Home Health MA plans
are they working?
Home Health is facing increased challenges to sustainable care delivery in the home. The latest from the increased co-pays being faced by many seniors as their premiums go up and their pension is diminished by rising costs to just live.
Premiums continue to rise, co-pays are now hovering around $50 per visit while the cost-of living and struggle to pay for medication and food have skyrocketed to an almost unaffordable level. More seniors are now homeless or being forced to live with family, many in their vehicles, with others draining their pensions at a rapidly increasing rate.
Home care is at the forefront of some of these challenges. Deductibles, pre-authorization, and now co-pays are forcing patients to make healthcare decisions that will ultimately cost all of us much more as patients are becoming sicker and seeking care later. This is the free world, land of opportunity - but we are fast equaling the third world in reduced care outcomes and homelessness.
Home care agencies are being forced to review prior authorization which is adding further delay for patients to obtain care resulting in many unnecessary rehospitalizations. With the increase in chronically sick patients, home health agencies are facing decisions on how much care can be provided when CMS may not pay for the services delivered and then they decline those patients with more need.
A study in the JAMA Health Forum showed MA recipients received fewer home health visits and functional outcomes were worse than traditional Medicare beneficiaries. The MA patient's average home health stay was 1.62 days fewer than that of the traditional Medicare recipient with fewer nursing, physical therapy, occupational therapy, speech therapy, and home aide visits! https://jamanetwork.com/journals/jama-health-forum/fullarticle/2815745?resultClick=1#xd_co_f=YjQxMzZjZTYtYTU3Yy00ZTkzLTkyYWUtZWI5ZjUyZTJhYzIz~
In comparison, MA patients are also more likely to be community-discharged despite living alone with fewer resources for continued support. This increases the likelihood of rehospitalization or caregiver burnout.
Cost-reducing tools used by the MA's are limiting the provider's ability to deliver necessary care and at the same time reducing the number of providers willing to participate in these programs as they negatively target star ratings - which have become an important tool for insurance companies when choosing to contract with a provider.
Home health is being impacted the hardest when it’s needed the most. Our seniors deserve better.
Hospice Plan of Care
Will it ever leave the CMS top 10 list?
To address the common deficiency in the Plan of Care cited by CMS surveyors, it's crucial to shift the clinician's perspective and focus. Here are some strategies to bring about a change in approach:
Patient-Centered Approach: Emphasize the importance of a patient-centered Plan of Care. Clinicians must view the plan through the eyes of the patient, ensuring that it not only meets medical needs but also aligns with the patient's preferences, lifestyle, and goals. How we think about this will alter the way we create the patient's plan.
1. WHAT IS THE MAIN SYMPTOM THE PATIENT IS COMPLAINING ABOUT -
USE THE PATIENT’S WORDS - NOT THE EHR TEMPLATE!
2. NEXT FACTOR THE PATIENTS TERMINAL DIAGNOSIS AND COMORBIDITIES
3. CONSIDER HOW CAN HOSPICE CARE MAKE A DIFFERENCE
CONSIDER CREATING A WORKING TEMPLATE such as the example below:
Terminal disease - Lung cancer
Primary symptom - The patient states he has difficulty breathing and is annoyed that his nose is sore from the Oxygen. He is frightened that he will die in pain and suffering.
The Hospice difference - Hospice will teach the patient symptom management using: medication, relaxation, use of oxygen, and spiritual support, provide remediation for the nose soreness and offer alternatives, education on how the disease may progress, what to expect, and how the symptoms that present will be managed to relieve his fears.
Use your EHR plan of care to help you create your plan. All EHRs offer a template set of options for problems, interventions, and goals. This is usually where the future citation begins as the clinician puts the boxed template into the plan of care without any editing.
CMS is looking for two things -
you meet the conditions of participation for quality of care
you meet the Medicare policy to ensure claims will be paid
We suggest your staff try a pilot program or even create a PIP, to only use the OTHER options to create their own POC. It will then meet all the requirements for CMS. (Review the State Operations Manual Appendix M, section 418.56b,c,d).
The initial plan of care must include evidence of:
The patient's involvement in its creation - Use the patient's name, not pt/caregiver.
Your problem statement should be something the patient would say not a nurse's words. It should relate to a visible problem for the patient - a symptom, a behavior, a wound, his feelings.
