Department  of Health and Human Services 
OFFICE  OF 
INSPECTOR  GENERAL 
OPERATING  PRACTICES  OF  LOW-COST

HOME  HEALTH  AGENCIES

Seven  Studies 
#-
v  ~>  JUNE  GIBBS  BROWN 
2.
Inspector  General 
~  Ac 
q> 
FEBRUARY  1997
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OEI-04-93-00263  OFFICE  OF  INSPE~OR  GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452 is to 
protect  the integrity of the Department  of Health and Human Services programs as well as the 
health and welfare of beneficiaries served by them.  This statutory mission is carried out 
through a nationwide program of audits, investigations, inspections, sanctions, settlements, and 
fraud alerts.  The Inspector General informs the secreta~  of program and management 
problems, and recommends legislative, regulatory, and operational  approaches to correct them. 
Office  Of  Evaluation  And  Inspections 
The OIGS Office of Evaluation and Inspections (OEI) conducts short-term management and

program evaluations (called inspections) that focus on issues of concern to the Department,

the Congress, and the public.  The inspection reports provide findings and recommendations

on the efficiency, vulnerability, and effectiveness of departmental  programs.

OEIS Atlanta Regional Office prepared  this report under the direction of Jesse J. Flowers,

Regional Inspector General, and Christopher Koehler, Deputy Regional Inspector General.

Principal OEI staff included:

Atlanta Retion  Headquarters

Paula Bowker, Project Leader  Jennifer Antico, Program Specialist

Ron Kalil, Team Leader  Brian Ritchie, Program Analyst

Christopher H. Koehler, DRIG  Linda Moscoe, Program Analyst

Peggy Daniel, Program Analyst

Tammy Hipple, Statistician

James Green, Contractor

To obtain a copy of this report, call the Atlanta Regional Office at (404) 331-4108.
 EXECUTIVE  SUMMARY 
PURPOSE 
To  describe  practices  used  by selected  home  health  agencies  which  help  them  to provide 
low-cost  care  to Medicare  beneficiaries. 
BACKGROUND 
Medicare  expenditures  for home  health  services  have  increased  from  $3.3 billion  in  1990 
to $15.1 billion  in  1995 -- a nearly  5 fold increase  in just  5 years.  The  average  number  of 
visits per  beneficiary  for  all Medicare-certified  home  health  agencies  increased  from  50 in 
1993 to 58 in  1994.  Expenditures  vary significantly  among  home  health  agencies,  as do 
average  number  of visits per  beneficia~.  In 1993, two thirds  of home  health  agencies 
provided  an  average  of 33 visits per  beneficiary,  The  other  one  third  provided  81 visits. 
In previous  studies,  we determined  that  characteristics  of the  agencies,  characteristics  of 
patients,  diagnoses,  and  quality  of care  did not  explain  this wide variation. 
METHODOLOGY 
We  recently  analyzed  the  operating  practices  of home  health  agencies  to see  if that  could 
help  explain  the  difference.  As part  of that  study we conducted  in-depth  case  studies  of 
how low-cost  agencies  work. 
We  selected  seven  home  health  agencies  for review.  Our  selection  criteria  included 
location  in one  of the  five States  with  the  highest  Medicare  expenditures,  an  average 
number  of visits per  beneficiary  that  was lower  than  the  national  average  in  1993, and  no 
record  of investigation  or negative  audit  findings  or adverse  actions,  and  an assortment  of 
ownership  types. 
We  interviewed  management  and  key staff using a standardized  discussion  guide,  and 
reviewed  literature,  computer  and  manually-generated  data,  and  policies  and  procedures. 
FINDINGS 
We  could  not  determine  if the  operating  practices  of the  seven  agencies  we studied  cause 
lower  numbers  of visits and  lower  costs.  However,  the  case  studies  do illustrate  what 
some  home  health  agencies  are  doing  to control  costs while  still being  conscientious 
about  quality  of care. 
The  Seven  Home  Health  Agencies  We  Reviewed  Use  Well-Trained  Staff  In An 
	
Effort  To  Foster  Quality  Care  And  Early  Termination  Of SeMces.  All seven,  for 
example,  required  their  aides  to be State-certified,  and  in some  cases went  beyond 
i  Medicares  minimum  conditions  of participation  requirements  regarding  training 
and  orientation. 
F	 All Seven  Emphasize  Discharge  Planning.  Discharge  planning  is required  by 
Medicares  conditions  of participation.  The  seven  selected  agencies,  however, 
took  discharge  planning  extremely  seriously  and  made  an effort  to ensure  that  it 
began  at the  very beginning  of services.  They  also  stressed  informing  both 
patients  and  caregivers  that  the  goal  of home  health  care  was independence  as 
soon  as possible. 
E	 They  Closely  Monitor  Patient  Progress  To  Control  Excessive  Visits.  The 
monitoring  included  close  attention  of staff to each  patients  condition,  supervisory 
reviews,  quality  reviews,  data  analyses,  and  satisfaction  surveys  of both 
beneficiaries  and  referral  sources. 
Six Of The  Seven  Pay Staff A Salary  Or Hourly  Wage  Rather  Than  By The  Visit. 
	
Six of the  seven  said  paying  a salary  or by the  hour  is a way to help  minimize 
unnecessary  visits.  Management  believed  that  paying  by the  visit can  provide  an 
inducement  to perform  unnecessa~  visits, and  can  possibly  compromise  the 
quality  of care.  The  seventh  home  health  agency, which  paid  their  aide  staff by 
the  visit did successfully  keep  the  number  of visits low.  They  did this by closely 
monitoring  patients  and  by requiring  that  each  staff member  document  the 
homebound  status  of patients  during  each  visit. 
The  findings  suggest  that  operating  practices  similar  to those  described  above  could  help 
keep  costs  down without  jeopardizing  quality  of care.  More  detailed  descriptions  of the 
operating  practices  of these  seven  home  health  agencies,  along with  data  comparing  them 
to others,  can be  found  in the  appendices. 
ii  TABLE  OF  CONTENTS 
PAGE 
EXECUTIVE  SUMMARY

mODU~ON  . . . . . . . . . . . . . . . . . . . . ...  ..    ..  .    .  l

FINDINGS  . . . . . . . . . . . . . . . . . . ...  .-      .s5

.  Staff Training  . . . . . . . . . . . . . . ..  .  OO0.      s    ..5 
.  Discharge  Planning  . . . . . . . . . . . . . . . . . . . . . ..o.  oooooos.  00   6 

Monitoring  Patient  Progress.  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...6 
.Paying  Staff By Salary  . . . . . . . . . . . . . . . . . . . . . . .......  . ..9 
APPENDICES

Selected  Home  Health  Agencies  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..A-l

Characteristics  OfTheAgencies  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..B-l

