Home Health & Hospice Week

Tough times are ahead for home health agencies affected by the 10 percent outlier cap. Here are steps you can take to mitigate the policy's impact on your agency:

1. Assess your vulnerability. The 10 percent per agency cap will start applying immediately in January (see related story, p. 330). That means you need to find out right away if your payments will be limited, recommends Abilene, Texas-based financial consultant Bobby Dusek.

"An agency can look at their total outlier payments as a percentage of their total reimbursement to see if they might have a problem," Dusek advises. Since the cap will affect episodes that have already begun, "agencies need to look at their situation now," he stresses.

Remember: "It is only the outlier add-on that is capped, not the underlying HHRG payment for the episode," Dusek adds.

Clients of consultant Melinda Gaboury with Healthcare Provider Solutions in Nashville, Tenn., found they had to reduce their number of outlier patients from 44 to 12 and 32 to 15, respectively, to manage the cap. By starting early, they were able to get down to that number without putting the patients at risk, she says.

2. Explore ways to combat the cap. If you expect to exceed the 10 percent mark for outlier payments, you need to act now to mitigate the financial impact. You can explore alternative treatment plans with physicians, such as using insulin pumps, changing insulin frequency, or employing alternative wound therapy, the National Association for Home Care & Hospice suggests.

Current PPS outlier policy hasn't encouraged agencies to be very aggressive about turning care over to the patients or their caregivers, Gaboury notes. Now agencies will have more incentive for getting serious about finding ways to do so.

Even if caregivers can take over only part of the care, say injections required before and after their work day, that can help you cut costs for that outlier patient.

3. Put your clinicians on the case. They can explore alternative options like new training approaches to teach self-management or use of assistive devices, NAHC offers. For low vision patients, Gaboury's clients found a low vision program to enroll them in that taught them to selfadminister insulin, she relates.

4. Use your social workers. They can work to find other sources of care such as churches or volunteer groups, NAHC counsels. Or if care can't be located, they can work with the patient and their family on going to other care settings if they can't stay in the community.

5. Reach out to other agencies. If you're not in one of the high-suspicion areas, you can most likely find other agencies in your area with room under their outlier caps to take on some of your outlier patients, Gaboury says.

6. Halt outlier patient admission. Try to limit admission only temporarily, NAHC says. And if you must limit admission, "avoid restrictions on admissions by diagnosis or patient characteristics," the trade group advises. "Treat all potential outlier patients alike."

7. Use discharge as a last resort. Despite taking aggressive measures to turn over care to the patient or caregiver, discharge may be necessary to allow your agency to keep operating. If you must discharge patients, be sure to adhere to any state rules and your own agency rules for discharge, NAHC says.

Also, try to give patients and caregivers advance notice of the possibility of discharge so they and their families can work with you on alternatives, the trade group adds.