How to Transition to Value from Volume-Based Care Processes

How to Transition to Value from Volume-Based Care Processes

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Erin Cahill: Welcome to CareSmartz360 On Air, a home care podcast. I’m Erin Cahill, an Account Executive at Caresmartz. Today, we’re diving deep into the world of home care with a guest who’s revolutionizing the industry joining us is Arnie Cisneros, the owner and president of Home Health Strategic Management.

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Erin Cahill: Arnie is a nationally acclaimed home care, consultant and strategist, with a wealth of knowledge on transforming care delivery. In this episode, we’ll explore the critical shift from volume-based to value-based care in the home care industry. Arnie will break down what this means, why, it’s essential and how it impacts clients, caregivers and agencies alike

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Erin Cahill: get ready to learn how focusing on quality and outcomes can lead to better client care and a more sustainable future for home care providers. Let’s dive in welcome to the Podcast Arnie.

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Arnie: Thank you, Erin. Thanks for having me today.

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Erin Cahill: So we’ll jump right into it. What are the primary challenges? Home care agencies? Face when transitioning from a volume-based to a value-based care, model.

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Arnie: Thanks for that question, Erin. I’m going to start by giving a little background for people who don’t know me as to why I’m answering these questions for you.

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Arnie: I am a physical therapist with over 35 years of experience in home health.

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Arnie: I have a private practice that works with home health providers across the country to develop them into 4-plus star agencies with single-digit readmissions that qualify for the value-based purchasing bonus. So my private practice certainly takes agencies and transitions them from volume to value, and achieves the outcomes of the latest Pdgm and value-based purchasing reforms. So when I’m speaking today.

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Arnie: I’m speaking from the corner of the changes we make to your average home care agency. Many that are quality providers, 3 plus 4-star providers that still exist under a value model and in the value world.

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Arnie: So I will be talking about specific changes that are required to overcome the latest reforms and to provide better care in the value era than we did in the volume era. So back to your question, what are the primary challenges? Home care agencies face when transitioning from volume-based to value-based care models.

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Arnie: And the number one issue is the years of our volume-based home Health PPS model

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Arnie: presents the greatest challenge to us as providers seeking value-based success because

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Arnie: the Pps model was entirely volume-based. It didn’t matter how accurate your acuity profile at the start of care was on the oasis. You could still get paid well if you had the right volume of rehab. It didn’t matter how many visits you made. You could still survive financially if you had the right volume of rehab, and therefore it became a volume-based model rather than a model that got patients better.

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Arnie: So Medicare addressed those issues with the Pdgm. Reform and

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Arnie: moved all the acuity to the start of care. Oasis visit. Took the therapy volume out of the model payment, which meant we got a capitated model just like a hospital has for Drgs. We get X amount of dollars. It’s determined on our case, mix on our start of care, admission, visit, and anything we don’t spend in getting the patient better

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Arnie: is our margin.

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Arnie: So that really puts us on a different pathway of efficiency and best practice. That was not necessarily during the 20-plus Year Pps model. We worked on so numerous areas of our home health operational model belies, our value-based success. And this is the primary challenge for us to achieve value-based purchasing outcomes. I’m gonna give you a quick list of the things from the volume era that handicap us and obscure our value-based outcomes.

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Arnie: And as I give you this list, I want you to not. Just think of this list in home health. I want you to think of this list with regard to

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Arnie: healthcare providers in the Medicare world. I want you to think about this list for hospitals.

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Arnie: and the same list for subacute rehab and nursing homes, or the same list for inpatient rehab facilities, all of which are Medicare, part providers. Because when you see

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Arnie: how other providers handle these, this list, you will understand

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Arnie: how we deviate from the model when we don’t address them in the same manner. So the 1st list

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Arnie: item is, we work within a retroactive care model.

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Arnie: We don’t. We are managing our clinicians 2 weeks behind the visits. Usually it’s all a retroactive care model. We have

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Arnie: sometimes timely issues with our documentation, but we’re all managing care after the fact. Think about the way a hospital does it? If a nurse writes that the patient achieve the goals on Tuesday, they’re sending that patient home on Wednesday based on the nurse’s notes, which means they’re in real time.

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Arnie: So the 1st element is, we have to move from a retroactive care model to a real time care model and the reform for the value based purchasing. And the Pdgm does exactly that.

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Arnie: I mean, if we admit people 7 days a week, why can’t we admit people on the Wednesday that were sent sent to us on Tuesday? Every other Medicare provider does that?