Your interventions must be related to the problem stated by the patient (name) if it is a wound your interventions will be to teach (who) about wound care, to provide wound care when the patient or caregiver cannot, to assess the wound with your professional opinion, to coordinate the care with the Physician and the IDG, involve the physician (orders, IDG meeting, assessments and maybe pictures), provide wound care products and maybe assistive devices, teach body mechanics to prevent worsening or additional wounds.
Patients' goals must be their goals and in their words - I do not want the wound to hurt during dressing changes, I don't want to die alone, I don't want to be afraid. All too often when auditing charts we see goals medication given as ordered, POC effective are recent examples.
Remember it's also okay for your plan to not work. A great plan is a moving target that constantly changes as the patient declines or new symptoms appear of the treatment plans/medications need to be changed. Keep your plans simple. Stop adding problem statements for everything on admission. Write a plan that you can document to, one that is real, and manageable. Take small bites at the patient's condition. Don't plan to teach everything on admission in your plan it's not achievable! Plan for the most important issues, address the plan over the next few days and weeks, and then resolve to focus on a new challenge.
Interdisciplinary Collaboration: Plan consultation with various healthcare professionals, such as therapists, social workers, and nutritionists, to ensure a holistic and comprehensive approach. Involve your team. Hospices must clearly show physician involvement with the patient's plan of care. It is not enough just to utilize the physician through the IDG meeting.
Measurable Goals and Outcomes: Create specific, measurable, achievable, relevant, and time-bound (SMART) goals within the Plan of Care. This approach not only helps in better documenting patient progress but also provides a clear framework for evaluation during surveys.
Regular Plan Reviews: Highlight the importance of regular reviews and updates to the Plan of Care. Revisit and adjust the plan as needed based on the patient's evolving needs and progress. This will demonstrate a commitment to ongoing assessment and improvement. Use the recertification and the IDG to reevaluate your plan. Can you clearly articulate the rationale behind each element of the Plan of Care, making it easier for surveyors to understand the clinical reasoning and patient-centered approach.
Evidence-Based Practices: Emphasize the incorporation of evidence-based practices in the Plan of Care. As professionals, clinicians need to stay updated on the latest research and guidelines, ensuring that their plans reflect the best available evidence for optimal patient outcomes.
By reframing the approach to Plan of Care and incorporating these strategies, clinicians will create a more robust and patient-focused care plan that aligns with CMS expectations and addresses the concerns raised during surveys.
Hospice - Is your documentation defensible?
Hospice compliance has quickly followed the CMS focus on Home Health in recent years. It's now our turn to be in the spotlight. Are you ready?
Defensible documentation is not about the volume of words or the eloquence of your creation, it must prove why the care provided was essential to an outside auditor. The adage; Each note stands alone is never truer today than when this was written many years ago. As clinicians, we have been trained that if we didn't document it, we didn't do it. Today, as we have moved from paper to electronic documentation attempting to be more accurate and timely a common theme has evolved. The boxes are dutifully checked and the comments are left blank!
Checking symptoms managed or no complaints will not stand up in court when an incident occurs to which you stated they haven't an issue or you just checked a box with no explanation. If you check a box that states arrhythmia, or shortness of breath for example, and say nothing else you cannot defend this in years to come (most legal cases are 5-10 years before any request for you to attend a hearing will be issued). You MUST use the comments boxes provided and describe what you see.
We all work for Medicare and are mandated to follow the conditions of participation - these are the rules we follow to get paid. The key here is your PARTICIPATION what did you do - what was its consequence? Checking boxes doesn't accomplish the PARTICIPATION directive by either the clinician or the patient. Claim denials are increasing based on your documentation and words or lack thereof.
What is your professional clinical opinion? The patient is actively participating -what does that mean? POC is appropriate - For who and what? Reinforce the POC. All of these statements we have seen in recent reviews of documentation!
Where is the patient in these notes? Use the patient's words - not yours to describe where they are in their progress toward the endpoint (goal). "I want to walk with a steady gait to the kitchen" - are not words a patient would use. Ask your patient how they feel. What they want! "I want to have pain 4/10" Hospice patients are more likely to tell you "This pain is killing me, it hurts, I want to go to sleep and not wake up".
