Cathy Sorenson was skeptical but desperate. With an average daily census over 400 but a profit margin at a barely surviving level, the President and CEO of Home Healthcare Hospice and Community Services in Keene, New Hampshire, frankly rated her agency's overall performance as 'mediocre' and was ready to try anything to draw the best out of her staff. What she wound up trying, beginning in August, 2015, sounded impossible to her at first: one hundred percent utilization review for clinical management of home health.
Designed by Arnie Cisneros, PT, President of Home Health Strategic Management, the program he has dubbed SURCH (Service Utilization Review for Care in the Home) was installed at HHSM in July and kicked off agency-wide in early August. Before long, the agency's CMS star rating started climbing. From three stars since the inception of the rating system, it crept up to 3.5 in October, then to 4 stars in November. By January of this year, the agency reached the coveted 5-Star rating. Simultaneously, their case-mix weight rose from an anemic .81 to a remarkable 1.37, virtually doubling reimbursement per PPS episode from under $2,200 to over $3,600.
By April, word of the HHSM transformation had spread. The VNAA awarded the agency its 2016 "Innovative Model Award" during its annual meeting in Miami. In accepting the award for her agency, Ms. Sorenson said, "We tried to do it by ourselves but couldn’t reach the levels of efficiency, value, or Medicare compliance that the S.U.R.C.H. management produces. This process has revitalized and changed our culture in such a way, no one wants to go back to how we used to work."
Curiously, Ms. Sorenson told us, her average daily census reduced by half, from approximately 400 to 200. And yet, gross revenue is up, which begs the question, "What is SURCH, and how does it accomplish this kind of transformation?" This is how the CEO describes the HHSM story.
100% Utilization Review
Every field nurse completes every OASIS assessment in the presence of the patient, during a telephone consultation with a UR nurse in the office. The goal is to design a custom care plan, not one that follows an agency protocol for the average patient but one that calls for the exact number of visits this patient is likely to need. Where the agency average had been 12 or more therapy visits for a joint replacement patient, it is now from five to nine, and outcomes have improved. UR nurses continue to review every case with every nurse throughout each episode of care.
"We had been auditing start-of-care OASIS assessments but not resumption or discharge," Ms. Sorenson explained, "and we did the audits long after the visit ended. That practice never made a big difference in quality, consistency, or accurate documentation." In order to make this new policy work, she decided they had to make it a mandatory process for all frontline staff. There was some initial pushback but, in the words of Arnie Cisneros, "Pushback is a phase."
From Doubt to Enthusiasm
His platitude came true for HHSM. "Hospital nurses get used to carrying out care plans designed by someone else," he says. "Home care nurses can too." HHSM nurses initially resisted, thinking something was being taken away from them but, Ms. Sorenson noticed, they finally saw that they were being relieved of a burden and they grew to appreciate it. Nurses found they were getting better at the OASIS phone consultation. Where it initially took 20 minutes, they now report it takes about five.
"Initially, it was, 'You're telling me how to deliver care, and it's not the way I have always delivered care.' But before long, they saw the benefits and embraced the process. We only lost two staff members, one OT and one PT, and I was OK with that because those individuals with that level of disagreement, would have needed a lot of micro-management."
The SURCH program is designed to be effective, not easy, Cisneros admits, but it does produce results in a short period of time. "Legacy methods of care will not work under healthcare reform," he repeats in every presentation and conversation until it becomes a mantra. "The days of '3week9' are over if you intend to be around as ACOs, CJR bundles, and value-based payment systems spread from state to state. If you lay out a 60-day care plan, you fix it in your mind that you have 60 days to get this patient independent. Start with a 30-day care plan and extend it only if you have to. Do you know what ACOs and hospitals in CJR bundle programs say about a two-episode case with 30 visits? They say, 'I hope you made a lot of money because that's the last patient you're getting from us.'"
Patient Outcomes Create Financial Outcomes
In less than a year, the transformation at HHSM is nearly complete. They have achieved:
SURCH procedures that enable results like these include quick response following hospital discharge: early the next morning for most patients, same day for CJR patients; front-loading visits in order to achieve quicker patient independence; and ordering PT and OT services for nearly every patient.
Initially, Ms. Sorenson admits, some physicians, one New Hampshire hospitalist in particular, were uneasy with routine PT and OT services for every patient, reasoning, "They did not have therapy services before this hospitalization and they were not admitted for a therapy-related diagnosis." "Yes," she answers them, "but they've been in a hospital bed for four days. Our assessment indicates a fall risk that did not exist before."
Ms. Sorenson was concerned that such a dramatic improvement over a short period of time would raise MAC eyebrows. "I'm sure they would like to find that we are manipulating the system somehow," she smiles, "but when they see our documentation, our bullet-proof documentation, they quietly pay every claim."
About That Census Drop
So, with all this success, we had to ask, why is your census half what it used to be? Cathy Sorenson's explanation is steeped in healthcare reform era thinking. "Our admissions have remained steady," she points out, "but we are no longer wasting payer money by keeping them on service for two and three PPS episodes. We are able to help them meet their goals in 30 days most of the time. That has slashed our per-episode costs more than it has reduced our revenue. So, think about it, the patients are better off, the hospitals and ACOs are happy, the payers are happy, and we are making more money. Don't worry, as word spreads about what we are doing, and referral sources see our 5-star rating, our census will bounce back."