Site  Visit Summaries  . . . . . . . . . . . . . . . . . . . ..-OO  ocoooooc-l
 INTRODUCTION 
PURPOSE 
To  describe  practices  used  by selected  home  health  agencies  which  help  them  to provide 
low-cost  care  to Medicare  beneficiaries. 
BACKGROUND 
Home  health  care  is nursing,  therapeutic,  medical  social,  and  aide  services  provided  in a 
persons  home.  Home  health  care  allows people  with limited  mobility  to live 
independently  while  still receiving  professional  health  care  services.  All home  health 
services  must  be  specified  in a plan  of care  certified  by a physician. 
Title  XVIII,  Section  1861, of the  Social  Security  Act  authorized  Medicare  Part  A 
payments  for home  health  care.  For  beneficiaries  who  do not  have  Part  A entitlement, 
home  health  services  may be  covered  by Medicare  Part  B.  To  receive  Medicare 
reimbursement,  home  health  agencies  must  provide  a skilled  care  semice  to a 
homebound  beneficiary  on a part-time  or intermittent  basis. 
Growth  of Home  Health  Care 
Medicare  expenditures  for home  health  care  increased  dramatically  in recent  years.  To 
illustrate,  between  1990 and  1995 Medicare  expenditures  for home  health  care  grew from 
$3.3 billion  to $15.1 billion  -- a nearly  5 fold increase  in just  5 years. 
Between  1992 and  1993, Medicare  expenditures  for home  health  care  increased  by 78 
percent.  During  this period,  expenditures  for home  health  care  by all insurance  sources 
in the  United  States  increased  by 23.8 percent.  In contrast,  the  Health  Care  Financing 
Administrations  (HCFAS)  Office  of the  Actuary  estimated  that  the  cost of hospital  care 
increased  by 6.7 percent  between  1992 and  1993.  Likewise,  expenditures  for physician 
care  increased  by 5.8 percent  between  1992 and  1993. 
Variation  in Cost  of Care  Among  Home  Health  Agencies 
Medicare  expenditures  for home  health  care  per  beneficiary  varied  significantly  among 
home  health  agenciesl  in recent  years.  Importantly,  the  variation  in reimbursement  was 
not  explained  by differences  in diagnosis,  cost per  visit, quality  of care,  or beneficiary 
characteristics  such  as age,  gender,  and  race. 
lVariations  Among  Home  Health  Agencies  In Medicare  Payments  For Home  Health  Serviees  OEI-04-93-00260 
1
 Most  of the  variation  in reimbursement  was explained  by variations  in the  number  of 
home  health  visits per  beneficiary  among  home  health  agencies.  Medicare  regulations 
allow beneficiaries  to receive  an unlimited  number  of home  health  visits, and  some  home 
health  agencies  provide  five times  more  visits per  beneficiary  on average  than  others. 
On  average,  about  two thirds  of 6803 home  health  agencies  provided  home  health  care 
with  33 visits per  beneficiary  in 1993.  The  remaining  one  third  averaged  81 visits per 
beneficiary.  The  high-visit  home  health  agencies  were  more  likely to be  proprietary,  for-
profit  and  unaffiliated. 
Concern  About  High-Cost  Home  Health  Agencies 
The  wide variation  in number  of visits per  beneficiary  raised  serious  questions  about 
possible  differences  in operating  policies  and  practices  of high  and  low-cost  home  health 
agencies.  In our  previous  inspection,  we looked  at  quality  of care,  among  other  things,  of 
low-cost  and  high-cost  home  health  agencies.  We  used  the  only available  proxies  for 
quality  which were  and  are  available  from  HCFA  and  other  reliable  sources  -- complaints 
against  a home  health  agency,  survey  deficiencies,  and  accreditation  status.  With  respect 
to these  measures,  we found  that  low-cost  agencies  provided  care  that  was comparable  in 
quality  to that  provided  by high-cost  home  health  agencies,  but  they  did so with fewer 
visits per  beneficiary. 
This  suggested  that  operating  practices  used  by low-cost  home  health  agencies  might 
provide  examples  that  high-cost  home  health  agencies  could  follow to keep  cost  down 
without  adversely  affecting  quality  of care.  This  report  describes  some  of those  practices. 
METHODOLOGY 
selection  of Home  Health  Agencies  For  Case  Study 
We  selected  seven  home  health  agencies  for this inspection.  They  are  listed  in 
Appendix  A. 
To  select  the  home  health  agencies,  we first identified  and  listed  all home  health  agencies 
to whom  HCFA  had  paid  Medicare  claims  for home  health  service  in 1993.  We  used 
HCFAS National  Claims  History  Repository  (NCHR)  to identify  the  home  health 
agencies.  The  NCHR  shows both  Medicare  claims  for home  health  services  paid  by 
HCF~  and  provider  numbers  that  identify  States  in which  a home  health  agency  is 
located. 
From  the  listing  of home  health  agencies  that  received  Medicare  reimbursement  for 
home  health  service  in  1993, we used  the  following  criteria  to select  seven  home  health 
agencies. 
2
 -.	 They  must  be  located  in one  of the  five Project  Operation  Restore  Trust 
(ORT)  States.  Atleast  oneagency  must  deselected  from  each  of the  five 
ORT  States. 
-- They  must  average  fewer  than  50.4 visits per  beneficiary  during  calendar 
year  1993.  The  national  average  for home  health  agency visits per 
beneficiary  in  1993 was 50.4. 
-.	 They  must  provide  quality  care.  We based  our  quality  care  determination 
on number  of complaints  and  deficiencies  recorded  in HCFAS On-line 
Survey  and  Certification  Reporting  System.  Complaints  and  deficiencies 
are  commonly  used  by HCFA  as proxies  for quality  care. 
-- They  must  represent  various  types  of ownership,  including  government, 
proprietary,  for-profit,  and  not-for-profit,  We  determined  type  of 
ownership  for selected  agencies  by using HCFAS On-line  Survey  and 
Certification  Reporting  System. 
.- They  must  not  be  under  investigation,  or have  a record  of negative  audit 
findings  or adverse  actions.  We made  this determination  by coordinating 
with  the  OIG  Offices  of Audit  and  Investigations,  and  with appropriate 
Regional  Home  Health  Intermediaries  (RHHI). 
A summary  on the  extent  of home  health  services  provided  by selected  home  health 
agencies  is contained  in Appendix  B. 
Data  Collection  and  Analyses 
At  each  selected  home  health  agency  we interviewed  appropriate  officials  and  staff  using 
a standardized  discussion  guide.  We  also reviewed  operating  policies,  procedures,  and 
practices  to corroborate  and  document  responses  provided  to our  standardized  interview 
questions. 
We  compared  data  collected  at site visits, and  identified  common  practices  which  had 
been  successfully  implemented  by two or more  of the  home  health  agencies.  We  profiled 
the  practices  as the  basic  analysis  of our  report.  We  also identified  successful  practices 
that  were  unique  to  one  agency,  but  which  might  be  useful  if practiced  more  widely. 
Finally,  we analyzed  practices  which were  markedly  different  in the  home  health  agencies 
to determine  whether  such practices  had  differential  impact  on the  number  of visits.  We 
integrated  this information  into  the  body  of the  report  and  included  brief  individual  case 
studies  in Appendix  C. 
Our  case  studies  of seven  low-cost  home  health  agencies  supplement  a sumey  we 
conducted  of 300 randomly-selected  high and  low-cost  home  health  agencies.  In that 
study we describe  similarities  and  differences  in operating  practices  of these  agencies. 
Our  survey  results  are  contained  in an OIG  report  titled  Operating  Practices  of High-
3  Cost  And  Low-Cost  Home  Health  Agencies;  0EI-04-93-O0261.  As we discuss  in that 
report,  the  mere  existence  of formalized  operating  procedures  does  not  explain  why some 
agencies  incur  higher  costs while  others  incur  lower  costs.  The  case  studies  described  in 
this report  show how some  of the  lower-cost  agencies  are  trying to keep  their  costs down 
while  remaining  conscientious  about  quality  of care. 
OPERATION  RESTORE  TRUST 
This  inspection  was part  of the  Presidents  Operation  Restore  Trust  initiative.  The 
purpose  of Operation  Restore  Trust  (ORT)  is to identi~  and  prevent  fraud,  waste  and 
abuse  in the  Medicare  and  Medicaid  programs.  This  is a joint  initiative  involving  the 
Health  Care  Financing  Administration,  Administration  on Aging,  Office  of Inspector 
General,  and  various  State  agencies.  In  1995, Project  ORT  began  targeting  home  health 
agencies,  nursing  homes,  hospices,  and  durable  medical  equipment  suppliers  in five States 
f&  evaluations,  &dits,  and  investigations.  The  five States-a;e  Florida;  New York,  Texas, 
Illinois,  and  California.  These  States  account  for about  40 percent  of the  nations 
Medicare  and  Medicaid  beneficiaries  and  program  expenditures. 
We  conducted  this inspection  in accordance  with  the  Qualizy Standards for Inspections 
issued  by the  Presidents  Council  on Integrity  and  Efficiency. 
4
 FINDINGS

