IPS survival requires imagination
Creative solutions keep agencies afloat
Sen. Kit Bond (R-MO) and other lawmakers have proposed legislation that could alter or kill the Interim Payment System (IPS), but for the moment it's still a painful reality for most home care agencies. In virtually every response to Homecare Quality Management's annual reader survey last spring, respondents said surviving IPS was one of their biggest concerns. But they aren't letting it ruin their business. Instead, many agencies are putting on their thinking caps and coming up with new ways to stay in business.
The old "more is better" system is a hard habit to break, says Glenna Mills, BSN, a consultant with the Walnut Creek, CA, consulting firm Mills Pollin & Associates. But agencies can't "adopt" patients any more. "They really have to look for stability and discharge within three weeks," Mills says. To achieve that, every twice-daily patient has to be balanced with 27 patients that need just three visits each, she says.
One reader, who runs a freestanding agency on the West Coast, says her agency is actively marketing for short-term patients that will keep their average length of stay down. "We know we have to cut $2,200 per Medicare patient, and that means keeping the number of visits down," she says. "But we can't just abandon people who need ongoing care. Instead, we have to find one more short case per week."
Her agency is going to the emergency department of local hospitals to see if patients who are not admitted to the hospital might need a safety evaluation or follow-up visit. "It's gaming," says the source, who asked to remain anonymous. "We are just playing with numbers."
Ambulatory surgery is another area where her agency is marketing its services, and there are even a few physicians who are being targeted for the potential short-term patients they could provide.
Another strategy is to find creative ways to cut length of stay with existing patient bases. Lilia Rosenheimer, RN, MPA, associate director of nursing at Community Home Health in San Pablo, CA, says her agency has gone to a plastic surgeon who refers to Community Home Health and discussed changing some of the dressings he prefers. By using more absorbent ones, says Rosenheimer, some patients can reduce the need for bandage changes from twice a day to daily.
But this kind of monkeying with the numbers can be difficult for staff, warns Rosenheimer. "You can't get rid of longer-term patients altogether. If you did, the staff would go nuts with all the paperwork. But there is certainly some balancing going on."
Cutting costs where they can
IPS spurred United Medical Home Care Services in Cheyenne, WY, to start a clinical pathways program, says Kathy Niles, RN, clinical supervisor. "It was a way we saw to contain costs and minimize our time with patients," she says. "We needed to have a clearer idea of when we would be discharging patients."
There was some grumbling from nursing staff at the idea, Niles says, which began with an altered assessment form to get nurses used to a new format. "But then they got used to it and don't want to go back. They were clamoring for us to get our pathways completed."
The forms put more emphasis on patient education, goal setting, and outcomes. First out of the box was one for diabetes, and one for COPD is nearing completion. Niles isn't sure how the paths will work, though, because there have been no diabetes admissions in the three months since the pathway was implemented. "But we are in the right frame of mind now," she says.
Other agencies have turned to staffing changes to save money. But rather than letting the expensive RNs go, they are keeping them, says Mills. "They have the most experience, and each visit counts more now," she says. "They have to produce some results."
Rosenheimer has seen her office staff thinned, which means there is more work for clinical staff and management. "It's a huge amount of work for us, and the hard part is that with some things, like billing, if you make a mistake, now it's called fraud. We are very, very careful."
Consultant Tony Salvatore, of Home Care Management Associates in Springfield, PA, says his clients are doing everything from putting vendors on notice that rates are going down, to bailing out of Medicare altogether and taking on private duty and staffing work instead.
Another idea he sees gaining popularity is using telemedicine to enhance care that might otherwise be curtailed. Telemedicine is more than just a nurse calling patients to check up on them; Salvatore says the phone can be used for on-line infusion or oxygen monitoring. Not only can this decrease your visits, but it is a way to differentiate your agency and enhance services when others are cutting back, he adds.
Unfortunately, there currently is no reimbursement for telemedicine, which makes it a hard sell. "It's hard to get people to change their mindset and understand that they can actually generate business out of this," says Salvatore.
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