Don't wait to prepare for pay for performance, get a head start now
Get performance improvement process in place now to be ready
While the dates are not specific, and the actual model for the payment system is not yet developed, the reality for home health managers is that they have to prepare for a pay-for-performance payment structure in 2007 if they accept Medicare patients.
How do you prepare for something that is not yet defined? Home health managers may find it easier than it sounds, say experts interviewed by Hospital Home Health.
"The home health industry is in a unique position of readiness for pay for performance compared to other segments of health care," says Barbara McCann, vice president and chief clinical officer of Interim HealthCare in Sunrise, FL. "Home health agencies have been collecting and submitting outcome data for five years and have had this information public for the past three years on the Centers for Medicare and Medicaid Services [CMS] Home Health Compare web site," she points out.
"We don't know what payment model CMS will use for pay for performance," admits McCann, who serves as chair of the American Association for Homecare's pay-for-performance task force, which has been developing a proposal for CMS to consider. "The measurements used for Home Health Compare seem to be the most logical starting point because agencies are already collecting the data and the information is already used to compare quality and outcomes," she says.
At this time, CMS is using 2007 as the starting point for a voluntary program of participation in pay for performance, says Pamela Teenier, RN, BSN, MBA, CHCE, director of Medicare operations for Gentiva Health System in Corpus Christi, TX. Even though the term "voluntary" is used, Teenier says agencies that don't participate may face a reduction in reimbursements so everyone who accepts Medicare patients should prepare.
The key to success in a pay-for-performance environment will be continuous monitoring of outcome data and a performance improvement process that enables an agency to identify areas of improvement and make changes that are needed, says Teenier. "Every home health agency will have to develop a quality mindset," she says. "This means that staff education related to quality outcomes and performance improvement programs are ongoing, continuous efforts," she explains. An agency that reviews performance data on a semi-annual or annual basis will not have the opportunity to address low scores before reimbursement is affected, she adds.
If Home Health Compare becomes the basis for a pay-for-performance model, it is important to remember that the data are reported on a 12-month rolling basis, so improvements you make within your agency won't affect the data overnight, Teenier points out. "That is why it is critical that agencies start their programs to monitor and manage data in 2006," she says.
The assumption among experts is that there will be a top tier and a lower tier set for reimbursement based upon outcomes. "We still don't know what the break point will be for these tiers and we don't know if there will be bonuses awarded for improvements or significant changes even if an agency doesn't reach a higher tier," says McCann. "I would like to see some sort of bonus awarded to agencies that are improving so that we don't discourage people," she adds.
The first step for a manager is to take a good look at his or her agency's revenue, suggests McCann. "All home health managers must ask themselves if Medicare represents a significant portion of their revenue, and if not, do they want to participate in pay for performance," she says. All agencies that accept Medicare will have to submit required data and will have to meet certain requirements to obtain the highest level of reimbursement, she points out. "This means that an agency manager with an agency that has a small number of Medicare patients may choose not to participate in Medicare at all if it is not in the agency's best interest to gear up to meet pay-for-performance requirements," she adds.
PI process essential
A well-structured, ongoing performance improvement process capable of identifying and developing changes that improve outcomes is essential for success in pay for performance, says McCann. "Some agencies will need to invest in technology in order to monitor and manage data," she says. "Even if the agency can't justify the expense of point-of-care technology, such as laptops, it will be essential to invest in the right software to monitor the data on an ongoing basis," she adds.
"I don't believe that agencies will have to add personnel in order to meet pay-for-performance requirements but more agencies will need to look at case management as one way to be more efficient and more effective," suggests McCann.
Teenier also believes that additional staff won't be necessary but she does recommend that one person, at a senior level in administration, be responsible for oversight of the performance improvement process related to pay for performance. "This responsibility can be incorporated into an existing position but it is essential that someone with the authority to direct change have the ultimate responsibility for the process," she says.
While the specifics of pay for performance are not yet released, Teenier says that managers should start looking carefully at their Home Health Compare results now. "There are hot topics for home health at this time so an agency can start looking at those issues, reduction in hospitalization, for example," she says. "But it is also important to look at how you are doing compared to national benchmarks because you may identify opportunities for improvement in an area that may be important but may not be a hot topic right now," she adds.
Managers also need to review their case mix carefully, says McCann. "Can one agency handle the cost of patients who are predominantly wound care patients or will it be better to balance the case mix with a variety of services?" she asks. "These are the types of questions that each manager needs to consider," she adds.
Perhaps the biggest change that will have to be faced by home health managers is a change in nurses' behavior, warns McCann. "Pay for performance will require careful clinical management of a patient, as opposed to following a physician's orders," she says. "This will require nurses, managers, physicians, and therapists to work together to identify the best way to treat the patient to get the best outcome," she points out. The key will be to create a culture of performance improvement that results in all staff members constantly asking themselves, "Is this the best way to treat this patient?"
This change must be created through education of all staff members, as well as restructuring your clinical staff where needed, in order to foster a team approach that encourages communication, suggests McCann.
"We are accustomed to having some nurse managers and some task-oriented nurses on our staffs but in order to be effective under a pay-for-performance system, it is essential that all clinical personnel look at managing patient care rather than accomplishing tasks assigned for the patient," she explains. This will require all staff members to assess a patient's condition, evaluate the effectiveness of current treatment, and communicate to a case manager or supervisor if a treatment is not working, she adds.
When setting up your performance improvement process be sure you are prepared to investigate the reasons for lower ratings in different categories, says McCann. She explains, "Data is like a car's dashboard warning lights. Your engine light might be on but there may be a dozen different reasons for the warning. It takes careful review of the details to find the reason for the warning and identify a fix for the problem."
Sources
For more information, contact:
- Barbara McCann, vice president and chief clinical officer, Interim HealthCare, 1601 Sawgrass Corporate Parkway, Sunrise, FL 33323. Phone: (800) 338-7786 or (954) 858-2761.E-mail: [email protected].
- Pamela Teenier, RN, BSN, MBA, CHCE, director of medicare operations, Gentiva Health System, 13806 Debloom Street, Corpus Christi, TX 78418. Phone: (361) 949-0399. Fax: (913) 814-5501. E-mail: [email protected].
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