Generally,  the  philosophy  of all seven  home  health  agencies  we inspected  was to provide 
quality  care  to patients  while  simultaneously  moving  patients  to a point  of independent 
living.  Regardless  ofhowloftily  orhowsimply  anagenq  stated  itsphilosophy,  the 
overriding  theme  was to teach  patients  to care  for themselves,  to teach  caregivers  to care 
for the  patient,  and  to help  patients  function  independently.  Each  emphasized  quality 
care  as a precursor  to patients  gaining  independent  living status  and  early  discharges 
from  home  care.  Accordingly,  they  attempted  to assure  quality  care  by using well trained 
staffs, focusing  on discharging  patients,  assuring  that  care  provided  was consistent  with 
patient  needs,  and  eliminating  incentives  for staff to make  unnecessary  home  health  care 
visits. 
We  could  not  determine  if these  operating  practices  cause  lower  numbers  of visits and 
lower  costs.  However,  the  case  studies  do illustrate  what  some  home  health  agencies  are 
doing  to control  costs while  still being  conscientious  about  quality  of care. 
The  Seven  Home  Health  Agencies  We  Reviewed  Use  Well Trained  Staff  In An Effort 
To  Foster  Quality  Care  And  Early  Termination  Of Home  Health  SeMce 
Each  of the  seven  selected  agencies  required  their  staffs to be well qualified  for their 
jobs.  To  illustrate,  all seven  required  home  health  aides  to be  State-certified.  As 
required  by the  Medicare  program  conditions  of participation,  all seven  required  aides  to 
attend  at least  12 hours  of in-service  training.  However,  two went  beyond  the  minimum 
requirements.  One,  for example,  required  an additional  40 hours  of training  for newly 
hired  aides.  Another  required  home  health  aides  to complete  48 hours  of continuing 
education  every  2 years. 
Likewise,  the  seven  selected  agencies  required  skilled  staffs  to undergo  extensive 
orientation  and  training.  One,  for  example,  required  registered  nurses  to undergo  a 3 
month  orientation.  At  another,  the  orientation  was customized  to the  individual  needs  of 
skilled  staff  members,  One  required  RNs  to go through  an orientation  followed  by a 12-
week  mentoring  program.  Another  required  the  nurses  to attend  at least  ten  in-service 
training  programs  yearly. 
To  assure  that  staff  are  well qualified,  five of the  agencies  required  all new hires  to pass 
a competency  and  skills evaluation.  One  only hired  experienced  staff,  hiring  skilled  staff 
from  other  agencies,  and  aides  from  a State  registry.  Additionally,  most  of them  checked 
references  of new hires.  Some  even  required  that  staff have  a current  immunization 
record  and  liability  insurance. 
5
 All Seven  Emphasize  Discharge  Planning  Starting  When  A Patient  Is Admitted  For 
Home  Health  Care 
All seven  home  health  agencies  said they begin  discharge  planning  during  the  first visit 
with  a new patient.  Such  planning  is required  by HCFAS Conditions  of Participation  for 
Medicare  home  health  agencies.  The  agencies  staffs emphasized  that  home  health  care 
should  be  tailored  to a patients  needs,  and  it should  be  terminated  when  a patient  is 
capable  of independent  living.  Typically,  when  commencing  service,  selected  staffs 
evaluated  a patients  condition,  and  estimated  duration  and  number  of home  health  care 
visits to be  made.  Staffs  at the  home  health  agencies  we reviewed  emphasized  that  the 
focus  is on moving  a patient  to a point  of independent  living. 
Patients  and  family members  who  are  involved  in caring  for patients,  are  advised  when 
home  health  care  commences  that  it is temporary  care.  Patients  are  never  allowed  to 
believe  that  home  health  care  is permanent.  This  helps  avoid  any misunderstandings  and 
pressure  to continue  care  after  a patient  is no longer  homebound.  Staff  at  all seven 
home  health  agencies  included  in our  study, advised  us that  they  strictly  follow the 
Medicare  homebound  criteria  when  deciding  whether  or not  to initiate,  continue,  or 
terminate  home  health  care. 
As a patients  condition  changes,  the  plan  of care  is adjusted.  If a patient  progresses 
faster  than  expected  to a point  of independent  living, care  is terminated  and  the  patient 
is discharged. 
The  home  health  agencies  we reviewed  told  us that  the  orientation  toward  ending  home 
health  services  provides  a framework  for preventing  unnecessa~  visits.  For  example,  one 
manager  told  us that  staff  see  discharge  planning  as a contract.  The  staff provide 
estimates  to patients  and  their  families  on what  care  to expect,  length  of care,  and 
number  of visits.  Such  discharge  planning  sets a tone  within  the  agency  that  unnecessary 
visits will not  be  made.  It also establishes  an understanding  with  patients  that  home 
health  care  services  are  time-limited,  and  it helps  focus patients  toward  reaching 
independence. 
They  Closely  Monitor  Patient  Progress  To  Control  Excessive  Visits 
Each  of the  home  health  agencies  we inspected  had  written  procedures  and  operating 
practices  for  evaluating  and  monitoring  patient  condition,  and  determining  that  patients 
were  progressing  toward  independent  living as planned.  The  home  health  agencies  used 
a variety  of evaluation  and  monitoring  practices,  including  staff monitoring  of patient 
condition,  supervisory  reviews,  quality  reviews,  and  analyses  of types  and  number  of 
patient  visits.  Usually,  individual  agencies  used  a combination  of the  various  techniques. 
Staff  Monitoring  The  seven  home  health  agencies  we inspected  required  all staff  to 
constantly  evaluate  and  monitor  beneficiaries  to determine  that  home  health  services  are 
reasonable  and  necessary.  The  evaluation  and  monitoring  started  immediately  after  a 
patient  was referred  for  home  health  care  and  continued  until  a patient  was discharged. 
6  For  each  patient,  the  agencies  performed  an initial  patient  evaluation 2.  Generally,  a

registered  nurse  did the  initial  evaluation.  Typically,  the  RN  contacted  a patients

physician  for medical  orders  and  did a physical  examination  of the  patient  to determine

homebound  status,  types  of home  care  needed,  frequency  of home  care  visits, and

duration  of visits.  This  information  was then  incorporated  into  a plan  of care  for the

patient.

According  to staffs we interviewed,  the  initial  patient  evaluation  is vitally important  to

assuring  that  care  is reasonable  and  necessary  for each  patient.  It helps  avoid

unnecessary  home  health  care  visits.  One  director,  for example,  said  the  initial

evaluation  assures  appropriate  service  and  controls  use.  Another  said  the  most

important  question  answered  by the  initial  evaluation  is whether  home  health  care  will

benefit  a patient  by restoring  or improving  ability  to function  independently.  Another

agency  devoted  an entire  section  of the  procedures  manual  to the  initial  evaluation.  The

focus  of the  procedures  was on determining  eligibility  for home  care,  and  the  types  and

frequency  of service  needed.  Procedures  at  another  agency  required  staff to contact  a

patients  physician  within  48 hours  of referral  to ascertain,  among  other  things,

appropriate  types,  frequency,  and  duration  of home  health  services.

After  starting  home  health  care,  each  of the  seven  home  health  agencies  required  staffs

to continuously  evaluate  a patients  progress.  For  this purpose,  most  of the  home  health

agencies  assigned  each  patient  to a case  manager.  The  case  manager  was always a

registered  nurse.  The  objective  was to assure  that  services  provided  are  consistent  with

patient  needs,  and  that  patients  progress  as rapidly  as possible  to a point  where  they  can

function  independently.

