Riding the Care Coordination Wave

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By Rhonda Oakes, Regulatory Analyst, Change Healthcare and Michael Mayer, CIO, Americare Companies
Home Health Care Coordination

It was a Frenchman who said, “The more things change, the more they remain the same.” It could just as easily have been the Centers for Medicare & Medicaid Services (CMS) about its goal to encourage healthcare providers to provide better care at lower cost. Regardless of the changes swirling around our industry, CMS pushes steadfastly toward that goal.

To that end, we have new Home Health Conditions of Participation (CoPs) regarding care coordination in home health. It boils down to this: home health is no longer about going out to take care of a hip-replacement recipient or a someone who experienced a cardiac episode. It’s about becoming a health coach.

On the bright side, nurses we’ve encountered are well disciplined to perform these basic skills, so the guidelines shouldn’t require drastic changes. From what we’ve observed, it’s more a matter of mentoring and support of the nurses in these rolls.

The research

CMS is basing its care-coordination push on research that shows patients who experience primary care as delivered by an integrated, multidisciplinary team that explicitly includes at least one staff care coordinator have better outcomes.

Specifically, they found:

  • Reductions in ED visits
  • Noticeable decreases in medication costs
  • Reduced inpatient charges
  • Reduced overall charges
  • Average savings per patient
  • Significant increases in survival with fewer readmissions
  • Lower total annual Medicare costs for beneficiaries participating in pilot projects compared to control groups
  • Increased patient confidence in self-managing care
  • Improved quality of care
  • Increased safety of older adults during transition from an acute care setting to the home
  • Improved clinical outcomes and reduced costs
  • Improved patient satisfaction overall

The details

CMS is allowing home health organizations to accept orders from multiple physicians. However, it has clearly stated that someone from the home health organization must assume the role of a care coordinator whenever multiple physicians are included in the plan of care. Asked directly about this, CMS responded in an email that if an HHA (home health agency) chooses to place itself in the role of a direct recipient of orders from multiple physicians, it is incumbent on the HHA to assume the role of a care coordinator in order to ensure that patient needs are continuously met and that there is no duplication or contradiction of services.

That care coordinator role will ideally be filled by RN’s with a year or so of hospital experience—so they have a good understanding of team-based case management.

Fortunately, once they understand the purpose behind the new guidelines, most clinicians see their value. When strong communication and standardized coordination are in place, nurses in the field experience a drop in after-hours visits. Patients with escalating health issues are identified before they enter a health crisis, and well before they have an urgent need to visit the ED.

However, the way you restructure your clinical staff to emphasize care coordination should depend on the level of case management your patient population requires.

For example, are they patients who need extensive after-care interventions or ongoing disease management or are they more straightforward after-care interventions (i.e., orthopedic surgery) and wellness care?

CMS defines three case management models:

  1. RN Case Manager (aka Primary Care). One nurse is caring for all the needs of a patient from admission to discharge. In addition to providing the primary nursing care, she is responsible for coordinating the other services (referrals, appointments, services) and coordinates planning and discharge.
  2. Supportive Case Manager/Health Coach. One nurse is in charge of coordinating care for the patients assigned to their team. The team may include nurses, therapists, social workers, nursing aids and unlicensed assistive personnel that care for a group of patients assigned to that specific team.
  3. Clinical Manager. New role defined by CMS to encourage agencies to determine how they need to re-allocate resources to meet the intent of the role. This person is responsible for scheduling, coordination, and care services.

Using Case Manager

Once you’ve selected the method for coordinating care, you need to determine how to demonstrate your compliance to CMS. We recommend using the Case Conference feature in Homecare Advisor™ from Change Healthcare. All of the following can be accomplished using Case Conference:

  1. Review orders received to meet the patient’s needs. Communicate new orders/changes in the plan of care to all physicians involved and applicable team members in a standardized process. Help ensure attending physician receives a plan of care update.
  2. Coordinate visits.
  3. Conduct a team review of organization outcomes/patient goals. Which patients are on target to achieve their goals, and for which patients are changes indicated?
  4. Are patients on target for planned discharge?
  5. Review of preventive care and interventions to mitigate hospitalization/ED visits

Involve IT

The stronger emphasis on coordinated care is an opportunity for home health organizations to evaluate current processes and task allocations. Are your nurses and supervisors buried in paperwork? This may be the time to shift tasks to back-office operations and give nurses more time with patients.

Similarly, are you using your software to the fullest extent possible? You can help ensure this is the case by including IT personnel in clinical operations meetings as you work to comply with new CoPs.

Finally, take a step back from your current staff configurations. Consider what positions you’ll need to accomplish CoPs compliance and what positions you’ll need going forward. Wipe the slate clean and rearrange your org chart according to the future, not the past.

Learn how an experienced home health IT partner can help your organization transition to updated CoPs.

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