Statement examples above appear almost daily in notes we review and in a court will NOT stand up!
Every note must tell the patient's story, explaining clearly why your care is essential and focused on the plan of care and terminal diagnosis. You don't need to write a book, just be specific, descriptive, and detailed, using the patient as your focus. Engaging your patient in this process is crucial, as EHR is now a part of the daily routine. Checking boxes and vague answers will result in denials of claims!
Clinical notes today have become vague and disconnected. How many of you document late at night over your dinner? You've now become separated from the situation and the documentation becomes sterile and inaccurate.
Consider a hospice patient admitted for COPD, you check the box short of breath and use Oxygen on admission 2-3 L continuously. Then move on to the next section and repeat a similar process until all the sections are complete. You select items from the EHR catalog of interventions and goals and paste them into your plan of care -every patient with the same interventions and goals word for word.
This doesn't meet CMS conditions of participation which states that "the plan must be meaningful and measurable".
The assessment is vague at best and will not give the auditor a picture of your patient and the severity of their illness and terminality.
Consider it's now time to recertify the patient -you didn't do this admission, the vital signs are pretty stable and he/she may have even gained weight (?edema) How can you compare today (the recertification) -to the admission if there is no description of the patient? REMEMBER the auditor never sees your patient. The picture painted in their review is solely based on your words. Auditors use their knowledge from their years of clinical review for the prognosis of a patient with your designated terminal disease. They rely upon the LCD (local coverage determination document) to guide them in their expectations for your plan of care. A patient in crisis on admission with symptoms needing to be managed should NOT have a frequency of 1w9 for the RN! We see this daily. Increase your frequency around the admission and tailor it down as their symptoms are managed, and increase again as they become symptomatic. A great frequency is always moving. eg: 3w1, 2w1, 1w7.
An example of defensible charting would be:
Admission COPD, RESPIRATORY SECTION Pt short of breath evidenced by an increased respiratory rate to 40, three weeks ago could speak without having to pause to catch his breath. On admission using Oxygen 2-3L continuously 1 month ago use of Oxygen was PRN. A recent respiratory infection has left him with continuous Oxygen use. He remains short of breath even at rest. Upon removal of the Oxygen, Pulse ox decreased to 85% after 2 minutes sitting in chair respirations increased from 40-50 with visible anxiety. Return of the Oxygen returned the patient to his baseline at this visit.
Plan of care -Intervention Patient BOB (include the pts name to personalize the plan) will remain comfortable with Oxygen at 2-3L continuously and the nurse will monitor for increased demand or anxiety from shortness of breath.
Goal - PT BOB states he wishes _______________.
Your plan of care must be specific and detailed with an endpoint on the journey (or goal). Plan for next visit wound care is NOT sufficient! But we've seen this. What kind of wound care and why, is the RN teaching the caregiver how is that progressing? These are the critical thinking skills and assessments that need to be visible in your documentation.
Your plan will hit a hard stop if a crisis happens in the home, the skill required is to now update and redirect your plan and then tell the audience why you just made the changes you did and what the consequences of these changes may be. Why are you there? Why does this matter? It is okay to resolve a plan of care item for a goal unmet so long as you state why. Maybe this goal cannot be met if the caregiver struggles to be taught, do you need to use pictures and demonstration v words? Resolve this goal and create a new one to better meet the needs of your patient/caregiver. Use names whenever possible; Patient BOB caregiver SUSIE now you've met a condition that your plan is personalized!
We challenge you to document in 50% of your homes and engage the patient, each week trying to increase the in-home documentation. Edit and complete the notes after-hours if you must -editing is much easier than completely documenting late at night.
Take credit for the work you're doing and the benefits you made to that patient's life and care.
Hospice patients only die once!
Make their journey the best it can be!
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2023 Final Rule -Home Health summary
The Final Rule was released on November 1, rushing in like our current winter season- some like snow some do not! Whatever your preference this will have a lasting impact in our beloved industry, and for many, reduce patient access to care at home.
In summary, the CMS rule will provide a 0.8% increase in payment. However, deep cuts are hidden in the details. On top of the permanent rate cut in 2023 of 3.95% CMS added another reduction of 2.89% for prospective payment adjustments. When combined; the total payment increase is only 0.8% as the adjustment is not applied to the LUPAs.
