Vijaya is a Healthcare Expert at Nalashaa and has experience in business transformation, payer-provider integration, product design & implementation and healthcare system evaluation & selection. She has been actively involved in Meaningful Use, PQRS, HHVBP, CPC+, CCM and MACRA implementations and has extensive exposure to Clinical and Financial areas of the US healthcare ecosystem.

Vijayalaxmi Kudekar

HOME HEALTHREGULATIONSEHR vendors need to update offerings to accommodate federal regulations and assist providers with value-based care.

OverviewStarting January 1 2020, the Home Health Prospective Payment

System (HH PPS) may have a drastic change, which proposes

case-mix methodology re�nements and parameters are de�ned

under the rule released last year for Home Health Grouping model

(HHGM).

This proposed rule; also called the Patient-Driven Groupings

Model for Medicare home health payments, primarily relies on

patient needs, rather than a therapy threshold to determine the

reimbursement. It helps advance the Trump Administration’s

Meaningful Measures initiative which represents a new approach

to quality measures that foster operational e�ciencies, and

reduce costs of collection and reporting during quality measure-

ment.

As per the press release by CMS, the cost impact related to the

updated data collection processes is estimated to result in a net

$60 million in annualized cost savings to HHAs, or $5,150 in

annualized cost savings per HHA. This is because of the proposed

implementation of PDGM and the proposed changes to HH QRP

that will be e�ective from the beginning of the CY 2020.

Major highlights of the rule

Case-Mix Adjustment changes – including a change

in the unit of payment from a 60-day episode of care

to a 30-day episode of care.

Introduction of Home Infusion therapy - includes

“Remote Patient Monitoring” cost under Medicare

home health bene�t

Changes in the Home Health Value Based Purchas-

ing (HHVBP) model

Changes in the Home Health Quality Reporting

Program (HHQRP) requirements

Promotion of Health Information Exchange

01

02

03

04

05

1 Copyright © 2018 Nalashaa

Case-Mix Adjustment changesTo adjust for case-mix, the HH PPS uses a 153-category case-mix classification system to assign patients to a home health resource group (HHRG). This includes the national, standardized 60-day episode payment rates, changes in the national per-visit rates (HIPPS code calculation), and adding non-routine supply (NRS) conversion factor with the base rate. The clinical severity level, functional severity level, and service utilization are computed from responses to selected data elements in the OASIS assessment instrument and are used to place the patient in a particular HHRG. Each HHRG has an associated case-mix weight used in calculating the payment for an episode. Therapy service use is measured by the number of therapy visits provided during the episode and can be categorized into nine visit level categories (or thresh-olds). For more details on HHRG calculation and updates in case-mix adjustment, please click here.

Remote Patient MonitoringThe CMS has proposed that home health providers would be able to include the costs of remote patient monitoring as an allowable cost in home health agency’s cost report.

Although home health providers would not be directly reimbursed for the installation and use of equipment, CMS uses cost reports to determine if the home health providers are being paid appropriately. Currently, remote monitoring technology could not be included in these cost reports, and officials say that the change could incentivize broader use of technology improving care through access to real-time data. This would allow home health agencies to report the costs associated with technology, including infrastructure upgrades and equipment, as well as wage and labor costs associated with using the equipment.

Home infusion therapy is a treatment option for patients with a wide range of acute and chronic conditions, ranging from bacterial infections to more complex conditions such as late-stage heart failure and immune deficiencies. It provides improved safety and better outcomes since it is given at patient’s convenience and at home.

This includes nursing services furnished under Conditions of Participation (CoPs) in accordance with plan of care, patient training and education, remote monitoring services for the provision of home infusion therapy and home infusion drugs furnished by a qualified home infusion therapy supplier.

Diseases that may require infusion therapy include infections that are unresponsive to oral antibiotics, cancer and cancer-related pain, dehydration, and gastrointestinal diseases or disorders which prevent normal functioning of the gastrointestinal system. Other conditions treated with specialty infusion therapies may include some forms of cancers, congestive heart failure, Crohn’s Disease, hemophilia, hepatitis, immune deficiencies, multiple sclerosis, and rheumatoid arthritis.

Infusion therapy originates with a prescription order from a physician or another qualified prescriber who is overseeing the care of the patient, and is sent to a home infusion therapy supplier, which is a state-licensed pharmacy, physician, or other providers of services or suppliers licensed by the state.

Admission source

Community or institutional source; the period is placed into 1 of the 2 groups

Low, medium, or high; the period is placed into 1 of the 3 groups

Functional level

An episode will be calculated based on the following five categories

Timing Early or late; the period is placed into 1 of the 2 groups

Clinical grouping

Musculoskeletal (MS) rehab, neuro/stroke rehab,

wounds,

Medication Management Teaching and Assessment (MMTA),

Behavioral, or complex nursing care; the period is placed into 1 of the 6 groups

No or yes; based on the secondary diagnosis;

The period is placed into 1 of the 2 groups

Comorbidity adjustment

2 Copyright © 2018 Nalashaa

There are three areas to demonstrate that home infusion therapy

program meets the accreditation organization’s standards:

Ensuring that all patients have a Plan of Care from the

physician including the need for prescribed infusion

therapy

Having respective procedures to ensure remote

monitoring services are provided

Having procedures to ensure that patients receive

education and training on the e�ective use of medica-

tions and equipment at home.