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Arnie: And when you get on this path. It starts to outline the elements that we deviate from the model. One of the reasons we can’t admit on Wednesday for a Tuesday referral is because we don’t have control of our clinicians. Schedules.

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Arnie: Think about that! Think of a hospital! Couldn’t get a nurse assigned to the room because they had a nurse, but they couldn’t get assigned. Those are things we have to deal with.

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Arnie: So, secondly, timeliness

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Arnie: number 2, admission, acuity, aptitude. How well do we do capturing what the patient’s illness is, and acuity is through the oasis start of care.

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Arnie: Now the oasis is a 25. Actually, it’s a 29 year old document. I’ve been doing the oasis for 29 years. I started 5 years before the industry because I was working with a test agency.

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arnie: So

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Arnie: the average oasis is 70 to 72% accurate in the acuity questions across America.

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Arnie: Think about that.

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Arnie: That means you’re only getting a patient

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Arnie: 70 to 72% or 3 quarters as well clinically as Medicare would like you to do. And even more importantly than that, you’re only collecting 70 to 72% of the money. Medicare wants to pay you.

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Arnie: So unless agencies and most haven’t have done something to assure that their oasis is

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Arnie: our level is 98% or better accuracy in the case, mixed questions you are leaving money and care outcomes on the table. These are the kinds of things we did not react to during the 20-year Pps era that now spell success. The plan of care for the Bbp version

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Arnie: value-based purchasing says, how fast can we get the patient better. So if you’re still writing an 8-week order.

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Arnie: you’re 25 years behind the model. If you’re still running one time, 9 nursing visits. You’re 25 years behind the model, and you have. You’re really running in the other direction. The power industry is moving.

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Arnie: the lack of timely or qualified documentation for utilization management documentation for coverage is a basic element of the value-based world. And since we don’t have qualified documentation, most of our documentation doesn’t require or doesn’t have, the required elements for Medicare in our notes are, we can’t manage our utilization through that. And that is

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Arnie: the life and breadth of Bbp value-based purchasing outcomes, lack of an episode management. We don’t have our notes in timely, so we don’t read them every day. What if your favorite aunt went to the hospital, and she was in the hospital, where people die and get sick and get infected all the time, and she was ready to go home on Tuesday.

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Arnie: but because the note wasn’t ready, they didn’t get here home until Friday. Would you be okay with that? That’s what we do every day in home. Health we have, and those are easy for us to change

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Arnie: lack of compliance.
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Arnie: If you’re not compliant in the hospital or nurse you don’t want. I rf, you get discharged, and therefore people become compliant.

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Arnie: If we in my model people have to be demonstrated to be compliant. That’s a responsibility of qualification, a clinician-centered model in home health. We run our model through the clinician. Most of our many of our clinicians are not at full productivity. You would never see a hospital or nursing home doing that.

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Arnie: we allow clinicians to cancel care through missed visits which I don’t even understand how it exists in today’s model, and we have home health. Contemporary concerns with gaming.

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Arnie: Some Emrs will tell you to do this because you make more money. Optimizing areas of the models beyond qualified clinical outcomes kind of distorts our path. So

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Arnie: we don’t manage in the mode of other Medicare parts, a provider. That’s the 1st thing we have to do, and something that we’ve gotten in the habit of saying, because we’re in such a transitional phase for home health from volume to value, and people expect, if they have a good attitude, things will just improve, but it’s not a good attitude, and something we end up saying, quite a bit is, nothing changes

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Arnie: if nothing changes. So if you want to move from a successful value-based provider to a successful value-based provider. A lot of your things are going to change over 50 to 70% of your daily routine will change.

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Arnie: And when you think well, I’ve been doing this for 20 years. That was a different model for 20 years, but unless you change.

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Arnie: nothing will change.

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Erin Cahill: Yeah, no, absolutely. That was really valuable. How can home care agencies measure and demonstrate the value they bring to clients and payers.
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Arnie: Well, that’s a great question there, and thank you for that. I remember I was marketing for somebody was a

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Arnie: healthcare hospital chain in the Southern US, and we went into a doctor’s office, and he was very, very personable, and we were marketing him, and he made a statement, not to me, but to the group that was that I was with.

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Arnie: he said, you know everybody comes in and tells me their nurses are the greatest, and I think they believe their nurses are the greatest, but everybody tells me that. How do I know who’s the greatest? Everybody tells me that therapists are the greatest. But people aren’t talking about their publicly traded outcomes on the Internet.

