Vijaya is a Healthcare Expert at Nalashaa and has experience in business transformation, payer-provider integration, product design & implementation and healthcare system evaluation & selection. She has been actively involved in Meaningful Use, PQRS, HHVBP, CPC+, CCM and MACRA implementations and has extensive exposure to Clinical and Financial areas of the US healthcare ecosystem.
Vijayalaxmi Kudekar
HOME HEALTHREGULATIONSEHR vendors need to update offerings to accommodate federal regulations and assist providers with value-based care.
OverviewStarting January 1 2020, the Home Health Prospective Payment
System (HH PPS) may have a drastic change, which proposes
case-mix methodology re�nements and parameters are de�ned
under the rule released last year for Home Health Grouping model
(HHGM).
This proposed rule; also called the Patient-Driven Groupings
Model for Medicare home health payments, primarily relies on
patient needs, rather than a therapy threshold to determine the
reimbursement. It helps advance the Trump Administration’s
Meaningful Measures initiative which represents a new approach
to quality measures that foster operational e�ciencies, and
reduce costs of collection and reporting during quality measure-
ment.
As per the press release by CMS, the cost impact related to the
updated data collection processes is estimated to result in a net
$60 million in annualized cost savings to HHAs, or $5,150 in
annualized cost savings per HHA. This is because of the proposed
implementation of PDGM and the proposed changes to HH QRP
that will be e�ective from the beginning of the CY 2020.
Major highlights of the rule
Case-Mix Adjustment changes – including a change
in the unit of payment from a 60-day episode of care
to a 30-day episode of care.
Introduction of Home Infusion therapy - includes
“Remote Patient Monitoring” cost under Medicare
home health bene�t
Changes in the Home Health Value Based Purchas-
ing (HHVBP) model
Changes in the Home Health Quality Reporting
Program (HHQRP) requirements
Promotion of Health Information Exchange
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Case-Mix Adjustment changesTo adjust for case-mix, the HH PPS uses a 153-category case-mix classification system to assign patients to a home health resource group (HHRG). This includes the national, standardized 60-day episode payment rates, changes in the national per-visit rates (HIPPS code calculation), and adding non-routine supply (NRS) conversion factor with the base rate. The clinical severity level, functional severity level, and service utilization are computed from responses to selected data elements in the OASIS assessment instrument and are used to place the patient in a particular HHRG. Each HHRG has an associated case-mix weight used in calculating the payment for an episode. Therapy service use is measured by the number of therapy visits provided during the episode and can be categorized into nine visit level categories (or thresh-olds). For more details on HHRG calculation and updates in case-mix adjustment, please click here.
Remote Patient MonitoringThe CMS has proposed that home health providers would be able to include the costs of remote patient monitoring as an allowable cost in home health agency’s cost report.
Although home health providers would not be directly reimbursed for the installation and use of equipment, CMS uses cost reports to determine if the home health providers are being paid appropriately. Currently, remote monitoring technology could not be included in these cost reports, and officials say that the change could incentivize broader use of technology improving care through access to real-time data. This would allow home health agencies to report the costs associated with technology, including infrastructure upgrades and equipment, as well as wage and labor costs associated with using the equipment.
Home infusion therapy is a treatment option for patients with a wide range of acute and chronic conditions, ranging from bacterial infections to more complex conditions such as late-stage heart failure and immune deficiencies. It provides improved safety and better outcomes since it is given at patient’s convenience and at home.
This includes nursing services furnished under Conditions of Participation (CoPs) in accordance with plan of care, patient training and education, remote monitoring services for the provision of home infusion therapy and home infusion drugs furnished by a qualified home infusion therapy supplier.
Diseases that may require infusion therapy include infections that are unresponsive to oral antibiotics, cancer and cancer-related pain, dehydration, and gastrointestinal diseases or disorders which prevent normal functioning of the gastrointestinal system. Other conditions treated with specialty infusion therapies may include some forms of cancers, congestive heart failure, Crohn’s Disease, hemophilia, hepatitis, immune deficiencies, multiple sclerosis, and rheumatoid arthritis.
Infusion therapy originates with a prescription order from a physician or another qualified prescriber who is overseeing the care of the patient, and is sent to a home infusion therapy supplier, which is a state-licensed pharmacy, physician, or other providers of services or suppliers licensed by the state.
Admission source
Community or institutional source; the period is placed into 1 of the 2 groups
Low, medium, or high; the period is placed into 1 of the 3 groups
Functional level
An episode will be calculated based on the following five categories
Timing Early or late; the period is placed into 1 of the 2 groups
Clinical grouping
Musculoskeletal (MS) rehab, neuro/stroke rehab,
wounds,
Medication Management Teaching and Assessment (MMTA),
Behavioral, or complex nursing care; the period is placed into 1 of the 6 groups
No or yes; based on the secondary diagnosis;
The period is placed into 1 of the 2 groups
Comorbidity adjustment
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There are three areas to demonstrate that home infusion therapy
program meets the accreditation organization’s standards:
Ensuring that all patients have a Plan of Care from the
physician including the need for prescribed infusion
therapy
Having respective procedures to ensure remote
monitoring services are provided
Having procedures to ensure that patients receive
education and training on the e�ective use of medica-
tions and equipment at home.