CMS published a fact sheet where they describe the reasons for the prospective payment adjustments (2.890%), as a result off assumed behaviour changes and PDGM implementation. The final rule has added changes to the PDGM case mix weights and LUPA thresholds. CMS now requires Home Health agencies to meet or exceed 90% for all required OASIS submissions.
Changes to clinical groupings is seeing an overall decrease in 7/13 measures ranging from 0.2%-1.9% with the greatest decrease being in the MS rehab grouping. HHRG scores saw a majority decrease ranging from 0%—5% with only 12 measures seeing the greater than 5%.
The rule describes the CME perception that huge profits are being made at the expense of patient care. Agencies are struggling to recruit and retain staff and the cost of expenses continue to rise to meet market demands. In addition, agencies are going to need to be ready for proposed payment reductions based on their perfomance.
CMS has revised the baseline year being used to determine payments as 2023 from 2022.
Takeaways from the rule
• PDGM recalibrations of case mix weights
• Payment increase of 0.8%
• Revision of VBP measures to start in 2025 CY
• Change to VBP baseline year to 2023 CY for performance year 2025 CY.
CMS has targetted adding new elements for future initiatives
• cognitive functioning and behavioral health
• performance measures focused on stabilization and maintenance in chronic diseases
• social risk factor assessment
• focus on COPD patients
• monitoring of utilization of Home Health aides
Key reminders from the 2023 Final Rule
OASIS for ALL payers will begin January 2025
Reporting purposes will utilize all data starting July 2025.
As care delivered in the home is the future of healthcare and agencies operate on a fixed income they are being asked to do more with less. Excellence in staffing management, document oversight and review will all be key factors in an agencies survival.
For more information on our services, reach out to us today and discover how we can assist you on your health journey.
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2023 Final Rule - Hospice summary
The Final Rule was released on November 1, 2023. Whatever your preference this will have a lasting impact in our beloved industry, and for many, reduce patient access to care at home. CMS has released a fact sheet to accompany the ruling. Agenices are breathing a sigh of relief that we didn’t get the predicited cut. However, the elephant in the room is that CMS believes behaviours have changed in the industry and the focus moving forward is to look at service utilisation, use or lack of use of Hospice aides for example, frequencys that are not determined by symptoms but agency standards and fraud and abuse in agency ownership.
The key take aways are detailed below. Please ensure you read the entire ruling as it applies to your area of healthcare.
Specific to Hospice the following changes will be seen:
• Addition of the Marriage Family Health Therapist and Mental Health Counsellor instead of the MSW in the IDG. These therapists /counselors must be employed directly by the hospice FT, PT or per diem.
• May 1 2024, the hospice certifying physician will be required to enroll in Medicare or formally opt out.
• The hospice cap amount for FY 2024 is $33494.01 which is similar to 2023 Fy cap amount which was held at $32486.92 an slight increase of 3.1%.
For those agencies who participated in submitting the required quality data they will receive a 3.1% payment increase.
Hospices who participated will see their -
RHC 1-60 raised from $211.34 - $218.33,
RHC days 61+ raised from $167.00 to $172.35.
o Continuous care full rate (24hrs) will raise from $63.42/hour (2023) to $65.23/hour.
o Respite in patient raises from $492.10 (2023) to $507.71
o GIP increased from $1110.76 (2023) to $1145.31.
For those who failed to submit they will see a decrease of -0.9% (3.1% - 4%).
• Telehealth services – the statute expired in May 2023 and the final rule related to subsection 418.204 of the COP’s CMS removed subsection (d) to eliminate the use of telehealth technology during the PHE.
• The Public Health Emergency also allowed for Face to Face encounters to be performed using telehealth. This statue will expire on Dec 31, 2024.
CMS also reported on the utilization of the HQRP (Hospice Quality Reporting Program) among hospices, revealing that 18% of all eligible Medicare-certified hospices were non-compliant and will consequently face an APU payment reduction.
FUTURE FOCUS AREAS revealed in the final rule include:-
The OIG has identified many smaller agencies with a common ownership. Background and fingerprinting is now required for all new owners and administrative level employees in an attempt to combat this perceived fraud. The OIG also detailed the many agencies that have been granted licenses, some having never taken a patient into care, then selling the license for a hefty profit. To combat this the final rule stipulates that a license cannot be sold or transferred for three years from issue.
