in real time. EVV systems provide caregivers the tools to easily communicate changes in a patients’ status, enabling the agency to request authorization changes which allow for a patient to receive more appropriate care, avoid costly acute care utilizations, and remain in their home, thus bringing in additional revenues.

Tip 3: Be ready for the future, part 2: Value-based Payment Models

Value-based payment models will continue to gain traction with MCOs, and home care agencies can use EVV to benefit from it. EVV software is a primary way to capture real time data in the home, and in fact, home care providers are going to have a hard time participating in the value-based payment models without capturing critical data at the point of care, which then allows for measuring outcomes and progress, sharing information with other providers and adjusting to the data.

Reducing Costs

Tip 4: Efficiencies in Scheduling, Claims, Billing and Authorization

EVV applications in the field can eliminate a great deal of paperwork required to support caregivers. Aside from automatically creating time stamps on when caregivers arrive and leave, the solution allows for the ability to record visit tasks, which saves time and eliminates the paper work associated with filling out time sheets or duty sheets.  Workflow efficiencies are also gained by eliminating the time associated with printing, mailing, scanning, and storing paper documents.  This access to real time data allows for daily billing (if desired) and no longer leaves the billing process dependent upon the paper being returned to the office.  Additionally, the EVV system can ensure services rendered are authorized, and even prompt caregivers to provide services that are included in the Plan of Care.

Tip 5: Streamlining Payroll for Caregivers

Paper-based timesheets are the bane of just about any employee who has to deal with them, whether it’s filling them out or recording them. EVV – by its very nature – creates major cost efficiencies here for caregivers and agencies. Each visit verified through the EVV application provides a digital record of the hours a caregiver has worked, the number of visits made, and time in-between visits. The data can easily be funneled into the agency’s payroll system, expediting payment, and the recording of all the associated information daily vs having to rely on a weekly timecard to be provided into the office.

Tip 6: Improve Standing as Employer of Choice, Lowering Retention and Training Costs

The less paperwork a home care agency requires from its caregivers, the more timely and accurate the data is.  The downstream effect also delivers a positive improvement on cash flow for the agency.   Caregivers don’t have to worry about missing a payroll run because of late documentation, which also leads to better agency/employee relations, lower turnover, and less recruitment and training costs for the human resources departments.

Aside from the following tips, the proactive use of EVV solutions also results in two byproducts, one that adds to revenue and another that reduces costs. MCOs are looking for “preferred provider” agencies which do more than just “check the box” with how they care for their members. EVV tools, when used to proactively manage cases, help agencies and MCOs communicate. Costs are reduced – and audit risks lowered – through the same proactive management, which catches mistakes, missed patients and allows for corrective actions in real time, all while offering protection for the agency against allegations of fraud and abuse.

About the Author: Tom Underwood is the CEO of Sandata Technologies (www.sandata.com), a national provider of electronic visit verification and home care management software solutions can be reached at tunderwood@sandata.com

©2017 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

“The Future of Home Health Care: A Strategic Framework for Optimizing Value” [which is the final report from the Alliance for Home Health Quality & Innovation, and which was published online on 10/20/2016 in Home Health Care Management 28 (4) and reproduced in: http://journals.sagepub.com/doi/full/10.1177/1084822316666368] discusses four key characteristics that  home health organization of the future must aim toward. It also discusses ways that Medicare-certified agencies must be positioned to be leaders in the home health market today and in the future. [The 4 key characteristics of today’s healthcare at home agencies are identified by the author as:

!) being patient- and person-centered and 2)  being seamlessly connected and coordinated.  Other key characteristics are 3) offerings high quality patient care; and 4) being technology enabled.  Shellhart provides details about how healthcare at home agencies as a whole and her employer– Change Healthcare (Brentwood, TN)–are aspiring to meet these key demands for future healthcare at home success. One example she provides is Change Healthcare staffpersons’ use of Doc Center– an EMR that helps connect at-home patients with other caregivers and in effect better coordinate the patients’ care at home. Other advantages of the Doc Center’s use  in helping to foster goodwill among referral sources are also described.  Finally, the author describes her company’s intention to help other healthcare at home industry players to build and promote their businesses successfully, especially through effective use of patient monitoring.]

Patient- and Person-Centered
The 2017 Home Health Conditions of Participation places a heightened focus on patient rights and the provision of written information for the patient on visit schedules, medication schedules, treatments and other pertinent instructions. The McKesson Homecare and McKesson Hospice clinical solutions have been enhanced with an updated plan of care document to help ensure attending physicians remain informed of their patients’ care across the post-acute care continuum. Our care planning provides an interdisciplinary, patient-centered approach to focus on patient preferences, needs and values. This approach encourages patient involvement and understanding of their clinical status to promote their overall health.

This year, we’re in discussions with a long-recognized vendor of patient education materials to bring our customers a customized patient education solution integrated with our clinical product. Our intention for this solution, Health E-U™, is to provide clinicians with access to tools, built into their workflow, that allow for the printing or emailing of education materials to patients and/or their families. Furthermore, our intention is to bring the tracking and results of that interaction into the plan of care to help demonstrate that your clinicians are providing education and reduce the amount of manual documentation they must complete.