The CMS envisions that this would allow patients to share real-time
data with caregivers and push providers to use technology to track
clinical data for monitoring and analysis.
Home Health Value Based Pur-chasing ModelThis model aims to provide incentives for better quality care with
greater e�ciency, study potential quality, and e�ciency measures for
appropriateness in HH setting and enhance the current public report-
ing process. There is a change in the number of states providing
services under this model. Now, all the Medicare-certi�ed HHAs
providing services in nine states - Arizona, Florida, Iowa, Maryland,
Massachusetts, Nebraska, North Carolina, Tennessee, and Washing-
ton (competing HHAs) are required to compete in the Model.
The CMS proposes to remove two OASIS-based measures, “In�uenza
Immunization Received for Current Flu Season” measure, and the
“Pneumococcal Polysaccharide Vaccine Ever Received” measure from
the set of applicable measures. It will
Replace three OASIS-based measures with two
proposed composite measures on total change in
self-care and mobility.
Amend how it calculates the Total Performance Scores
by changing the weighting methodology for
OASIS-based, claims-based, and HHCAHPS measures.
Rescore the maximum amount of improvement points.
A major change is also seen in the payment adjustment, starting this
year, and the weighting methodology. The payment adjustment will
be increased incrementally over the course ranging from 3% to 8%
for the CY 2018 to 2022. This is given based on each HHA’s Total
Performance Score (TPS). Here is a quick snapshot on the current and
proposed weight.
The TPS will now be scaled to 90% of the score and an additional 10%
will be given to the new measures. Besides this, there will be changes
in the OASIS based measures.
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OASIS
56.25%
35%
Current weight
Proposed weight
12.5%
30%Current weight
Proposed weight
Claims
31.25%35%
Current weightProposed weight
HHCAHPS
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Home Health Quality Reporting ProgramTo put patients �rst under Meaningful Measures initiative, the CMS
proposes to remove the following measures out of the current 31
OASIS measures. This o�ers an opportunity for HIT vendors to simpli-
fy their solutions and make life a little easier for HHAs:
Depression assessment conducted measure
Diabetic foot care and patient/caregiver education
implemented during all episodes of care measure
Multifactor fall risk assessment conducted for all the
patients who can ambulate (NQF #0537) measure
Pneumococcal polysaccharide vaccine ever received
measure
Improvements in the status of surgical wounds
measure
Emergency department use without hospital readmis-
sion during the �rst 30 Days of HH (NQF #2505) measure
Re-hospitalization during the �rst 30 days of HH (NQF
#2380) measure
Two new measures are planned to be introduced and the CMS
intends to specify the measures no later than Jan 1, 2020, which will
be adopted in the beginning of Jan 1, 2021.
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There is no change
in the HHCAHPS survey
requirements.
Health Information Exchange
The CMS aims to focus on advancing the health informa-tion exchange. The IMPACT Act requires assessment data to be standardized and made interoperable to allow exchange of data among providers and patients. For post-acute care, CMS is developing Data Element Library (DEL) to serve as a publically available, centralized, authoritative resource for standardized data elements and their associated mappings in health IT standards. OASIS is one of the assessment items included in DEL by CMS. The DEL database includes post-acute care (PAC) assessment questions and their response options, as well as other associated details including the assessment version, item labels, item status, copyright information, CMS item usage, skip pattern information, lookback periods, and linked health IT standards.
For more details on interoperability, please refer to our CoP whitepaper.
Health Information Exchange allows health care profes-sionals and patients to appropriately access and securely share a patient’s med-ical information elec-tronically.
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Areas where technology helps providers cope with the new changes
Areas where technology helps providers cope with the new changes
Document Management
Document Management Solution to consolidate documents and promote interoperability
Absence of structured documentation including plan of care and clinical docu-ments that HHAs need to maintain costs agencies time and money. To allow information exchange through remote monitoring, patients should be able to send documents as part of emergency preparedness plan mentioned under CoPs.
By systematically managing documents using technology, providers could focus on patient care. Besides main-taining the clinical records, a discharge or ToC document can help with a smooth transition.
Plan of Care
Quick information exchange through digitization
Inefficient data management is adversely affecting assessment and quality of care for HHAs. If the HHA sees any major problems while provid-ing care, the aide can send the plan of care and the results of plan to the physician to understand the gravity of the situation and administer proper care.
