The vision for this blog is to create a community of harmonious professionals across the care continuum who encourage each other in exploring digital media as a way to support businesses and families dealing with elder care.
Written on December 1st, 2010 by tasha
People who have known me for a long time will remember that the original name of my business was “Let’s Collaborate!” Collaboration has long been a theme of my work, and so I was excited to learn of an article by Ellen Surburg, Director of Bloomington Hospital Home Health and Hospice concerning ways home health and hospice can collaborate more effectively for their own benefits and for the benefit of patients and families.
Ellen’s insights are drawn from research and analysis of quality and payment metrics from the point of view of both providers. I found her explanation of the pressures faced by the two services instructive, as it led to an understanding of how to build a win:win relationship.
The first factor to consider are the cultural differences which not only result in differing goals of care but also, and very importantly, differing quality measures:
There is an inherent unfairness to home health in the OASIS model. As Ellen points out, “Because some patients cannot improve even with excellent care, OASIS scores are not necessarily indicative of quality of care. It is probably not realistic to expect this kind of improvement in a growing elderly population.”
Helping the home health providers improve their OASIS scores may well be an entrée for earlier referral to hospice. Recognizing and appropriately referring patients who, in the natural order of things, are not likely to improve, can allow home health providers to offset the inaccurate negative skew to their quality metric.
A 2006 Briggs Corporation survey of the top home health agencies in Home Health Compare revealed several common practices. Number 8 on the list of practices by top scorers was referral to specialized support services, including palliative care or bridge programs.
Pay for performance is looming on the horizon for home health. A key component of quality performance is likely to revolve around acute care hospitalization. From CMS’ point of view, hospitalization of a home health patient is an adverse event. Repeated hospitalizations can be a sign of the normal course of decline with patients (and their families) who are not receiving the support of palliation and a palliative care team.
Hospices can help home health agencies reduce their hospitalization rates by assisting home health to identify patients/families more appropriate for palliation than cure. Not only does this give patients and families the support needed to manage escalating symptoms and reduce crises, it also positions the home health agency to share in a greater portion of cost savings if/when pay for performance is in place.
While a reduction in home health census is inevitable with a referral, timing is everything. In this, I found Ellen’s description of the two payment models very insightful:
An appropriate, wisely-timed referral to hospice can be a win:win:win for home health, hospice and the family.
A home health agency will be able to retain 100% of its 60-day episode charge if the patient is transferred to a hospice after the 5th visit in that 60-day interval. Hospice will then have longer time to get to know the patients/families and engage the full level of support. And patients/families will have the benefit of longer lengths of service. (Research shows that 3 months is optimal as patient/family perceived services and benefits plateau out after 3 months of care.)
As with all care providers, we get attached to our patients. We don’t like to let them go. And then with the financial loss, it’s even more difficult. But understanding and working with the financial and quality metrics pressuring both organizations can help the two to collaborate more effectively.
Much as timely referrals can improve home health quality scores and eventually pay for performance, with appropriate timing, a home-health-to-hospice referral can also be made in a way that optimizes the home health revenue stream.
If you would like to have a copy of Ellen’s article, email me at tasha@elderpagesonline.com and I will be happy to get you one.
What have you found to be practical ways to forge a stronger alliance between home health and hospice?
As one who works with both hospices and home health agencies, I am very much in favor of intelligent, compassionate collaboration for improved patient care….and I note the positive concepts for ACOs and the PPACA demonstration pilots, and this interesting listserv discussion string. However, referral discussions between providers who are not co-owned must be undertaken prudently, in light of the antikickback laws which prohibit cross referral “agreements” in certain circumstances. Also, home health is under scrutiny from CMS and MedPac for practices which may “game” certain reimbursement opportunities. So a practice of routinely transferring patients to hospice just after the fourth visit in a certification period [thus entitling the HHA to the full episode payment] could raise questions.
Debby Randall JD
——————————————-
drandall.solutions@comcast.net
Law Office of Deborah Randall;Telehealth Consultant
202-257-7073
Thank you for this insight, Deborah. As an academic, the Medicare reimbursement system is a labarynth to me, with nuances only folks working with it day-to-day can fully understand. I so admire people like you who can add these extra dimensions. Extremely important and much appreciated!