Finally, we believe that a great way to help ensure that the patient remains in the center is with a patient/family portal. We’re actively working through the steps to make this a reality. As that solution unfolds, we intend to bring care plan information and patient education tools directly into the portal for patients and family to feel informed and connected with you as their provider of choice for their home health needs.

Seamlessly Connected and Coordinated
As the barriers to the approval of home health services are torn down (example: homebound status), home health organizations of the future will find themselves more responsible for the coordination of care. The patient’s home will be viewed as the central node. A significant focus will be placed on the transition of the patient from institutional settings to home. For home health organizations to successfully coordinate care and services across different providers, suppliers and services, they must be connected across the continuum of care, according to the article.

We at Change Healthcare are continually evaluating and updating our strategic approach to connectivity, making sure that it is considered, not as a singular solution, but embedded within our applications along workflow paths.

Doc Center is an example of a tool that can be used to help coordinate vital information in the care of the patient. By attaching documents to the patient record with Doc Center, it’s easier for clinicians and staff to collaborate regarding complex referrals to determine whether to accept a referral. This approach allows your organization to get a decision to the referral source quickly and helps ensure patients get the care they require in a timely manner. This approach benefits not only the patient but also helps to foster goodwill with referral sources and ensure that your organization is not accepting referrals that are costly to your bottom line due to locations, type of care required, payer or other factors.

Document Manager, new technology included in Release 14.1, serves as a centralized location for tracking and printing clinical documentation. It allows you to not only choose which documents you need to print and send for signature or for claims, but it also allows you to track documents within the software. Additionally, Document Manager lets you track documents based on number of days outstanding, admission/episode, insurance payer and more. This gives you the ability to prioritize outstanding documentation for follow-up based on items that are most important to your business. Examples include whether it is items holding up claims with the highest revenue or those that have been outstanding the longest. There is no need to track documents outside of the McKesson software manually or with another software platform.

Within our EMR, users have access to a continuity of care document (CCD). The CCD generated by McKesson Homecare not only includes vital clinical information such as medication, diagnosis and allergies, it also serves as a complete clinical summary of the patient. Capabilities such as secure direct messaging and membership in the CommonWell Health Alliance network enable us to easily exchange health information. This year we’ll extend the capabilities of our direct messaging as an intra-agency mail system that enables you to attach documents.

High Quality Patient Care
Above all else, home health organizations must ensure they can consistently deliver high quality care for their patients. While many studies point to the home care model as the least expensive care model, those models rely on that care preventing, or (worse) not causing, emergent or acute care admissions. As a result, home health organizations must not only focus on the acute or chronic medical conditions, but also on patient safety: medication safety, falls risk and disaster preparedness. Payers will pick organizations that can demonstrate consistency in care that allows patients to get and remain home safely, the article states.

This year we have designed and developed the functionality to assist you in documenting emergency preparedness information specific to individual patients. Additionally, we’re adding the OASIS Analyst™ solution to our portfolio, which provides scrubbing analytics and managerial oversight to help ensure the OASIS is answered accurately, as well as a readmission/emergent care predictor. An accurate OASIS and insight into a patient’s admission risk factors help inform the development of a care plan that facilitates the best potential outcomes. Furthermore, with our new McKesson Homecare™ Insight platform for business and clinical intelligence, we’ve made it easier than ever for you to demonstrate to your value to referral partners.

Technology-Enabled
According to market intelligence firm Tractica, the number of consumers engaging in some form of home health technology is expected to increase from 14.3 million worldwide in 2014 to approximately 78.5 million by 2020. The different product categories include medical monitoring and management, remote consultations, eldercare, and health and wellness.

In the 2016 survey of US Health Consumers, Deloitte found that caregiver scenarios were most popular for consumers for remote patient monitoring. Forty percent of respondents said they likely would approve of sensor use for two caregiver scenarios: location tracking and fall detection. Deloitte’s research suggests that companies implementing home care technologies should prioritize keeping the patient information safe, including the patient’s caregivers and ensuring a seamless user experience.

While remote monitoring has struggled to take a significant foothold in home health due to a lack of financial incentives, we believe that it will play a key role in the future of home health. Therefore, we’re researching and investigating what role we can—or should—play in supporting you in procuring and utilizing remote monitoring tools, as well as incorporating that data into the medical record to help bring the right information to the right people at the right time.

At Change Healthcare, we see it as our responsibility to equip you with an enterprise solution that not only meets, but exceeds, your expectations so that you can focus your efforts on building and promoting your business. Now, more than ever, you need tools that clinicians not only find easy to use, but want to use because they enable better patient care. You need to know that clerical staff and management have the tools to easily identify exceptions where intervention is needed rather than pouring through reports and data to do their jobs. Last, but not least, you need your directors and executives to be able to spend their time on strategy and building the business.