Digitization will enable quick informa-tion exchange and decisive actions promoting enhanced healthcare quali-ty. To facilitate communication with an HHA and a physician, the systems used by both should be interoperable. To do so, the HHA’s EHR can send CCDA docu-ment to the physician’s EHR. Most physicians have ONC certified EHRs, so the complete loop is automated.
For more details on Plan of Care, refer to CoP whitepaper.
Identity ManagementEMPI solution to detect duplicate records
Duplicate records provide a splintered view of patient’s medical history, leading to unnecessary services/tests putting the patient at risk. In addition, many denials are due to the inability to identify patients correctly based on the data provided.
A carefully implemented EMPI solution can help HHAs to minimize the expens-es related to unnecessary tests/proce-dures, record maintenance costs and the possibility of lawsuits.
Digitized and Structured Assessments
DEL to create an electronic, distrib-utable, and centralized
resource of CMS assessment data
Historically, assessments have been a choice that
different HHAs exercised differently causing problem with
a lack of standardization. It is almost impossible for HHAs to have a number driven approach to gauge improvement across patients due to the subjectivity and variety of these
assessments.
DEL, is an opportunity for HIT vendors to eliminate
the hassles associated with subjectivity and
variety of assessments, and bring a structure to unstructured data. Through this, HHAs will be able to compare improvement in a patient’s condition across time horizon and patients with relatable situations/conditions.
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Analytics
Track patient progress to get actionable insights
A major risk faced by the HHAs is the lack of insight into quality of care and patient progress resulting in negligence in care. To provide better quality care and focus on outcomes, Home Health agencies should look at building analytics capabilities using data they already have from the ecosystem.
Tracking patient progress becomes a major component under the QAPI as it provides actionable insights by tracking quality indicators. This aids in analyzing the quality of care and rectify-ing negligence in care or investigating allegations on negli-gence in care. Dashboards can be configured to track measur-able outcomes and improvements, which would provide insights for the providers as well as motivation for the patients.
Clinical Decision Support (CDS)
Enhanced health related decisions to improve healthcare delivery
For HHAs, numerous decisions made on a daily basis are not only exhaustive but also entail risks of lawsuits. Human cogni-tion is subjective and need not be accurate which calls for the need of technology for assistance.
An EHR supporting CDS can support your staff through suggested interventions triggered based on every agency’s context. They can be provided with a checklist for better care decisions and alignment with QAPI requirements. More on QAPI, here.
Patient portal
Advanced health information engagement to enhance care management
Patients get the most effective care when they collaborate with caregivers. Absence of an elaborate patient-centric approach can cause decline in health outcomes and revenue while increasing manual labor. To address this, Home health EHRs should start exposing the information or provide a portal to the patient so that everything is electronically main-tained.
Patients get the most effective care in a patient centric system where they acquire better awareness through complete care details. Patient portals could be enhanced to empower patients by allowing them to track the progress of care, upload shareable health information document, send complaints, make payments or initiate transfers to another home health agency easily.
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Interoperability with DevicesRemote Monitoring devices to reduce quantity of care while maintaining quality
Attending to all patients 24/7 is a waste of time, resourc-es, and revenue considering the varied level of care required by each patient. In the absence of a definite way to measure the amount of attention required, justification of care and hence, the expense are often questionable.
Remote patient monitoring is an effective way to reduce quantity while maintaining quality as it focuses on ‘man-agement by exception’. Advancement in the technology has empowered HHAs’ staff to spend their resources in a more productive manner. With remote monitoring devices, HHAs can track patient movements, measure vitals, monitor sleep patterns, detect fall and so on. Via interoperability, the immense data collected by the device could be analyzed for insights using analytics.
Social risk profilingIncreased patient participation for effective clinical actions
With the US healthcare industry’s relentless pursuit of value-based-reimbursements, there are efforts to stratify reasons and find the root cause behind rising cost. Recent findings are suggestive of a correlation (if not causation) between social risk factors and patient outcomes. While a lot of providers in the acute space are concerned with what happens within the settings, HHAs live in a very different context. They have little or no control over what their patients do in the absence of HHA aides.
A closer look at these softer aspects of a patient may offer significant insight into patient context and behav-ior. With this, they can tweak their care provisioning to invite more participation from patients, thereby improving the effectiveness of their clinical actions.
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ConclusionWhile technology isn’t the complete solution for problems that HHAs face, it is certainly an important lever that can be used to overcome their challenges while staying compliant with regulations. It’s true that HHAs know their context and business better and understand the chal-lenges too. However, many a time in the past, several industries have solved their challenges in unconventional ways borrowing ideas or concepts from entirely disconnected industries. Perhaps, new standardization and compliance requirements will help HHAs with interoperability and quality of care for patients and reduce the burden of different regulatory submissions.
If you would like to bounce off your thoughts on this, let’s have a conversation.
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