Service lines can help in categorizing patients
When you put together reports for managed care organizations (MCOs) or quality improvement projects, you probably use ICD-9 codes or categorize patients based on primary diagnosis. But these groupings may not accurately reflect the type of care you provide for patients.
After all, when your nurses visit patients they are given cases based on the type of service they will provide, not necessarily based on the diagnosis, says Alexis Wilson, RN, MPH, PhD, founder and chief research officer of Outcome Concept Systems Inc. of Seattle. Her company provides a software program based on the Outcome and Assessment Information Set (OASIS) and provides benchmarking services for the home care industry.
For example, nurses might see two patients for infusion care and provide similar services, although one patient has AIDS and the other has cancer. These two patients would be put into different diagnostic groups when it’s time to measure outcomes.
Instead, Wilson suggests, these patients might more easily fit into the same grouping of infusion care. "My idea was to take a look at grouping patients according to actual services they receive," she says. "You could be an AIDS patient, but the primary services you receive from the agency are infusion services."
Wilson developed a list of 14 service lines based on this concept. Service lines are a potentially useful tool for research and are a better tool to help agencies understand the costs and outcomes of their services, Wilson adds. (See list of service lines, p. 181.)
"This is a creative way of categorizing patients, and it reflects the way we talk about patient care on a day-to-day basis," says Pamela Ferrari, RN, director of quality assurance of Visiting Nurse Association of Hudson Valley in Mt. Kisko, NY. The agency serves a county north of New York City with 90,000 visits last year. "Nurses don’t say, I have a patient with urinary retention’; they say, I have a catheter change,’" Ferrari explains.
Ferrari has used the service lines for quality improvement goals and for marketing purposes. Service lines have helped the agency make decisions about what types of services to market now that the home health landscape is topsy-turvy under Medicare’s interim payment system (IPS).
"For example, we wanted to know whether the psychiatric program is something we should be marketing at this point," Ferrari explains. Her question was: "Are psychiatric services using certified psychiatric nurses a financially solvent part of the business to be in at this time?"
Ferrari pulled up all of the case data related to the service line for psychiatric care. It corresponds to ICD-9 codes of 290 and 319. The statistics showed that psychiatric care is profitable and its clinical outcomes were positive.
Ferrari says she found that patients who saw a psychiatric nurse required fewer overall visits than patients who had other home care services. Plus the psychiatric patients had equally good outcomes, and their care costs less when compared with other patients, she adds.
Unlike diabetic and wound care cases where the agency’s services exceeded its Medicare beneficiary cap and the agency lost money under a prospective payment system, psychiatric services fell below the cap, Ferrari says.
Another benefit of using service lines is that they are fairly easy to translate from ICD-9 codes collected from an agency’s database and from OASIS tools. Care plans also may be used.
Ferrari and Wilson explain how quality managers can use service lines with these pointers:
• Develop better outcomes reports.
"Service lines can be useful for developing practice patterns or best practices for caring for patients," Wilson says. For example, quality managers can use service lines to compare outcomes among patients using similar services to see which type of treatment resulted in fewer visits, hospitalizations, and emergency room visits.
Visiting Nurse Association of Hudson Valley has a standards manual with care plans that list requirements. For example, the standard requirements for treating a terminally ill patient require nurses to discuss hospice and make a social worker referral, Ferrari says. "These are our standards, and when every nurse goes out to see a patient and write a care plan, my quality assurance department checks that care plan against the service lines," Ferrari says.
Quality managers review and compare the outcomes for patients in that service line. They check to see how many patients were admitted to the hospital and how many developed competency in handling their disease. With diabetic patients, for instance, the quality manager checks to see how many patients who had a skilled deficit in insulin injection when admitted had shown improvement in their ability to self-inject insulin. "And it might show us how many visits it took to get them independent," Ferrari says.
Then these outcomes might be compared with care plans to see whether cases with the better outcomes followed the agency’s standard requirements for that type of case. If the number of visits seemed high or if the outcomes were disappointing, then the agency might have a diabetes specialist provide an inservice on special techniques for instructing patients on insulin injection.
Visiting Nurse Association of Hudson Valley did exactly that with diabetic cases, and then quality managers checked again after the inservice to see if outcomes improved. "We were looking at the percentage of patients who go from having minimal to moderate skill to competence in diabetic care," Ferrari says."We saw a 25% improvement."
• Learn which programs to develop and eliminate.
Visiting Nurse Association of Hudson Valley had a nurse leave who had specialized in wound care and ostomy care. "Our question was, Should we hire a new person, and is it an area of business we want to be encouraging and talking up?’" Ferrari says. "We’re not going to turn people away, but should we seek them out in this environment?" For example, if the agency wanted to market to wound care patients, it could market its services to a local wound care clinic.
Ferrari pulled up data on all patients under the service line for wound/ostomy care. Wound care corresponds to ICD-9 codes 870 and 8977, but since any patient can develop a wound, ICD-9 codes might not reflect the true number of wound patients. Ferrari suggests quality managers use the OASIS tool to track all of the wound care patients. On the OASIS tool, questions M440 and M550 pertain to wound and ostomy care.
Ferrari found that her agency’s wound care patients require a lot of nursing visits. "And you don’t want to take on patients who take up a lot of visits under IPS," Ferrari says. "So it appears we don’t want to market a wound care program."
But this didn’t provide the whole answer, so Ferrari made another comparison, using the wound care service line. She compared the number of visits for patients treated by the wound care specialist vs. the number of visits for patients treated by other nurses.
She found that nurses who are wound care specialists reduce the number of visits per wound case. It made sense to at least train one nurse to become a wound care specialist.
• Demonstrate over- or underutilization.
Ferrari also took a look at patients who are overutilizers, such as patients who have received services for more than a year. The 14th service line, which is open-ended, could be used for checking patients with long lengths of stay.
"I do a consistent reporting of those patients," Ferrari adds. "I look at why we haven’t succeeded with this patient yet." Perhaps the nurse is at fault, or perhaps it’s just that there is a solution to the problem that no one has taken the time to find. "Say you have a patient still on service for catheter care, and maybe the patient could get to the doctor once a month to have that catheter changed," Ferrari suggests.
Another example might be a patient who has received long-term service because he needs a regular injection of Calcimar, a drug that increases bone density. Perhaps that patient now could benefit from a new nasal spray drug that has the same benefits and that the patient could administer himself, Ferrari says.
Anecdotal evidence suggests the strategy is working, Ferrari says. "We’ve had people learn to administer their own medications and treatments who never had before."
• Market the more profitable services.
Service lines give a clear picture of the average cost of a particular service, its average number of visits, and its outcomes, Wilson says. They can be used to market a home care agency’s services to managed care organizations, who often are looking for that type of data.
However, Ferrari says MCOs so far have not show a lot of interest in the information. "My gut feeling is they’ll accept a contract if you take the lowest price they have," she says.
"What will change is they’re going to start looking for agencies that have the kind of information we have as we move into an environment of risk adjustment and cost sharing," Ferrari adds.
However, the agency has used the service lines to determine other marketing strategies, including shifting focus to its psychiatric program.
Ferrari adds that service lines work and could be one more way for quality managers to compare outcomes and utilization rates. "You need to use all of your information to make informed business decisions."
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