Creating pathways will be critical in coming year
PPS and managed care contracts require changes
It may seem an insurmountable task: to improve the quality of a patient’s care, to teach family members how to care for the patient, and to make fewer home visits than you have in the past.
It can be done, but you will need to do plenty of advance legwork, according to an expert on how managed care is changing the home care industry.
And if your agency finds itself involved in more contracts under the prospective payment system (PPS) and capitation, then your agency will have to be ready. "Just because prospective pay hasn’t hit your doorstep yet doesn’t mean you can just sit back and stay as you are," says Margo Zink, RN, BSN, MN, EDD, CNAA, a home care consultant in Timonium, MD. Zink has been involved with home care agencies in developing managed care and development strategies.
Zink offers these suggestions on how to prepare for PPS and other managed care changes:
* Know your current outcomes.
To survive under prospective pay and capitation contracts, agency administrators must understand what their own outcomes and costs are.
This is important because these two reimbursement methods shift some financial risk back to the health care provider.
Prospective pay refers to a reimbursement method in which providers are paid a pre-determined amount of money regardless of their actual costs in providing care. This amount is set in advance by the provider and payer. Capitation refers to a negotiated amount of money that is paid to a provider on a regular basis to cover all of the health care services needed by each covered person.
Zink recommends agencies start by tracking their typical visit pattern, finding answers to these questions:
• What is the average number of visits now provided?
• How many patients have achieved the desired outcome?
• Why did "X" percentage of patients not achieve the desired outcome?
Then they can analyze their own outcomes by finding answers to these questions:
• What is the average number of visits for other agencies in your region?
• How does your average number of visits compare with other agencies?
• Why might your number of visits be higher or lower?
• What kind of patients do you have?
• How might you improve the care of your high-risk patients?
• What outcomes are reasonable?
• How can you achieve the outcomes during fewer visits?
"If you don’t have a goal, how do you know if you’ve ever met it," Zink says. "So what would be a reasonable goal? And it has to be about patient outcomes vs. nursing outcomes."
* Use critical pathways or protocols.
The care needs to be systematic with all staff in order to improve the quality of care and to achieve this in fewer visits, Zink says.
Agencies will need to have the staff buy-in to this process, so it should include starting focus groups or subcommittees to examine specific patient populations and their outcomes, she says.
Nurses will need time to adjust, just as they have needed time to adjust to lap-top computer documentation, Zink says. "Look at the learning process of how long it took them to even get back to the same productivity they had before the computer."
The key will be to show nurses how these protocols or pathways are in their patients’ best interests. "I think a nurse’s basic feeling is altruistic: I’m going to be there, and I don’t care how much it costs,’" Zink explains. "But being there a long time doesn’t mean you’re going to be more effective for the patient."
Then start explaining the new mindset of looking at the whole patient process, rather than the per visit process. Using critical pathways or protocols established for specific diagnoses will help nurses plan how they can make each visit more effective.
* Encourage the patient to buy into process.
"Patients are focusing on quality even more than in the past, and the patient will be as satisfied if not more satisfied with fewer visits," Zink says.
It’s the quality of the time spent with patients that matters most, she adds.
Show patients the game plan of each visit and what the nurse expects the patient to accomplish during the visit, Zink advises. "The patient has to do his part; the nurse does her part."
Say, for example, an agency has established a five-visit pathway for treating diabetic patients. During each visit, the patient is expected to learn more about taking care of his or her own disease.
But it becomes clear to the nurse after an initial assessment that a particular patient will not succeed in learning that quickly because of vision problems.
If an agency has studied its own outcomes patterns for diabetic patients, then it will have information about how many additional visits may be necessary for diabetic patients with this difficulty, Zink says.
"If you keep a good data collection, then you could justify an outlier, a patient who cannot be taught in five visits," she adds. "That would be evidence to go back to the managed care organization and say that this patient has other situations that prohibit him from being taught in five visits."
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