©2017 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

As payment models shift from volume to value, health care providers must meticulously document every step of their care plan and track results to prove they are providing consistent, high-quality care. Poor documentation carries severe financial penalties, including delayed or denied payments and fewer referrals from hospitals and physicians. Create a defensible documentation system that can withstand the scrutiny of auditors, watchdogs, and other health care providers.[Rowan provides 5 detailed essential components of necessary documentation of healthcare at home provided services under Value-based Care.]

Essential #1 – Take Documentation Seriously
Your agency may never have been audited, but be prepared for extra scrutiny. In July, Federal oversight investigators told Congress that CMS made more than $16 billion in improper payments to private Medicare Advantage providers in 2016. Officials also cited home health agencies for documentation errors, without specifically citing fraud as a reason for the problems:

CMS official Jonathan Morse did little to clear up any confusion over billing mistakes. In his written testimony, he said that improper payments are “most often payments for which there is no or insufficient supporting documentation to determine whether the service…was medically necessary.”

With billions at stake, the Office of the Inspector General’s 2017 Workplan promised more scrutiny for caregivers and insurers. The National Law Review warned, “Healthcare organizations are well-advised to review their internal audit and compliance plans on a regular basis” and encouraged providers to use the workplan as a guideline. One area of focus was “assessment of home health agency accurate reporting of patient information for recertification survey.”

Assemble a dedicated compliance team to perform random internal audits. That will help you identify and correct problems before regulators find them.

Essential #2 – Train Staff on Workflow Documentation & Management
Most documentation errors are mistakes – but costly ones if they result in denial. Staffers must know who is responsible for what and understand how to document care. Every new initiative like value-based purchasing and alternative payment models, brings new requirements.

Even long-time employees need regular training on new systems, billing codes, and basic instruction on completing new documents. The time and money spent on staff education and training is an investment in your success.

Essential #3 – Communicate With Stakeholders
The 2016 Pre-Claim Review (PCR) rollout in Illinois was rocky at best, partially because physicians weren’t adequately trained and informed about their roles in the process. A recent study by researchers at the University of Colorado School of Medicine highlighted communication problems between physicians, hospitals, and home health providers as a contributing factor to hospital readmissions.

“Many areas of care are disrupted by communication challenges, including disparities in medication lists, lack of clarity in who is responsible for writing patient care orders, inaccessible hospital records and resistance from clinicians to accept accountability.”

Better communication improves the patient’s quality of care, outcome, and satisfaction – all of which affect an agency’s CMS STAR rating. In some cases, agencies worked to help physicians and hospital personnel understand new CMS requirements and regulations. That kind of collaboration helps build positive relationships and improve documentation quality.

Essential #4: Maintain Complete Documentation – For Patients & Payers
Remember that the quality documentation you provide as part of patient care may not be enough to satisfy payer requirements. They expect you to prove that any care provided was “reasonable and medically necessary.” If you do not, the claim is denied.

Untimately, the more information you provide about the patient’s condition and progress, the better.  It is not enough to mention in a treatment note that patient “can walk unassisted for short periods,” for example. Instead, include objective measurements like “patient was able to walk unassisted from the bedroom to kitchen, a distance of approximately 20 feet.”  Each subsequent treatment note should track that progress as well.  The documentation taken as a whole should offer a complete narrative of the patient’s initial condition, progress, and outcome.

Consider the audience when telling this story. Trained health care professionals recognize jargon and acronyms. Government contractors or insurance company employees without medical training may not. Reports and notes should contain explanations that laypeople can follow and understand.

Essential #5: Improve Documentation and Communication by Leveraging Technology
Technology is a critical factor in defensible documentation. It places a patient’s medication record and treatment plan literally at your fingertips. Everyone works off the same plan and has the same information. This helps prevent avoidable problems like adverse drug interactions, conflicting provider instructions or denials due to incomplete documentation. But only if you use it!

New initiatives, such as value based purchasing, require communication and collaboration among caregivers.  As the American Hospital Association reported:

The current inability for electronic systems to speak the same language to one another and to efficiently and correctly transmit information – to be interoperable – is among the most pressing issues facing health care stakeholders today.

Even so, many small to medium-sized providers are reluctant to change systems, even when it may mean upgrading from a system that has been putting them in compliance jeopardy because of its lax standards. While they recognize the benefits, they worry about the system’s purchase and training costs. However, the cost of compliance-oriented software is a fraction of a single regulatory payment reversal due to inadequate documentation. What you are looking for is a cost-effective solution, not a cheap solution, that helps you move from clipboards to tablets, from spreadsheets to robust tracking. You must increase data reliability and meet the demands of new quality and payment models. You must be able to exchange patient data with other providers, using interoperability tools that connect users and referrers, including connection to large, hospital-based EMRs.

Defensible documentation is a straightforward concept. Problems arise from insufficient training, confusing regulations, and communication problems with other stakeholders. Be proactive to stop problems before they start.

©2017 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