The CMS envisions that this would allow patients to share real-time

data with caregivers and push providers to use technology to track

clinical data for monitoring and analysis.

Home Health Value Based Pur-chasing ModelThis model aims to provide incentives for better quality care with

greater e�ciency, study potential quality, and e�ciency measures for

appropriateness in HH setting and enhance the current public report-

ing process. There is a change in the number of states providing

services under this model. Now, all the Medicare-certi�ed HHAs

providing services in nine states - Arizona, Florida, Iowa, Maryland,

Massachusetts, Nebraska, North Carolina, Tennessee, and Washing-

ton (competing HHAs) are required to compete in the Model.

The CMS proposes to remove two OASIS-based measures, “In�uenza

Immunization Received for Current Flu Season” measure, and the

“Pneumococcal Polysaccharide Vaccine Ever Received” measure from

the set of applicable measures. It will

Replace three OASIS-based measures with two

proposed composite measures on total change in

self-care and mobility.

Amend how it calculates the Total Performance Scores

by changing the weighting methodology for

OASIS-based, claims-based, and HHCAHPS measures.

Rescore the maximum amount of improvement points.

A major change is also seen in the payment adjustment, starting this

year, and the weighting methodology. The payment adjustment will

be increased incrementally over the course ranging from 3% to 8%

for the CY 2018 to 2022. This is given based on each HHA’s Total

Performance Score (TPS). Here is a quick snapshot on the current and

proposed weight.

The TPS will now be scaled to 90% of the score and an additional 10%

will be given to the new measures. Besides this, there will be changes

in the OASIS based measures.

01

02

03

01

02

03

OASIS

56.25%

35%

Current weight

Proposed weight

12.5%

30%Current weight

Proposed weight

Claims

31.25%35%

Current weightProposed weight

HHCAHPS

3 Copyright © 2018 Nalashaa

Home Health Quality Reporting ProgramTo put patients �rst under Meaningful Measures initiative, the CMS

proposes to remove the following measures out of the current 31

OASIS measures. This o�ers an opportunity for HIT vendors to simpli-

fy their solutions and make life a little easier for HHAs:

Depression assessment conducted measure

Diabetic foot care and patient/caregiver education

implemented during all episodes of care measure

Multifactor fall risk assessment conducted for all the

patients who can ambulate (NQF #0537) measure

Pneumococcal polysaccharide vaccine ever received

measure

Improvements in the status of surgical wounds

measure

Emergency department use without hospital readmis-

sion during the �rst 30 Days of HH (NQF #2505) measure

Re-hospitalization during the �rst 30 days of HH (NQF

#2380) measure

Two new measures are planned to be introduced and the CMS

intends to specify the measures no later than Jan 1, 2020, which will

be adopted in the beginning of Jan 1, 2021.

0102

04

0506

07

03

There is no change

in the HHCAHPS survey

requirements.

Health Information Exchange

The CMS aims to focus on advancing the health informa-tion exchange. The IMPACT Act requires assessment data to be standardized and made interoperable to allow exchange of data among providers and patients. For post-acute care, CMS is developing Data Element Library (DEL) to serve as a publically available, centralized, authoritative resource for standardized data elements and their associated mappings in health IT standards. OASIS is one of the assessment items included in DEL by CMS. The DEL database includes post-acute care (PAC) assessment questions and their response options, as well as other associated details including the assessment version, item labels, item status, copyright information, CMS item usage, skip pattern information, lookback periods, and linked health IT standards.

For more details on interoperability, please refer to our CoP whitepaper.

Health Information Exchange allows health care profes-sionals and patients to appropriately access and securely share a patient’s med-ical information elec-tronically.

4 Copyright © 2018 Nalashaa

Areas where technology helps providers cope with the new changes

Areas where technology helps providers cope with the new changes

Document Management

Document Management Solution to consolidate documents and promote interoperability

Absence of structured documentation including plan of care and clinical docu-ments that HHAs need to maintain costs agencies time and money. To allow information exchange through remote monitoring, patients should be able to send documents as part of emergency preparedness plan mentioned under CoPs.

By systematically managing documents using technology, providers could focus on patient care. Besides main-taining the clinical records, a discharge or ToC document can help with a smooth transition.

Plan of Care

Quick information exchange through digitization

Inefficient data management is adversely affecting assessment and quality of care for HHAs. If the HHA sees any major problems while provid-ing care, the aide can send the plan of care and the results of plan to the physician to understand the gravity of the situation and administer proper care.

Digitization will enable quick informa-tion exchange and decisive actions promoting enhanced healthcare quali-ty. To facilitate communication with an HHA and a physician, the systems used by both should be interoperable. To do so, the HHA’s EHR can send CCDA docu-ment to the physician’s EHR. Most physicians have ONC certified EHRs, so the complete loop is automated.