One  director  advised  us that  constant  evaluation  of a patients  condition  is the  key to

assuring  appropriate  services  and  number  of visits.  As a patients  condition  changes,  the

plan  of care  is updated,  and when  the  patient  is no longer  homebound  care  is

terminated.  As part  of its case  management,  one  agency,  for example,  conducted  daily

reviews  of patient  progress  and  services  provided.  Another  encouraged  staff who  contact

patients  to advise  the  nurse  manager  of any change  in patient  condition.  Another

required  staff  to contact  the  case  manager  within  24 hours  of providing  home  care  to a

patient.  Finally,  another  agency  required  staff  to document  and  certify  a patients

homebound  status  after  each  visit.

Supemisory  Reviews:  In addition  to constant  evaluation  of each  patients  condition  by

field  staff,  each  home  health  agency  required  supervisory  review  of patient  services.  The

method  of supervision  varied  among  the  seven  home  health  agencies.  However,  to

assure  that  home  care  was appropriate  and  reasonable  to patient  needs,  supervisory

nurses  typically  reviewed  progress  notes  and  followed-up  as appropriate,  compared

patient  progress  to plans  of care,  and  evaluated  patients  personally.  One  agency

required  supervisory  nurses  to visit patients  at  least  every  14 days.  Such visits may be

2 
The  HHAs  used various  terms  to refer to the initial evaluations.  For example,  they used such terms  as initial 
assessment,  initial screening,  and start  of care visit.  made  jointly  with  or independently  of the  aides  and  nurses  actually  providing  care.  One 
director  said  the  goal  of such  supervisory  review  is to move  a patient  out  of service  as 
quickly  as feasible.  Another  director  said the  skill of supervisory  nurses  leads  to more 
appropriate  patient  care  which  results  in fewer  home  care  visits. 
One  of the  home  health  agencies  we inspected  told  us nurse  supervisors  are  responsible 
for questioning  any deviation  in service,  and  apparent  failure  of patients  to respond 
appropriately.  Another  agency  said  that  if the  supervisory  nurse  observes  a discrepancy 
between  a patients  condition  and  plan  of care,  the  nurse  may initiate  action  to replace 
aides  and  nurses,  and  to terminate  or increase  the  frequency  of home  care  visits. 
Likewise,  each  of the  seven  home  health  agencies  we inspected  had  specific  procedures 
for recording,  investigating,  and  resolving  complaints.  Such procedures  for complaints 
are  required  by the  Medicare  program  conditions  of participation.  When  a patient 
complains  about  care,  it is recorded  and  brought  to the  attention  of the  supervisory 
nurse.  One  agency  required  that  supemisory  nurses  investigate  any complaint  within  24 
hours  after  it is received.  Equally  important,  however,  is the  practice  of some  home 
health  agencies  of analyzing  and  summarizing  complaints.  The  purpose  is to identify 
systemic  problems  that  might  adversely  impact  patient  progress  toward  achieving 
independent  living status.  The  resolution  of such  systemic  weaknesses  clearly  results  in 
earlier  discharges  and  fewer  visits per  beneficiary  than  would  otherwise  be  possible. 
Quality  Reviews:  All seven  home  health  agencies  we inspected  performed  some  type  of 
quality  review  on patient  services.  The  agencies  typically  used  a combination  of 
techniques,  including  quality  assurance  teams,  peer  reviews,  staff conferences,  and 
utilization  review  committees. 
One  home  health  agency  described  the  quality  assurance  policy as to systematically  and 
objectively  evaluate  the  quality  and  appropriateness  of patient  care.  To  this end,  a 
utilization  review  committee  met  quarterly  to assure  appropriate  delive~  and  use  of 
services.  Another  agency  used  a quality  management  team  to identify  problems  and 
trends  in care,  and  to intervene  when  needed  to improve  patient  care.  Another  agency 
convened  a utilization  review  committee  which included  agency  members  and  members 
of the  community.  The  committee  met  quarterly  to review  beneficiary  records  of home 
health  care.  Another  agency  used  a quality  improvement  audit  to regularly  evaluate 
beneficiary  records  to determine  that  home  health  care  was appropriate  for patient 
needs.  One  agency  conducted  quarterly  peer  reviews  of patient  care.  Finally,  most  of 
the  home  health  agencies  used  monthly  conferences  or quarterly  conferences  to help 
assure  that  appropriate  care  was provided,  and  to control  excessive  visits. 
Satisfaction  Surveyx  Six of the  seven  home  health  agencies  included  in our  inspection 
conducted  patient  satisfaction  surveys to monitor  appropriateness  of care.  For  example, 
one  agency  verbally  surveyed  all patients  at the  beginning  of service  and  immediately 
after  discharge.  Additionally,  this agency  conducted  a monthly  mail  sumey  of a random 
sample  of patients  who  are  currently  receiving  services.  Each  quarter,  another  agency 
surveyed  a 5 percent  sample  of its patients  by telephone,  and  another  10 percent  sample 
8  by mail.  Oneagenq  that  sumeyed  itspatients  used  anoutside  organization  toanalpe

the  results,  and  to compare  the  agencys performance  to that  of other  agencies  who used

the  same  outside  organization.  Patients  included  in the  survey were  those  that  had  been

admitted  for  home  health  care  12 months,  6 months,  and  1 month  earlier  than  the  survey

date.

Likewise,  six of our  selected  home  health  agencies  regularly  conducted  satisfaction

surveys  of physicians  and  others  who referred  patients  to them  for home  health  care.

For  example,  twice  a year  one  agency  surveyed  about  80 percent  of the  physicians  and

others  who  referred  patients  to the  agency.

Data  halysex  Four  of the  seven  home  health  agencies  we inspected  collected  and

analyzed  statistical  data  on services  provided  to identi~  trends  and  monitor  use--e.g.,

number  of visits.  When  such analyses  showed  an unusually  large  number  of visits per

beneficiary  over  time,  it might  trigger  other  more  penetrating  types  of analyses,  such as a

supervisory  review  or quality  analyses.  One  agency  maintained  an automated  data  base

for tracking  and  analyzing  home  health  use over  time.

Six Of The  Seven  Home  Health  Agencies  Pay Staff A Salruy Or  Hourly  Wage  Rather

Than  By Visit To  Help  Minimke  Umecessary  Visits

Six of the  seven  home  health  agencies  we inspected  paid  home  health  aides  a salary  or

hourly  wage  rather  than  compensating  based  on number  of visits they  made.  The

remaining  agency  paid  home  health  aides  by the visit.  Likewise,  five of the  seven  home

health  agencies  paid  their  nursing  staff by the  hour  or a salary.  One  paid  nurses  by the

visit.  The  remaining  agency  compensated  some  nurses  by the  hour  and  others  by the

visit.

According  to some  agency  directors,  compensating  by the  salary  or hourly  wage

eliminates  an  incentive  for  staff to make  unnecessary  visits.  For  example,  the  manager  at

one  agency  which  paid  home  health  aides  by the  hour  said the  aides  understand  that

there  are  no quotas  for numbers  of visits per  beneficiary,  and  no  advantage  in making  as

many  as possible.  According  to the  Aide  Coordinator,  each  home  health  aide  visits five

to six patients  per  day, on average.  The  Coordinator  stressed  that  service  quality  would

be  diminished  if an  aide  made  more  than  five or six home  health  care  visits per  day.

Similarly,  the  manager  at another  agency  said that  paying  staff by the  hour,  rather  than

by the  visit, helps  ensure  quality  semice.  At this  agency,  staff are  instructed  to deliver  as

many  skilled  services  in one  visit as are  appropriate,  based  on each  patients

individualized  plan  of care.

