Home Health & Hospice Week

Kick your quality improvement plan into gear with VBP only 5 months away.

Whether you’re in one of the nine pilot states for Value-Based Purchasing or not, you have no time to waste when it comes to improving your outcomes.

Why? Superior outcomes are going to be the only thing standing between you and a possible payment penalty of up to 8 percent under the VBP model that the Centers for Medicare & Medicaid Services proposed in the 2016 home health prospective payment system proposed rule published in the July 10 Federal Register.

Recap: Under the proposal, all home health agencies in Massachusetts, Maryland, North Carolina, Florida, Washington state, Arizona, Iowa, Nebraska, and Tennessee will begin VBP on Jan. 1. CMS will “adjust” up to 5 percent of those agencies’

Medicare reimbursement for 2016 and 2017 outcomes; up to 6 percent for 2018; and up to 8 percent for 2019 and 2020. The adjustments based on 2016 outcomes would take effect in 2018 and so forth (see more details in Eli’s HCW, Vol. XXIV, No. 24). CMS will calculate the VBP scores based on 29 patient outcomes derived from OASIS, CAHPS, and claims.

Even if you aren’t in one of the nine pilot states (which may change in the final rule anyway), you need to get going on improving your outcomes, urges attorney Robert Markette Jr. with Hall Render in Indianapolis. You can expect CMS to move quickly on implementing VBP across the board, and your outcomes influence your star ratings on Home Health Compare, among other things.

Under the VBP model, CMS will determine whether you receive a penalty or bonus based on your scores as compared to your peers. And many of those peers have already been working on their outcomes for months, if not years. 

“New kids on the block” will have to play catch-up, says financial expert Pat Laff with Laff Associates in Hilton Head Island, S.C. 

Consider this advice to boost your outcomes, bolster your star rating, and safeguard your reimbursement:

• Focus on the data. You need to know what your numbers are for all phases of quality improvement. Relying on the months-old outcomes data CMS supplies via Home Health Compare isn’t going to cut it anymore, Laff advises. Either internally or through a vendor, you need access to realtime data for the 29 measures that will make up your VBP score (see Eli’s HCW, Vol. XXIV, No. 24) and the nine measures that determine your star rating (see Eli’s HCW, Vol. XXIV, No. 18).
  
• Formulate a QI plan. Your strategy to improve your outcomes is going to be long term and involve many steps, experts caution. Take the time to map it out so that the rest of your efforts aren’t wasted.
  
• Prioritize your targets. It’s not realistic to tackle improving all 29 VBP outcomes at once. Select specific care processes and outcome measures to work on, counsels Pat Jump with Rice Lake, Wis.-based Acorn’s End Training & Consulting.
  

One way to target areas for improvement is to look on Home Health Compare for those VBP outcomes where you perform the worst in relation to your peers. Another method is to look for a high percentage of claims downcodes, which could indicate poor communication between therapists and nurses, offered Laff Associates’ Lynda Laff and SHP’s Chris Attaya in a VBP presentation at the recent National Association for Home Care & Hospice Financial Management Conference in Nashville.

• Develop plan details. With input from your OASIS and direct care staff, develop a plan of action to improve rates of compliance with best practice interventions, Jump advises. Decide who is included on your improvement team, and be sure to designate authority and responsibility for the plan, Laff and Attaya said.
  
• Set incremental goals. Rome wasn’t built in a day, and your QI goals won’t be achieved quickly either. But you need to make sure you are making significant progress toward your desired achievement. Set milestones to attain along the way, Laff and Attaya recommended.
  
• Implement the plan and monitor. Don’t waste time endlessly tweaking your approach. With VBP on the horizon and star ratings already up on Home Health Compare, you need to make it snappy,
  

Laff and Attaya emphasized. Once it’s up and running, monitor for improvement, Jump says.

• Improve OASIS accuracy. Many HHAs have made the mistake of skimping on OASIS education, and the result is outcomes that don’t reflect the care the agency is actually furnishing, Pat Laff warns. Sink some resources into thorough OASIS education for all your clinicians who fill out the form.
  

Pitfall: HHAs often send one or two staffers to OASIS education, then have them come back and teach the rest of the staff. Sometimes that works, but often it doesn’t, Pat Laff cautions. If your OASIS scores are suffering, you may need to invest in an OASIS trainer to furnish an in-service for all relevant personnel.

• Focus on ADLs. A big area for OASIS inaccuracy is Activities of Daily Living items, Pat Laff stresses. Often, there is inconsistency between an admission and discharge OASIS due to a nurse versus therapist completing them. A nurse will start out coding a patient higher than she really merits on the ADLs, then when the therapist codes the patient accurately at the end of the episode it appears as though the patient has merely stayed the same or even deteriorated.
  

The best case scenario is to have therapists complete the OASIS for these items. But if that’s not possible, at least have therapists train nurses on how to code the OASIS items properly at admission, Pat Laff urges.

Requiring a nurse-therapist conference before submitting the OASIS is a surefire way to ensure accuracy, Pat Laff adds. But “it’s huge process change for most folks,” he admits.

• Incentivize accuracy and improvement. A thorough QI plan for VBP should involve rewarding staffers — on an individual basis — for outcome achievement, Laff recommends. That will require you to drill down to the individual clinicians’ data.
  
• Delegate responsibility. You can’t avoid VBP penalties by just relying on supervisors to review OASIS and fix everything, Pat Laff emphasizes.
  

You need to have competent staff in place who can get up to speed on OASIS, diagnosis coding, and other necessities.

Warning: This may mean eliminating poor performers, Lynda Laff and Attaya said in their presentation. Note: For more VBP preparation advice, see Lynda Laff and Attaya’s slides from their presentation at www.nahc.org/assets/1/7/FM15-403.pdf.

The 2016 HH PPS proposed rule is at www.gpo.gov/fdsys/pkg/FR-2015-07-10/pdf/2015-16790.pdf; comments are due Sept. 4. You can order a recording of Markette’s Eli-sponsored audioconferencereviewing the proposed rule at www.audioeducator.com/home-health/home-health-pps-2016-proposed-rule-07-13-2015.html.