The focus for Medicare certified home health agencies will shift from volume-based payments when Home Health Value-Based Purchasing model (HHVBP) goes into effect on January 1, 2023. The intent of HHVBP is to create a more efficient healthcare system, improve lives and positively impact entire communities.
HHVBP Quality Measures
The goal of HHVBP is budget conscious delivery of quality care to Medicare beneficiaries. There are three specific objectives aimed at meeting CMS HHVBP Quality Measures:
- Incentivizing the offering of better quality of care while using less Medicare dollars
- Researching new potential quality and efficiency measures for appropriateness in the home health setting
- Improving publicly reporting processes
What is HHVBP?
The Center for Medicare and Medicaid Innovation (Innovation Center) implemented the original Home Health Value-Based Purchasing Model as a pilot project from January 1, 2016 through December 31, 2021. The model was designed to support greater quality and efficiency of care among Medicare-certified Home Health Agencies. Participation was required from all Medicare-certified HHAs in nine selected states representing different geographic areas within the United States. These HHAs were paid on quality of care rather than quantity of services. Results showed reductions in acute hospitalizations and skilled nursing facility stays. Thus, CMS proposed expanding the model to all 50 states and U.S. territories to further reduce Medicare spending and improve quality in 2021. The CY 2022 HH PPS Final rule outlined the expansion of the model.
In this blog we will outline complex changes that are going to impact the home health industry, but more importantly we will cover the real-life steps individual agencies can take to ensure they are ready for the changes.
What do we know about HHVBP?
We know that HHVBP has a lot of moving parts, but it is intended to equate to better care while reducing the cost of care and focusing on quality of outcomes rather than quantity of services. HHAs will compete against their own internal baseline and externally with agencies of similar size across the country. CMS will look at a set of quality measures and derive a home health value based purchasing total performance score. Because the model is so complex, CMS allowed for 2022 to serve as a pre-implementation year, so that providers have the opportunity to train and share resources with their staff, but come January 1, 2023 it’s show time!
The Changes Your Agency Needs to Adopt to be HHVBP Ready
Beginning in 2023 the Home Health Value-Based Purchasing Program will result in agencies being judged on performance items. The first payment adjustment year (when agencies will be paid based on 2023 performance =/- 5% max adjustment) is 2025. This means that agencies that perform above average in 2023 will share in the savings of up to a 5% maximum and those who perform below average will lose reimbursement up to 5% compared to the comparable agencies that they compete with. This makes it imperative that agencies have the following steps in place to prepare.
Step 1 Educate on HHVBP
Educate all staff on HHVBP and make sure everyone has an understanding of the ramifications of performance spanning from organizational leadership down to the individual level. One of the biggest factors that you can control will be OASIS documentation. OASIS training should focus on accuracy and completeness of the patient assessment, particularly the Start of Care, Resumption of Care, and Discharge time points. Testing clinicians’ skill sets and OASIS competency related to complex patients is vital with HHVBP. Know your agency’s overall baseline of competency and identify areas of deficiency so that you can focus on strengthening those areas, which will be very important with the implementation of OASIS E in 2023.
Another piece of VBP total performance score is the Home Health CAHPS Survey. The HHCAHPS survey is a 34-item questionnaire to measure patients’ perceptions of their skilled home care and those results are publicly reported. Questions cover topics such as: communication about care, pain, and prescription medication use, the care received from a home health agency, staying informed about scheduling, and global ratings. The survey can be completed by the patient, or the patient may have a proxy answer the questionnaire. One thing that agencies can do is to take time to educate staff and help them develop an understanding of the survey and be certain that they are aware that patient’s may be asked to complete these after being discharged from care. By doing so, clinicians can set goals targeted to adequately address all their patients’ needs in specific areas addressed on the survey and thereby improve the overall patient experience.
Step 2 Know how to Collect and Analyze Data
Keep in mind that comparison data is going to be among the most valuable data for your agency. An agency can review specific HHVBP quality measures from 2019 going forward to see what has improved and what areas need some extra attention. This gives a good indication of achievement score trends. Next, agencies can locate their HHVBP thresholds and benchmarks file in iQIES and identify which measures may need the most attention. Based on that information, they can develop and then review an action plan with their team to address areas of deficiency.
Where to start
Not in a particular order, here are some initial data collection tools you may have access to that will help create a baseline for analysis:
- OASIS reports
- HHCAHPS reports
- Home Health Compare reports
- internal quality audit data
- Learn all the capabilities of your EMR–reporting, scrubbers, comparison tools
- Consider using outsourcing vendors for benchmarking and analytics
By collecting and then dissecting this data, agencies can make data-driven decisions about where they need to exert energy the most to improve care, and improve outcomes as viewed from the public perspective.
Step 3 Step up your QAPI Game
Compliance, Analysis, Regulatory, Reimbursement, Education…OH MY!
We advise agencies to approach QAPI as a mindset of growth and improvement rather than a mind-altering endless task of checkbox after checkbox.
To start with, agencies will need to evaluate their current QI Process and QAPI program, and evaluate the focus of prioritizing Quality Improvement Activities. Rather than secretly drawing straws to decide who will focus on QI (again, this is an all-in, full team effort), simply develop clinical strategies that align your agency’s improvement efforts with the HHVBP model goals. By collaborating and developing standard internal core indicators specific to your agency and reviewing specific measures together, you can implement changes for improvement.
Here are a few simple steps agencies cant take:
- Front loading visits
- Including caregivers/family in holistic education
- Developing internal standardized protocols
- “Good-night” or “Tuck-In” calls
- Telehealth monitoring
- Training staff to use language similar to language used in the HHCAHPS survey during patient visits and education sessions
Step 4 Consider increasing or rearranging staff
It’s no secret in home health that your staff can make or break you. The current on-going nursing shortage and great resignation movement has created an intensified revolving door in regard to staffing. Many agencies are feeling the pain of being short staffed and despite shuffling the schedule, offering over-time/bonus incentives, and somehow managing to survive day to day, at the end of the day patient care is what suffers the most. Patients want consistent care rather than a continual parade of different faces week after week. Studies show that seeing the same clinician on a regular basis provides patients with vital benefits that can supplement their overall care. Consistency is beneficial.
Some benefits of consistency include:
- Being able to identify and swiftly address changes in health
- Collaboration and good communication with family/caregivers and others involved in the patient’s care
- Trust and credibility for the care received
With all this in mind, changes in staffing roles may be necessary. Hire experienced staff and incentivize clinicians to become OASIS certified. If you aren’t able to hire experienced staff, then it is best practice to invest in training, education, and professional development from the onset of hiring. Not only will you likely see a return in revenue once training is complete, but that will be mirrored in your publicly reported outcomes and patient satisfaction.
Another area that may be of concern in agencies is with support staff. You know, those good folks in the office that answer phones, keep the supply closet in check, schedule visits, talk to family members, and basically everything else that contributes to the efficiency of running an agency:Intake, Medical Records, Scheduling, Human Resources, Education/Training, and QAPI. High turnover rates can impact these areas as well. Take inventory of what everyone is doing, and find ways to help them perform their jobs more efficiently and proficiently.
It is always wise to assess to be sure you aren’t over/under utilizing talents. If your Clinical Manager is processing orders, acting as a liaison for the field staff, providing education, conducting case conferences, reviewing OASIS/Plan of Cares, and having to make field visits due to short staffing, then they are doing too much! In addition to hiring clinical staff, consider outsourcing quality to OASIS-certified quality review specialists to conduct clinical record reviews. This step alone can be one of the most meaningful improvements an agency can make to get ready as well as navigate through HHVBP.
The Foundation for HHVBP is Ultimately Quality
HHVBP can ultimately be deduced to this- If your agency is truly focused on providing quality care and capturing documentation accurately to reflect the care given, then you are headed in the right direction. Regardless, patient care comes first and when sincere, compassionate, quality care is being delivered, your outcomes will reflect your good deeds. In conclusion, if you wish to know all the ins and outs of HHVBP, including how and what data is measured, and how CMS reaches the conclusion as to whether your agency is on par, there is information available on the CMS website that continues to be updated regarding the HHVBP Model.