Some  agency  managers  we interviewed  stated  that  paying  staff by the  visit offers  an

incentive  for  staff to provide  unnecessary  visits.  However,  the  agency  that  paid  home

health  aide  staff  by the  visit did successfully  keep  the  number  of visits per  beneficiary

low.  According  to the  Director  and  staff, they  kept  the  number  of visits low by closely

monitoring  patients,  and  by requiring  that  the  staff document  the  homebound  status  of

9
 each  patient  during  each  visit.  Such monitoring  enabled  the  agency  to timely  terminate 
home  health  visits based  on patient  condition. 
10
 APPENDIX  A 
SELECIED  HOME  HEALTH  AGENCIES  (HHAs) 
..	 Mid-Florida  Home  Health  Services,  Winter  Haven,  Florida 
not-for-profit,  private,  hospital-based 
-- Premier  Health  Connection,  Walnut  Creek,  California 
proprietary,  nonaffiliated 
.- Holy  Cross  Home  Health  Services,  Chicago,  Illinois 
not-for-profit,  religious-affiliated 
..	 American  Care,  Inc., Newburgh,  New York 
proprietary,  non-affiliated 
..	 Westchester  County  Department  of Health,  Hawthorne,  New York 
government-operated  Official  Health  Agency 
.- Spohn  Home  Health,  Corpus  Christi,  Texas 
not-for-profit,  religious-affiliated,  hospital-based 
.- Linden  Municipal  Hospital  Home  Health  Systems,  Linden,  Texas 
not-for-profit,  hospital-based 
A-1
 APPENDIX  B 
CHARACXENSTICS  OF THE  SELECTED  HOME  HEALTH  AGENCIES 
Average  Number  Of Visits Per  Beneficiary  By Selected  Home  Health  Agencies  Was 
Lower  Than  The  National  Average 
Nationwide,  the  average  home  health  agency  made  50.4 visits per  beneficiary  in 1993 and 
58.4 visits in 1994.  Table  1 shows that  in 1993 and  1994 the  seven  home  health  agencies 
we selected  for our  case  study  averaged  25.1 and  27.0 visits per  beneficiary  -- about  half 
the  national  average. 
The  average  number  of visits per  beneficiary  by our  seven  selected  home  health  agencies 
ranged  from  19 to 31 in  1993, and  from  23 to 33 in 1994. 
TABLE  1 
Comparison  Of Visits By Selected  HHAs 
To The  National  Average 
1993  1994 
Average  Visits  Average  Visits 
Premier  Health  Connection  24  23 
Mid-Florida  Home  Health  Services  27  28 
Holy  Cross  Home  Health  Services  20  24 
Westchester  County  Dept.  of Health  20  25 
American  Care,  Inc.  31  31 
Spohn  Home  Health  Care  25  32 
Linden  Municipal  Hospital  Home  Health  19  33 
Systems 
NATIONAL  AVERAGE  I  50  I  58 
Source  of Data:  HCFAS National  Claims  History  File 
B-1
 Average  Number  of Visits Per  Benefickq  By Selected  Home  Health  Agencies  Was 
Lower  Than  The  State  Average  For  All Home  Health  Agencies  Located  In The  State 
In both  1993 and  1994, each  of the  seven  home  health  agencies  we selected  for  case 
study  averaged  fewer  visits per  beneficiary  than  did the  average  home  health  agency  in 
the  State  where  they were  located.  Table  2 compares  the  number  of visits per 
beneficiary  by our  selected  agencies  to the  average  number  of visits by all home  health 
agencies  located  in their  respective  States. 
TABLE  2 
Comparison  Of Average  Visits By Selected  HHAs 
To The  State  Averages 
1993  1994 
Average  Visits By  I  Average  Visits By 
HHA  HIM  I  STATE  I  HHA  I  STATE 
Premier  Health  Connection  24136123139 
I  I 
Mid-Florida  Home  Health  Services  27  57  28  I  60 
Holy Cross  Home  Health  Services  20140124145 
I 
Westchester  County  Dept.  of Health  20  42125139 
American  Care,  Inc.  31  I  42  I  31  I  39 
Spohn  Home  Health  Care  +--F--F

Linden  Municipal  Hospital  Home 
Health  Systems 
B-2  Average  Number  Of Aide  Visits By Selected  Home  Health  Agencies  Was  Lower  Than 
The  National  Average 
In a prior  inspection  (OEI-04-93-O0260)  on variation  in average  Medicare  reimbursement 
per  beneficiary  for home  health  care,  we found  that  some  agencies  averaged  seven  times 
more  aide  visits than  others.  Table  3 shows that  all seven  home  health  agencies  we 
inspected  averaged  below  the  national  average  in aide  visits per  beneficiary  in 1993 and 
1994.  Our  seven  selected  home  health  agencies  averaged  less than  half  the  national 
average  in 1993, and  only one  averaged  more  than  half the  national  average  in 1994. 
TABLE  3 
Average  Number  Of Home  Health  Aide  Visits Per 
Beneficiary  By Selected  Home  Health  Agencies 
Compared  To The  National  Average 
1993  1994 
Average  Visits  Average  Visits 
Premier  Health  Connection  4.5  4.0 
Mid-Florida  Home  Health  Services  8.8  8.4 
Holy  Cross  Home  Health  Services  5.3  7.0 
Westchester  County  Dept.  of Health  5.1  7.5 
American  Care,  Inc.  10.7  11.6 
Spohn  Home  Health  Care  9.0  11.0 
Linden  Municipal  Hospital  Home  Health  7.9  16.9 
Systems 
NATIONAL  AVERAGE  I  23.6  I  27.6 
B-3
 Average  Number  Of Skilled  Nursing  Visits By Selected  Home  Health  Agencies  Was 
Lower  Than  the  National  Average 
In both  1993 and  1994, skilled  nursing  visits per  beneficiary  by selected  home  health 
agencies  averaged  well below  the  national  averages  (See  table  4). 
TABLE  4

Average  Number  Of Skilled  Nursing  Visits Per  Beneficiary

By Selected  Home  Health  Agencies

Compared  To The  National  Average

1993  1994 
Average  Visits  Average  Visits 
Westchester  County  Dept.  of Health
 9.3  10.9 
Holy  Cross  Home  Health  Services
 10.4  11.4 
Spohn  Home  Health
 10.5  14.4 
Linden  Municipal  Hospital  Home  Health
 System  10.6  15.7 
Mid-Florida  Home  Health  Services
 12.5  14.0 
Premier  Health  Connection
 14.5  14.4 
American  Care,  Inc.
 16.7  15.8 
NATIONAL  AVERAGE
 21.5  25.1 
B-4
 APPENDIX  C 
SITEV ISISTt nmowms
HOME  HEALTH  AGENCY  PAGE 
Mid-Florida  Home  Health  Services
 c-2 
Premier  Health  Connection
 c-5 
Holy  Cross  Home  Health  Services
 C-8 
American  Care,  Inc.
 C-n 
Westchester  County  Department  of Health
 C-14 
Spohn  Home  Health
 C-17 
Linden  Municipal  Hospital  Home  Health  Systems
 C-20 
c-1  MID-FLORIDA  HOME  HEALTH  SERVICES 
WINTER  HAVEN,  FLORIDA 
General  and  Background

This  home  health  agency  is a not-for-profit,  hospital-based  home  health  agency  which  is a

division  of Mid-Florida  Medical  Services,  They  have  one  branch  and  serve  the

population  of 2,000-square-mile  Polk  County,  Florida.  Polk  County  has  a population  of

approximately  one  half  million  people  who live in both  urban  and  rural  areas.

Mid-Florida  Home  Health  Services  first received  JCAHO  accreditation  in  1991.  They

are  also  members  of the  National  Association  for Home  Care,  the  Associated  Home

Health  Industries  of Florida,  and  the  Florida  Hospital  Association  Home  Care  Section.

Their  policies,  budget,  financial  status,  quality  improvement  process,  program

development  and  program  evaluation  are  overseen  by a volunteer  board  of trustees  who

are  appointed  by the  Parent  Board  of Mid-Florida  Medical  Services.

The  agencys  average  reimbursement  per  beneficiary  in 1993 was $1448 and  the  average

number  of visits per  beneficiary  was 27.  In  1993, the  majority  of their  Medicare

beneficiaries  were  between  the  ages of 65 and  79 (59 percent),  and  most  were  white  (90

percent).  The  majority  of their  work  in 1993 and  1994 (83 percent  and  86 percent

respectively)  was done  for Medicare  beneficiaries.  In  1993 they  had  100 FTEs.  In

addition  to FTEs,  they  use  approximately  24 contract  employees  who  are  therapists  or

medical  social workers.

How  does  the  Home  Health  Agency  ensure  that  the  people  they  are  seining  are  qualified

for Medicare  home  health  care  and  the  appropriate  number  and  types  of services  are

provided?

This  home  health  agencys Medicare  beneficiaries  usually  come  from  a hospital  into

home  care.  Typically  patients  are  referred  by a discharge  planner  or social worker;

however,  a patient,  patients  family,  or attending  physician  will occasionally  suggest  home

care.  Once  a referral  is received  by the  agency,  they  send  an RN  out  to perform  a start

of care  (SOC)  visit.  An  entire  section  of their  procedures  manual  is devoted  to ensuring

eligibility  and  determining  types  of services  and  frequency  of visits during  an SOC visit.

The  agency  has  a precise,  written  definition  of homebound.  If a person  is non-

ambulatory,  needs  assistance  to leave  home  or leaves  home  infrequently,  or uses  a device

to assist  in moving  around,  the  person  is probably  homebound.  More  precisely,  the

procedures  manual  points  out  that  documentation  of a persons  homebound  status  is

important  on the  very first visit, and  that  such  documentation  needs  to include  such

things  as shortness  of breath;  weakness;  use  of assistance  devices  such as walker,  cane,

wheelchair,  bedside  commode,  shower  chair;  need  for assistance  from  care  giveq  or other

indicators  of limited  mobility.

c-2  Because  of the  agencys emphasis  on patient  independence,  discharge  planning  is part  of 
the  very first visit to a new patient.  If a person  has  consistently  met  the  goals  in the 
assessment  file and  on his/her  plan  of care,  and  if s/he  remains  unchanged  for 2 to 3 
weeks  at that  level  of performance,  then  the  home  health  agency  staff  are  to discontinue 
home  care  services. 
The  key to insuring  that  only necessa~  services  and  an appropriate  number  of visits are 
given is constant  reevaluation  of the  beneficiary.  As a persons  condition  changes,  the 
goals  in his or her  file are  updated.  If a person  has  a record  of a large  number  of visits 
over  a long period  of time,  a case  review  conference  may be  held  and  a supervisor  sent 
out  to evaluate  that  persons  condition. 
This  agency  maintains  data  bases  for tracking  numbers  of visits by type  and  contrasting 
those  figures  to the  previous  year  or years.  The  Quality  Control  (QC)  staff  are 
continually  reviewing  patient  records,  counting  visits and  matching  visits to notes  in each 
patients  file.  If no notes  are  found  to substantiate  a visit, that  visit is never  submitted  to 
Medicare  for reimbursement. 
How  does  the Home  Health  Agency  attempt to assure  quality  of services? 
This  home  health  agency  is extremely  active  in quality  assurance.  They  have  an entire

section  in their  manual  on total  quality  management  and  a formal  quality  improvement

plan.  The  plan  includes  quality  improvement  teams  which  identify  problems  and  trends

and  intervene  to improve  patient  outcomes.  The  teams  report  their  activities  to the

quality  improvement  (QI)  committee,  which  meets  quarterly.  The  QI  committee  also

monitors  satisfaction  surveys completed  by patients,  physicians,  and  referral  sources.  The

committee  issues  quarterly  reports  on the  results  of satisfaction  surveys,  non-admits,

patient  incident  reports,  and  employee  reports  to the  Board  of Trustees.

The  policy  on quality  improvement  is to systematically  and  objectively  monitor  and

evaluate  the  quality  and  appropriateness  of patient  care  by empowering  all staff  to be

part  of the  problem-finding  and  decision-making  process  on an ongoing  basis.  While  the

governing  body  assumes  overall  legal  authority  and  responsibility  for quality  improvement

planning  and  implementation,  the  Administrator  is responsible  for the  overall  program,

and  the  Quality  Management  Supemisor  is responsible  for the  actual  operations  of the

program.  In addition,  a Utilization  and  Clinical  Records  Review  Committee  meets

quarterly  to assure  that  services  are  delivered  appropriately  as needed  and  to identi~

inappropriate  utilization.  The  Patient  Care  Service  Director  is responsible  for  taking

action  to address  problems  or improve  care.

Concern  for giving quality  care  is further  reflected  in the  agencys commitment  to training

and  orientation.  RNs  are  in orientation  for three  months.  One  year  of case

management  experience  is required  prior  to an RN  being  considered  for a position  in

quality  assurance.  The  agency  has  an orientation  manual  for all new staff, who  are

required  to rotate  through  all sections  of the  organization,  to attend  a skills lab, and  to

have  a preceptor  accompany  them  in the  field.  RN  staff  are  assigned  to a geographic

c-3  area;  however,  within  each  area  an attempt  is always made  to make  the  best  match 
between  a patients  condition  and  care  needs  and  the  particular  skills and  experience  of 
an RN. 
Home  health  aides  are  also trained  to play a continuous  role  in ensuring  quality  care. 
Aides  are  required  to have  CNA  certification,  which  is supplemented  with  40 hours  of in-
house  training  bytheagenq,  field  evaluations  and  frequent  competent  testing.  Every 
two weeks  an RN  makes  a supervisory  visit to check  on the  performance  of an aide. 
Aides  are  paid  by the  hour  rather  than  by the visit, and  their  records  regarding  charges 
and  mileage  are  closely monitored  to ensure  accurate  reporting. 
What  is the  philosophy  of the  Home  Health  Agency? 
This  agency  has  developed  a comprehensive  manual  which  contains,  among  other  things, 
a formal,  written  philosophy.  An important  facet  of the  agencys philosophy  is to teach 
another  caregiver  or the  patient  to perform  the  tasks  that  agency  staff  are  performing  so 
that  they  can  decrease  and  eventually  cease  services.  The  written  philosophy  statement 
says that  the  primary  goal  of the  agency  is to provide  the  highest  quality  of health  care  to 
the  patient  while  using well qualified  staff, preserving  the  patient  in the  home,  and 
meeting  the  needs,  including  the  spiritual  needs,  of each  patient.  The  philosophy 
acknowledges  each  persons  right  to be treated  with  dignity and  respect. 
In addition  to a philosophy  statement,  the  manual  contains  a mission  statement,  a 
definition  of a patient,  and  a clear  statement  of the  agencys objectives.  It contains  a 
detailed  description  of each  job  in the  agency,  lines  of authority,  procedures  for 
performing  jobs,  time  card  completion,  Medicare  and  Medicaid  regulations,  safety 
guidelines,  procedures  for supplies,  charges  and  mileage,  and  a multitude  of other  details. 
c-4  PREMIER  HEALTH  CONNECTION 
WALNUT  CREE&  CA 
General  and Background 
Premier  Health  Connection,  previously  known  as the  Premier  Health  Semites  of the  Bay 
Area,  is a proprietary,  for-profit,  non-affiliated  home  health  agency  headquartered  in 
Walnut  Creek,  California.  It was established  in 1977, and  serves  the  entire  San Francisco 
Bay area,  including  the  mainly  urban  counties  of Alameda,  Contra  Costa,  Solano,  Napa, 
Sonoma,  San Francisco,  San Mateo,  and  Marin.  In addition  to Medicare  patients,  they 
also  serve  private  pay, third-party  pay, Medicaid  (Medi-Cal),  and  HMO  patients  of 
Kaiser-Perrnanente. 
The  agency  is divided  into  two divisions,  the  Intermittent  Care  Division,  which  provides 
home  health  services,  and  the  Continuous  Care  Division, which  serves  people  who  need 
around-the-clock,  custodial  care  in their  homes.  The  agency  is run  by a governing  body 
of officers,  and  receives  guidance  from  an Advisory  Board  which  consists  of professional 
and  community  people  who  review  the  organizations  policies  and  recommend 
improvements.  The  Advisory  Board  is comprised  of at least  one  physician  and  an RN, 
one  of whom  is neither  an owner  nor  an employee  of Premier,  and  representatives  of 
consumers,  hospitals,  medical  and  other  health-related  entities  in their  market  area. 
Premier  has been  accredited  by JCAHO  since  1991.  They  received  a commendation 
from  JCAHO  after  their  most  recent  review  in 1994.  In addition,  they belong  to the 
CAHSAH  (California  Association  for Health  Services  at Home),  the  NAHC  (National 
Association  of Home  Care),  the  Bay Area  Regional  Council  (an  offshoot  of the 
CAHSAH),  and  the  Continuity  of Care  Council. 
In  1994, slightly more  than  half  (51.7 percent)  of their  visits were  made  to Medicare 
beneficiaries,  45.4 percent  to other/third  party,,  1.8 percent  to Medi-Cal,  and  1 percent 
to private/self  pay. 
How  does  the  Home  Health  Agency  ensure  that  the  people  they  are  serving  are  qualified 
for Medicare  home  health  care  and  that  the  appropriate  number  and  type  of seMces  are 
provided? 
The  agencys policy  and  procedures  manual  (PPM)  contains  several  sections  which 
address  eligibility.  Those  sections  include  a policy and  procedures  on verifying  the 
Medicare  status  of newly-referred  patients,  on acceptance  and  assignment  of referrals 
and  initial  assessment  of new patients,  and  on the  admission  criteria  and  protocol  for 
Medicare  beneficiaries.  Those  procedures  are  so detailed  that  they  require  the  staff 
person  who  opens  a case  to see  a Medicare  beneficiarys  Medicare  card. 
Agency  personnel  are  required  to verify and  document  for each  visit that  a Medicare 
beneficiary  is still homebound.  Ascertaining  that  a person  is in need  of skilled  services  is 
accomplished  through  a combination  of the  orders  received  from  his/her  attending 
c-5  physician  and  an  evaluation  of the  persons  condition  by the  staff person  who  opens  the 
case.  If a person  does  not  meet  all criteria  for admission,  agency  personnel  will notify 
the  referral  source  and  provide  information  on alternate  care  sources. 
Several  levels  of personnel  monitor  a case  to ensure  the  appropriateness  of the  number 
and  types  of visits.  As soon  as a patient  is evaluated,  a case  goes  to the  Utilization 
Review  Nurse,  who  develops  a Plan  of Care  specifying  the  frequency,  duration,  and  types 
of services  to be  provided.  The  completed  Plan  of Care  is sent  to the  attending  physician 
who  must  verify his/her  orders  and  sign the  plan.  In addition  the  Nursing  Supervisor, 
Utilization  Review  Nurse,  and  staff hold  monthly  team  meetings  and  patient  care 
conferences  in which  they  discuss  the  progress  of a patient  and  any appropriate  changes 
to a Plan  of Care.  Any employee  involved  in a patients  care  is empowered  to call a 
supervisor  or any other  discipline  to discuss a patients  progress. 
Agency  staff  are  required  to document  and  certify  as to the  condition  of a patient  after 
each  visit.  Each  plan  of care  is reviewed  every  60 days and  revised  as necessary  before 
being  sent  to the  certifying  physician  for signature.  The  PPM  requires  that  the 
frequency,  duration,  and  type  of services  be part  of this review. 
How  does  the  Home  Health  Agency  attempt  to assure  quality  of seMces? 
The  results  of patient  evaluations  are  fed  into  the  Quality  Assessment  and  Improvement 
Audit  Program.  The  Continuous  Utilization  Review/Quality  Improvement  Audit  Program 
ensures  that  services  are  appropriate;  that  patients  needs  are  met  both  quantitatively  and 
qualitatively;  that  each  patients  records  reflect  needs,  conditions,  problems,  goals, 
services,  diagnoses,  and  evidence  of medical  necessity  that  each  disciplines  role  is clearly 
delineated;  and  that  field  staff receive  ongoing  guidance  and  feedback.  Patient  care 
evaluations  and  clinical  records  are  audited  to monitor  quality  and  to address  problems 
or complaints. 
The  agency  also  operate  a Performance  Improvement  Plan.  The  plan  is intended  to 
achieve  the  best  possible  patient  service  and  is designed  to monitor  and  evaluate  the 
quality  of services,  pursue  opportunities  to improve  services,  and  resolve  problems. 
Included  in this plan  are  patient  and  client  satisfaction  sumeys.  Each  quarter  the  agency 
selects  5 percent  of their  patients  to survey by telephone  and  another  10 percent  to 
survey by postcard.  Twice  a year  they  survey about  80 percent  of physicians  and  other 
referral  sources  by mail. 
To  ensure  technical  skills and  competency,  the  agency  performs  a competency  and  skills 
evaluation  of all new  staff and  provides  an orientation.  RNs  participate  in a 12-week 
mentoring  program  following  orientation.  The  agencys standards  for hiring  aides  are 
higher  than  the  Medicare  conditions  of participation.  Aides  are  also required  to take  48 
hours  of continuing  education  every  two years. 
Two other  processes  which  relate  to quality  assurance  are  the  ethics forum  and  a 
semice  code  of ethics.  The  ethics  forum  provides  support  and  advice  in dealing  with 
C-6  ethical  dilemmas,  particularly  in more  complex  situations  and  in cases which  are  more 
problematic  for the  staff.  The  service  code  of ethics  is a pledge  which  agency  personnel 
take  in recognition  of the  importance  of providing  quality  services.  The  pledge  includes 
such principles  as consistently  providing  quality  service  in accordance  with the  highest 
professional  and  ethical  standards  possible;  abiding  by all Federal,  State,  and  local  laws, 
rules  and  regulations;  not  discriminating  on the  basis  of age,  race,  sex, creed,  color, 
national  origin  or handicap;  and  carefully  matching  skills and  abilities  of the  staff to the 
needs  of the  clients. 
What  is the  philosophy  of the  Home  Health  Agency? 
Their  policies  and  procedures  manual  contains  a written  mission  and  philosophy 
statement.  It says that  their  mission  is to provide  high-quality,  cost-effective  multi-
disciplinary  health  services  to patients  and  clients. 
Their  philosophy  statement  says that  home  care  plays an integral  part  in the  complete 
health  care  system,  supplying  patients  and  families  with a cost-effective  alternative  in the 
privacy  and  dignity  of their  place  of residence.  It goes  on to say that  they  believe  that 
each  patient  has  the  right  to considerate  and  respectful  care,  including  the  right  to live 
and  die with  all the  dignity  and  respect  that  human  life contains,  and  the  right  to know 
his/her  diagnosis. 
The  agencys emphasis  is on teaching  the  patient  or a caregiver  to provide  all the  care 
that  agency  staff  are  providing,  and  to, thereby,  make  the  patient  as independent  as 
possible,  as soon  as possible. 
c-7  HOLY  CROSS	 HOME  HEALTH  SERVICES 
CHICAGO,  IL 
General  and  Background 
Holy  Cross  Home  Health  Services  (HCHHS)  is a department  of Holy  Cross  Hospital, 
which was founded  by the  Sisters  of Saint  Casimir.  Home  health  services  were  started  in 
1990.  HCHHS  is a volunteer,  not-for-profit  agency  which  serves  patients  in metropolitan 
Chicago.  The  agency  has been  accredited  by JCAHO  since  1990, and  was last  surveyed 
by the  Commission  in  1995. 
The  agencys governing  body  is the  Board  of Trustees  of the  Holy  Cross  Hospital.  The 
Board  is legally  responsible  for the  home  health  agency  operations.  Responsibilities 
outlined  for the  Board  in the  policy and  procedures  manual  (PPM)  include  annually 
reviewing,  revising,  and  adopting  policies,  procedures  and  objectives  of the  Department, 
reviewing  the  Departments  operations,  and  appointing  the  Professional  Advisory 
Committee.  This  Committee  participates  in evaluating  the  home  health  services 
program.  A Professional  Advisory  Committee,  which  helps  guide  the  agency,  is 
comprised  of the  VP of the  hospital,  the  Director  of HCHHS,  the  Supervisor  of Patient 
Care  Services,  one  physician,  the  fiscal manager  and  human  resources  director  of the 
hospital,  selected  representatives  from  the  professional  services  offered,  a 
communication/data  processing  representative,  and  a community  representative  who is 
not  a hospital  or agency  employee. 
The  agencys  patient  population  is approximately  83 percent  Medicare  beneficiaries,  9 
percent  Medicaid  recipients,  and  8 percent  other  payers. 
The  agency  belongs  to the  Illinois Hospital  Association,  the  Illinois  Home  Care 
Association,  and  the  NAHC. 
How  does  the  Home  Health  Agency  ensure  that  the  people  they  are  serving  are  qualified 
for Medicare  home  health  care  and  that  the  appropriate  number  and  type  of seMces  are 
provided? 
According  to their  PPM,  referrals  may be  accepted  via telephone,  facsimile,  or in person, 
and  a referral  form  is completed  at that  time.  Following  the  initial  contact,  the  Home 
Health  Coordinator,  Supervisor  of Patient  Care  Semites,  or the  Director  may contact  the 
patient  or family  for additional  information.  All referrals  are  reviewed  and  approved  by 
the  Home  Health  Coordinator,  Supervisor  of Patient  Care  Services,  or Director  for 
appropriateness.  This verification  process  includes  contacting  a patients  attending 
physician,  if the  referral  source  was a non-physician,  to verify the  persons  homebound 
status  and  to obtain  care  orders.  The  review  also includes  ensuring  that  the  services  are 
necessary  and  reasonable.  If a patient  does  not  meet  all admission  criteria,  the  agency 
will recommend  another  source  of care  to the  patient,  family, or referral  source.  If the 
patient  has been  discharged  from  Holy  Cross  Hospital,  an interview  and  chart  review  are 
also performed  to ensure  appropriateness. 
C-8  The  majority  of the  home  care  referrals  come  from  the  hospital  and  physicians  offices.