Agencies will also be under claim review. Any license that has not seen activity in a 6 month period may be subject to revocation due to inactivity.
A 2018 OIG report found that hospices were incentivized to admit ineligible patients and to provide minimized services. CMS has created an algorithm based on Hospice survey scores, the Hospice Care index overall score and CAHPS to closely monitor the poorest performing hospices. They will also be auditing beneficiaries of the Hospice Medicare benefit to ensure eligibility and to reduce false certifications of terminal illness.
CMS has also committed to developing methodology to incorporate health equity into the hospice care model. More on this will follow in future months.
Rising living costs, staffing shortages, and incentives for staff retention are challenging hospices. Many smaller agencies have be acquired in a merger or acquisition by corporations created outside of the Hospice space traditionally, like Optum /United Healthcare or Humana. This shift from community-focused, charitable hospices to corporate entities raises concerns about the industry's future direction.
Given the increasing importance of home-based healthcare and agencies operating on fixed incomes, efficiency is crucial. Successful staffing management and meticulous document oversight are vital for survival. Familiarity with HQRP and CAHPS scores, regular monitoring, understanding completion rates, and implementing improvements are essential for agencies.
At QA Professionals, we recognize the operational focus required for success. Our servant leaders, with extensive hospice experience, understand CMS expectations, plan of care, OASIS, eligibility criteria, claims submission, RCM, and documentation standards. We're committed advocates and partners in your health journey.
To learn more about our services, contact QA Professionals https://admin@qaprofessionals.org today for assistance in navigating your healthcare challenges.
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DISCHARGE PLANNING
New Year, New CMS audit focus.
Will you pass this review?
All patients both Home Health and Hospice should have a goal-based discharge plan created on the day of Admission. Stories of citations and survey deficiency are being told by agencies large and small who are not following the CMS guidelines for care delivery. Every patient in Home Health or Hospice should have a discharge plan created within 5 days of the Admission. The single biggest reason for rehospitalization is unclear expectations by the patient unit and a lack of a care plan with defined goals.
Patients/Caregivers must be involved in the creation of their care plan. Clear goals must be developed and the patient and caregiver involvement documented.
For Hospice patients:
What do they want their death to look like?
Where do they want to die?
Who will be involved?
Do they have religious or spiritual preferences to be followed?
What support may the caregivers need?
What medications may be required to treat expected symptoms?
Do you discuss discharge at every IDG?
Is the family unit prepared?
For Home Health patients:
Is the trajectory to discharge planned and documented ?
What are their expectations?
What improvement measures will the agency monitor?
Is the patient's progress toward goals documented at EVERY visit?
Do you use a roadmap with the patient to guide them on the journey to self-care?
Are the goals set realistic?
Do you show collaboration across disciplines for the discharge?
Do you document to teach back processes to ensure patients/caregivers understand the teaching given to them?
As discharge looms do you hold a care conference with the patient unit and the clinicians?
Does the patient unit have the right equipment, supplies, and medications on hand at discharge?
MAXIMIZE THE POTENTIAL OF YOUR INTAKE TEAM
Intake may be your company’s weakest link. How and why you should maximize their potential?
Staffing challenges continue to be a huge concern for many agencies with many filling the intake department with non-clinical employees. Sales teams may be driving referrals that are not triaged. New regulations require greater details about the patient to be in your records -items such as immunizations, medications, and procedure dates; which many patients cannot provide.
Intake may currently be your weakest link but greatest unused asset!
Consider utilizing intake to call physicians’ offices to obtain labs, immunizations, test results, and medication lists, before the nurse goes to admit the patient. This will save many hours positively impacting revenues and reducing staff burnout. The Home Health OASIS now requires these items to be documented on every patient.
Using clinicians in intake can help triage the referral. Do the Face-to-face and progress notes detail why this patient is being referred to Home Health and the treatments ordered? Is the referral valid for the reason the patient is being seen in the home and does the progress note agree? Simple higher-level triage can save the admission team many hours in research or documentation enhancement and or correction later.
Create checklists of items required for the OASIS which could be collected during the intake process. DR orders, labs, results, procedure dates, medication lists, names, and contact information on the legal representative, scheduling the admission with all necessary parties present, allergies.