For more details on Plan of Care, refer to CoP whitepaper.

Identity ManagementEMPI solution to detect duplicate records

Duplicate records provide a splintered view of patient’s medical history, leading to unnecessary services/tests putting the patient at risk. In addition, many denials are due to the inability to identify patients correctly based on the data provided.

A carefully implemented EMPI solution can help HHAs to minimize the expens-es related to unnecessary tests/proce-dures, record maintenance costs and the possibility of lawsuits.

Digitized and Structured Assessments

DEL to create an electronic, distrib-utable, and centralized

resource of CMS assessment data

Historically, assessments have been a choice that

different HHAs exercised differently causing problem with

a lack of standardization. It is almost impossible for HHAs to have a number driven approach to gauge improvement across patients due to the subjectivity and variety of these

assessments.

DEL, is an opportunity for HIT vendors to eliminate

the hassles associated with subjectivity and

variety of assessments, and bring a structure to unstructured data. Through this, HHAs will be able to compare improvement in a patient’s condition across time horizon and patients with relatable situations/conditions.

5 Copyright © 2018 Nalashaa

Analytics

Track patient progress to get actionable insights

A major risk faced by the HHAs is the lack of insight into quality of care and patient progress resulting in negligence in care. To provide better quality care and focus on outcomes, Home Health agencies should look at building analytics capabilities using data they already have from the ecosystem.

Tracking patient progress becomes a major component under the QAPI as it provides actionable insights by tracking quality indicators. This aids in analyzing the quality of care and rectify-ing negligence in care or investigating allegations on negli-gence in care. Dashboards can be configured to track measur-able outcomes and improvements, which would provide insights for the providers as well as motivation for the patients.

Clinical Decision Support (CDS)

Enhanced health related decisions to improve healthcare delivery

For HHAs, numerous decisions made on a daily basis are not only exhaustive but also entail risks of lawsuits. Human cogni-tion is subjective and need not be accurate which calls for the need of technology for assistance.

An EHR supporting CDS can support your staff through suggested interventions triggered based on every agency’s context. They can be provided with a checklist for better care decisions and alignment with QAPI requirements. More on QAPI, here.

Patient portal

Advanced health information engagement to enhance care management

Patients get the most effective care when they collaborate with caregivers. Absence of an elaborate patient-centric approach can cause decline in health outcomes and revenue while increasing manual labor. To address this, Home health EHRs should start exposing the information or provide a portal to the patient so that everything is electronically main-tained.

Patients get the most effective care in a patient centric system where they acquire better awareness through complete care details. Patient portals could be enhanced to empower patients by allowing them to track the progress of care, upload shareable health information document, send complaints, make payments or initiate transfers to another home health agency easily.

6 Copyright © 2018 Nalashaa

Interoperability with DevicesRemote Monitoring devices to reduce quantity of care while maintaining quality

Attending to all patients 24/7 is a waste of time, resourc-es, and revenue considering the varied level of care required by each patient. In the absence of a definite way to measure the amount of attention required, justification of care and hence, the expense are often questionable.

Remote patient monitoring is an effective way to reduce quantity while maintaining quality as it focuses on ‘man-agement by exception’. Advancement in the technology has empowered HHAs’ staff to spend their resources in a more productive manner. With remote monitoring devices, HHAs can track patient movements, measure vitals, monitor sleep patterns, detect fall and so on. Via interoperability, the immense data collected by the device could be analyzed for insights using analytics.

Social risk profilingIncreased patient participation for effective clinical actions

With the US healthcare industry’s relentless pursuit of value-based-reimbursements, there are efforts to stratify reasons and find the root cause behind rising cost. Recent findings are suggestive of a correlation (if not causation) between social risk factors and patient outcomes. While a lot of providers in the acute space are concerned with what happens within the settings, HHAs live in a very different context. They have little or no control over what their patients do in the absence of HHA aides.

A closer look at these softer aspects of a patient may offer significant insight into patient context and behav-ior. With this, they can tweak their care provisioning to invite more participation from patients, thereby improving the effectiveness of their clinical actions.

7 Copyright © 2018 Nalashaa

ConclusionWhile technology isn’t the complete solution for problems that HHAs face, it is certainly an important lever that can be used to overcome their challenges while staying compliant with regulations. It’s true that HHAs know their context and business better and understand the chal-lenges too. However, many a time in the past, several industries have solved their challenges in unconventional ways borrowing ideas or concepts from entirely disconnected industries. Perhaps, new standardization and compliance requirements will help HHAs with interoperability and quality of care for patients and reduce the burden of different regulatory submissions.

If you would like to bounce off your thoughts on this, let’s have a conversation.

Connect withthe experts!

At Nalashaa, we partner with healthcare organizations of all stages, from startups to established firms, and work with them to build engaging user experiences that reduce organizational cost and risk. Our healthcare and technology expertise, along with our flexible engagement models, make us a great fit for developing the quality technology while reducing time to market and engineering costs.

About Us

555 US Highway 1 South, Suite 170, Iselin, NJ 08830, USA

732-602-2560 X 200 www.nalashaahealth.com

Reach Us: