By Florence Cino
Working as an RN for twenty-two years within the school health system, Waiver programs with OPWDD, home healthcare as a field RN, and now serving as Director of Patient Services for Edison Home Healthcare in New York City; I have seen and experienced the health care business from both a nursing perspective and administrative perspective, in terms of how healthcare companies strive to grow their bottom lines while maintaining quality home health services for their clients. Indeed, some clients may be eligible for Medicaid home care, but not be aware.
As with all industries, there are elements beyond our control and no shortage of bureaucracy to navigate. Value Based Payments are payments that are earned when an LHCSA licensed home care service agency performs well-meeting quality measures. The MLTC’s keep score on certain events that are monitored. They measure client falls, vaccinations, hospitalizations, and declining health status. They also look at uncovered or missed shifts where an Aide was not replaced for a call-out.
Below are some stumbling blocks that can impact a Home Health Care Agency’s bottom line:
LHCSA (Licensed Home Care Service Agency) RNs conduct in-home visits bi-annually for LHCSA clients to create and establish a plan of care based on individual needs. The plan of care is then discussed with the assigned Home Healthcare Aide and specifically outlines the care needs of the client. When an RN is conducting the home visit, information regarding flu vaccination prior to and during flu season, is gathered. Clients who refuse to be vaccinated are counseled and encouraged to obtain a flu shot. However, flu vaccinations are not mandatory, and it is the clients’ choice whether or not to vaccinate. The LHCSA RN is not the only RN who is making this recommendation for the annual flu shot, the MLTC’s (Managed Long-Term Care Agency’s) Case Manager RN, who is also assigned to this client makes recommendations to the client regarding flu shots. In addition, the UAS Assessment RN has an opportunity to make this recommendation to the client. With this said, based on Value Based Payments, only the LHCSA will be penalized for a client’s failure to get a flu shot through a decrease in their reimbursement rates if the flu vaccine is not completed with the contracted client. It is difficult to enforce flu vaccinations with clients since they are not mandated to comply with this request. Quarterly scores are given to the contracted LHCSA by MLTCs (Managed Long-term Care companies), and these scores determine the home healthcare company’s reimbursement rates.
Client hospitalizations and ER visits are another issue that affects the bottom line of LHCSAs. If a client has had a change in status, the Aide must notify the LHCSA and most often the recommendation is to call 911. Many of these clients are elderly and health conditions can escalate quickly. Early intervention is best, but subtle changes can go unnoticed. An Aide may not pick up on an early status change in his or her client. If there isn’t family support to assist with the client’s health monitoring, these clients may need to use the emergency room more often when their health declines. Only a doctor or nurse practitioner can provide the medical care to the client when they become ill. LHCSA policy requires that 911 be called when a client become ill if there is no family member to take responsibility. Frequent trips to the ER and hospital admissions adversely affect the Quality Measure score in this category and decrease the reimbursement rate to the LHCSA.
LHCSA policy dictates that if a client has a fall while receiving Aide services, the Aide is not allowed to help the client up or assist with the fall and must call 911. Picking up a client who has had a fall can have severe consequences for the client. There may be unknown injuries that cannot be visualized, both internally and externally. Moving a person who has had a fall without having the training or expertise in this field can create catastrophic consequences for the client’s health and wellbeing. A client must be evaluated and moved by paramedics who will determine if the injury requires further evaluation and treatment at the hospital. ER visits and hospital admissions are Quality Measures which can negatively affect reimbursement rates. A reputable LHCSA would never discourage calling 911 or taking the client to the emergency room. A client may refuse to go to the hospital and, when called, an EMT may clear someone medically and determine that the client is not in immediate harm and does not need to go to the hospital. The LHCSA is responsible for falls while on service and off service by the MLTC’s.
In addition to the Quality Measures affecting an LHCSA’s bottom line, paying overtime to Aides also decreases a company’s profit margin. Overtime will eat right into the LHCSA’s bottom line. It is very important that there are Aides available to cover shifts when there are call-outs or when there is suddenly more demand for Home Healthcare Aides and your company is being called upon to provide more Aides to fill this need. Lack of effective communication practices with a company’s Aides can exacerbate the need for companies to pay overtime.
Can Home Healthcare Agencies Keep a Healthy Bottom Line While Not Compromising Services?
Policies that exist within the home care and long-term care industries are necessary and should never be compromised. However, there are effective methods that can be employed to improve profits while maintaining and striving to improve client care. If we look very closely at each client regarding health status, family support system or lack of family support, their level of dependence for ADL’s, food preparation, medication reminders, social isolation, fall risks as well as skin integrity etc.; the Plan of Care will appropriately and effectively meet their comprehensive needs. The steps that will take us to a higher, more comprehensive level of care includes:
- Head-to-Toe Comprehensive RN Assessments that are discussed with the client’s personal MD
- Educating clients and their loved ones on LHCSA Policies
- Education provided by RNs regarding early intervention to prevent health conditions from escalating
- Use of technology for real-time staff communication, including ask staff to report changes right away so problems can be addressed before they get worse
- Recruitment of more Aides to reduce overtime
- Providing continuing education for RNs,
- Teach the Aides to report health status changes sooner, and teach both Aides and Clients to use Urgent Care Facilities instead of Emergency Rooms
- Communicate with clients’ doctors when needed.
By improving our client’s health with early intervention and better communication, Licensed Home Care Service Agencies will produce a positive effect to their bottom line.
Florence Cino is an RN, a twenty-two year veteran within the nursing industry, and Director of Patient Services for New York Home Healthcare Agency, Edison Home Healthcare.