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Arnie: They’re not talking about specific numbers of single-digit readmissions that they’ve been producing, which is what everybody wants, not people not going back to the hospital. They don’t talk to about their star ratings, and then patient satisfaction, and so on, and so forth, and timeliness, and so on, and so forth. So those are things that I think we use.

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Arnie: We assure our Pdgm value-based performance by real-time performance metrics for value and ongoing improvement.

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Arnie: So if I’ve got 3 managers working in the agency, I want their managers to send me an email at the end of the day with their product clinical staff productivity that day.

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Arnie: So I just wanted to stop and think how you can demonstrate the value. Well, 1st we have to quantify the value. So when every one of my managers is telling me how their team did that day, their team tends to do a little bit better

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Arnie: because the manager doesn’t want to tell you and send you an email every day. That says my job was substandard again today. So through that I’ve objectified managers and clinical staff below. Now I can ask questions about missed visits, lack of productivity, schedule, mismanagement, the patients, the clinicians whose patients fall more clinicians whose patients go back to the hospital more by objectifying the care with daily key performance indicators. Kpis, we call them

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Arnie: so we employ real-time performance metrics for ongoing value and improvement, because then we can move closer to people whose metrics are declining for that day. So that’s really something. I think.

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Arnie: we have to internalize that we do not manage our care and our agencies the way that other Medicare providers do, and that’s why we struggle to demonstrate our value to clients and payers is because we’re kind of at a subjective care model that we aren’t used to utilizing objectives to move forward.

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Erin Cahill: Right?

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Erin Cahill: And can you elaborate on the specific benefits that clients and caregivers experience under a value-based care, model?

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Arnie: Yes, so we have. My private practice has worked since the Impact Act was passed with a lot of Medicare experimental bundle models, and we work with numbers, numerous systems across the the country

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Arnie: in doing so, and one of the things you see is rapid care outcomes. You get the patients better

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arnie: faster under Pdgm. So I asked in my sessions, with hundreds and hundreds of people who wants to be a home health patient 20 years from now for 60 days, and who wants to be better and discharged than day? 17. And every single patient.

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arnie: every single attendee, raises their hand as if they were a patient wanting to be done in 17 days. But yet we all go into our agencies, and we write 45 and 60 day care programs because we haven’t internalized that. Pdgm says the faster you get them the better.

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Arnie: So rapid care outcomes increased efficiency in the delivery model optimizes outcomes. Now my better nurses do better than my lesser skilled nurses, and I can move to them and help improve their skill. My my therapist, whose patient who handle their patients better. Now we know that their patients fall and go back to hospital less than other patients who may not manage assistive devices and Prv. We have as well, so that allows us to move forward and it

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Arnie: it depersonalizes the care.

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Arnie: Do you want to go to a hospital and get treated very well by 3 different nurses over 3 different days? Or do you want to have a nurse, Linda on the second day, who was really good and the other nurses not be good? That’s the dip that’s home health today.

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Arnie: So how do we say we’re going to talk about the visits? We’re not going to talk about this nurse, who we think is good or not good, for whatever reason we think that, or this therapist who does what they want and doesn’t see the patients we want, for whatever reason they do that. So objectifying your care is what

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Arnie: is what is offered by value-based purchasing improved beneficiary value.

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Arnie: So

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Arnie: do we want a program that says it took me 6 weeks to get better because I cancelled 30% of your visits. Or do we want a program that says, this is how you’re gonna get better. And you’re not going to cancel my business. You’ll be done in day 17,

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Arnie: I think it’s clear what side I think we’ve fallen on, and and what side. I think we need to be on a lack of unremarkable home health outcomes during the PPS era. I mean.

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Arnie: our private value-based purchasing requires single-digit hospital readmissions. Now they require 7.9%.

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Arnie: Our average readmissions for the last 7 years has been 6.1%, because we learned how to keep people out of the hospital

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Arnie: during our bundle trials with impact

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arnie: pioneer aco system. Not. But nonetheless. For the previous 25 years, Medicare produced

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Arnie: 25% readmissions, and we were all good with it. Okay? Still, 25% when it could have been 6%. So I think lack of unremarkable outcomes. And we need an objective operational model. If we put it in. The staff likes it because the staff has worked there under a hospital, and the same model under a nursing home, etc, etc.

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Arnie: So those are great opportunities. Everything works better, and if it doesn’t work better you’re not doing it right.

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Arnie: That you want, and we have a different attitude about that in home health. Sometimes we’re really good. We’ve been doing it for so long. Do you want to go to a hospital that works like it did 20 years ago.

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Arnie: because many of our home health agencies work like they did 20 years ago.

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Erin Cahill: Right.

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Arnie: Thank you.

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Erin Cahill: So, Arnie, what are some practical steps that home care agencies can take to initiate that transition to value-based care.

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Arnie: Well, you want to analyze your data for value error potential.

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Arnie: I think if anybody was, it was so inclined they could reach out to me and I would

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Arnie: do the analysis. We do. The analysis that we do on agencies

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Arnie: talks about what your case mix is, what your average payment is what your nursing business prep is. So your therapy business prep. Sold. Your episodic admits per month. We don’t want to know your census.

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Arnie: because census is not how you get paid these days.

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Arnie: Getting people better discharging them is how you get paid in the value era.

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Arnie: and so by taking somebody and analyzing their care. It’s about objectifying your care.

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Arnie: and those are things that I think help bring care management from retroactive to real-time. We want to take the care control from the cars of our staff and the homes of our patients into the agency where we can manage it appropriately. We want to read the notes and derive the patient. We own the patient, and we staff it with our clinicians. We don’t hand it to our clinicians to own the patient

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Arnie: because they didn’t own the patient anywhere else. We eliminate right off the bat anything that could not happen anywhere else, and those would include

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Arnie: no non admits

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Arnie: no changing the frequency or duration order.

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Arnie: no independent discharges at the clinician staff level. None. They’ve never done it. No nurses discharge a patient from a hospital or nursing home, because she thought they were ready to go.

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Arnie: No, nurses said. We’re not going to admit a patient to a hospital nursing home when they got a referral there. Why, we all do it in home health.

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Arnie: They never wrote their frequency and duration order. If we’re letting them do that.

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Arnie: we’re still under the old model. So those are 1st steps we can take. We want to assure full timeliness and productivity. That’s the 1st 2 steps. Why would we not admit everybody?

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Arnie: And a 24 h basis. If our staff was not fully productive.

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Arnie: Think about that. We have staff. We are paying with the ability to admit these patients, and we’re missing

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Arnie: admitting the patient on the 1st day, that if you can’t do that, you can stop talking about anything else.

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Arnie: So the 1st thing is to assure full timeliness and productivity. If we struggle

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Arnie: to

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Arnie: not pay somebody

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Arnie: for work they didn’t do.

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Arnie: we’re going to struggle on the home health value era period. Think about that as a basic Hr technique management across the world, if not America.

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Arnie: If we pay people and can’t make them achieve productivity.

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Arnie: we can’t take the next step in the value-based purchasing world. So and finally address your visit content and related documentation. If we’re going to get a person better in 3 weeks and 6 visits instead of 2 months and 13 visits. We’re going to be doing different things during those visits, which means again back to the notes and back to documentation.

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Erin Cahill: Absolutely. And my last question for you, Arnie, how do you see the role of technology in supporting the value-based care transition in home care.

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Arnie: We you? I’ve made a little list for that, Erin. We use technology

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Arnie: literally 3,000% of what we used to do.

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Arnie: And we use it for all our key performance indicators in a daily basis. We use it for performance review in real-time metric management addressing trends for ongoing improvement. It’s basically it. We have no subjective opinions of our day-to-day performance beyond

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Arnie: key performance indicators. We don’t have an attitude that this team is good. But there’s numbers. Aren’t that good? We define everything through technology-based data in a real-time and ongoing manner. And it’s all about performance. Performance. We do not use technology, and sometimes it drifts into those areas for oasis accuracy. It does not achieve 98% accuracy for a plan of care, development

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Arnie: or for anything

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Arnie: predictive.
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Arnie: There is no no other. We have some predictive elements in some of our Emrs. No other element aspect of healthcare has that involved. A hospital doesn’t look at the patient. Say, well, we’re gonna try to get them better as fast as we can. But our software is predicting that happen in 3 days that does not happen. They try to get the patient better as fast as we can, so we do not do anything predictable. But again, we use our data and our technology for real-time propulsion of our care evolution through objective data.

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Erin Cahill: Perfect. Well, thank you, Arnie, for sharing your expertise to our audience. Thank you for tuning in until next time. I’m Erin Cahill signing off.

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Arnie: Sharon have a great day.

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Erin Cahill: You as well. Thanks so much, Arnie.

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Arnie: Bye-bye.