Triage the patient records at admission for the potential to recertify, prevention of LUPA, or re-hospitalization.
Intake can aid in revenue by calling facilities and hospitals to determine if the payer for the bed they are in is skilled or non-skilled.
Do you have comorbidities listed to support coding?
Is the patient on an antibiotic? Have they had an infection reported in the last 60 days?
Does the patient have an Advanced Directive and what does it state?
Intake can become your greatest asset and should not be your weakest link!
Are patients sicker when they leave a hospital?
Since Covid and the introduction of PDGM, some agencies are seeing referrals increasing with sicker and more complicated patients.
What does this mean for your agency?
PDGM divides Home Health care into episodes for timely payment and initiation of care delivery. Timing of care is critical to ensure payment. However, discharge planning by the hospitals can be delayed or even duplicated with patient referrals being sent out via AI-driven programs to multiple agencies who then can cherry-pick the referrals. If your agency doesn’t purchase one of these programs then you are relying on less timely referral methods which can often result in smaller agencies getting the bulk of the more care-intensive patients and with them comes the increased risk of rehospitalization and a potential LUPA!
Timely admission is critical -scheduling this around the patient’s discharge can be challenging as they arrange for equipment, receive medications, await family, etc., and the agency triages the referral documents.
Having a focused review process and an educated intake team can dramatically aid the admission process. Intake can ensure the admission is timely and smooth obtaining labs, results, orders, immunization records, comorbidities, and medication lists. Obtaining pre-authorization from commercial insurance can be a challenge again delaying timely access to care, increasing the risk of rehospitalization or the patient’s decision to even seek Home Health care.
The “Improving Seniors’ Timely Access to Care Act of 2023” https://www.congress.gov/bill/117th-congress/house-bill/3173 is designed to reduce some of the burdens in the authorization process by mandating a move to electronic prior authorization for Medicare Advantage Plans. This still requires a comprehensive review by the Agency to ensure care is delivered to the skill and progress notes from the physician’s orders and documents.
As staffing challenges continue to mount outsourcing your document review process is an excellent way to manage costs and ensure documentation meets the skill defined in the physician’s order and the clinician’s documentation is clear in defining the skill and plan of care to meet the goals for maximum improvement.
Exciting changes have arrived for Hospice care with the Final Rule 2023 approving the addition of the Marriage and Family Health Therapist and Mental Health counselors to the IDG team.
The CMS Conditions of Participation (COP) have been amended to include Marriage and Family Therapists and Mental Health counselors in the IDG team. So what does this mean for your agency?
Marriage and Family Therapists and Mental Health counselors are licensed professionals who can provide necessary counseling services as required in the Hospice COP's and play a role in developing the Plan of Care. Beware the COP also states the patient MUST have access to Social services and that these additional are not instead of! The Marriage and Family Therapist or Mental Health Counsellor cannot fulfill this requirement. Hospice must still have a Social Worker with a Master's in Social Work as the Supervisor for an LMSW or be the direct care provider.
They can be named in the IDG and then be a part of the patient's plan of care and complete a comprehensive assessment. If they are not part of the IDG they cannot perform these tasks.
They can be salaried, hourly, or per diem employees with the key being they must be DIRECT EMPLOYEES with a W2.
https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/bp102c09.pdf
They may also serve as Volunteers as Volunteers although non-paid are considered in the COP as an employee.
Hospices are required to have at least one of the three practitioners listed (SW, MFT, or MHC) as a member of the IDG. Note that a hospice must employ a SW as medical social services furnished by a qualified social worker are considered a core service under the Condition of Participation (see 42 C.F.R. § 418.64(c)). Please see the 2008 final rule, “Medicare and Medicaid Programs: Hospice Conditions of Participation” for details regarding medical social services at https://www.federalregister.gov/documents/2008/06/05/08-1305/medicare-and-medicaidprograms-hospice-conditions-of-participation (73 FR 32088)
The Marriage and Family Therapist and or Mental Health Counsellor do not need to enroll in PECOS if they only work for your hospice.
The Marriage and Family Therapist and or Mental Health Counsellor will not need supervision unless it is written into your policies.
QAP LLC -asking great questions = great answers!
We are your experienced document review team. Our industry leaders have years of experience directly in Home Health & Hospice. Let us help you.