At  the  time  of referral,  information  regarding  the  patients  eligibility  for Medicare  home

health  setices  is obtained,  including  the  Medicare  number,  skilled  care  needs,  physicians

orders,  and  homebound  status.  Prior  to discharge,  the  home  care  coordinator/hospital

liaison  visits as many  hospital  referrals  as possible  to confirm  needs  and  eligibility,  set

expectations  and  review  the  medical  chart  to facilitate  smooth  hospital  to home

transition.  The  appropriateness  of home  care  for a patient  is reconfirmed  during  the

initial  assessment  visit performed  by an RN.

All referrals  are  reviewed  and  approved  by the  Home  Health  Coordinator,  Supemisor  of

Patient  Care  Services,  or Director  to ensure  appropriateness.  This verification  process

includes  contacting  a patients  attending  physician,  if the  referral  source  was a non-

physician,  to verify the  persons  homebound  status  and  to obtain  care  orders.  The  review

also  includes  ensuring  that  the  services  are  necessary  and  reasonable.  If a patient  does

not  meet  all admission  criteria,  the  agency  will recommend  another  source  of care  to the

patient,  family,  or referral  source.

Monthly  meetings  are  held  among  the  various  disciplines  to discuss the  progress  of each

patient  and  to adjust  the  type  and  frequency  of visits accordingly,  In addition,  the

Supervisor  of Patient  Care  Services  has  case  conferences  with staff to discuss  each

patient.  She  also  reviews  notes  in each  case  file and  accompanies  all RNs  into  the  field

on problem  cases.

Their  PPM  also requires  that  the  physician  be  contacted  within  24-48 hours  of the  initial

visit to confirm  his/her  orders,  medications,  services,  frequency  of visits, frequency  of

communication,  parameters,  and  outcome  expectations.  When  recertification  is required,

the  physician  is contacted  by telephone  again.  When  agency  staff believe  the  patient

should  be  discharged,  the  physician  is once  again  contacted  approximately  one  to two

visits or no less than  one  week  prior  to discharge  to obtain  orders  to continue  care  or

authorization  to discharge.

How  does  the  Home  Health  Agency  attempt  to assure  quality  of seMces?

The  agency  employs  a variety  of mechanisms  to ensure  quality.  Their  PPM  requires  that

they  perform  case  management  to ensure  quality  patient  care  and  effective  coordination

of multi-disciplinary  care.  Case  management  requires  RNs  to assess  patients,  submit

appropriate  documentation,  follow-up  with  physicians,  and  maintain  the  frequency  of

visits in accordance  with the  Plan  of Care.  In addition,  RNs  are  required  to make

superviso~  visits at least  every  14 days, either  alone  or in tandem,  to oversee  the  work  of

home  health  aides.

The  PPM  also requires  that  staff  supemision  be  provided  at  all times.  This  includes  daily

discussions  on an informal  basis  regarding  patient  care  and  organizing  workloads,  formal

case  conferences,  reviews  of documentation,  observation  visits, and  chart  reviews.

c-9  The  agency  uses  the  Holy  Cross  Nursing  Service  Quality  Management  Report  as a

quality  assurance  monitoring  device.  This  report  ispartof  their  ongoing  Quality

Assurance  Review  and  includes  infection  surveillance,  home  health  aide  compliance,

reviewing  documentation,  measuring  patient  satisfaction  and  physician  satisfaction,  and

gathering  and  analyzing  statistical  data  to identify  trends  and  monitor  utilization

(including  average  number  of visits) by service  and  by discipline.  They  also  evaluate  case

files and  charts  of patients  who are  readmitted  to the  hospital  within  30 days of having

been  discharged  from  the  hospital  and  placed  in home  health  care.  Peer  reviews  of cases

are  conducted  on a quarterly  basis.

Any complaints  by a patient  or family member  are  followed  up within  24 hours  of

receipt,  as are  any negative  responses  on patient  or physician  satisfaction  surveys.  A

corrective  action  plan  must  be  developed  and  executed  for any complaints  received.  The

agency  must  respond  to recommendations  made  by either  body.

All new employees  must  go through  an orientation  period.  The  length  of the  orientation

is tailored  to fit the  needs  of each  person,  based  on that  persons  job  classification,

knowledge  level,  and  experience.  In addition,  an in-service  education  program  is offered

each  month.  RNs  are  required  to attend  at least  ten  in-service/competency  programs  per

year,  and  home  health  aides  are  required  to have  twelve  hours  of in-service  training  per

year,  three  hours  per  quarter.  RNs who are  on the  hospital  registxy and  are  not  full time

employees  of the  agency  are  encouraged  to attend  as many  in-service  training  sessions  as

possible.  Staff  are  also  encouraged  to attend  in-service  training  programs  offered  at Holy

Cross  Hospital.

What  is the  philosophy  of the  Home  Health  Agency?

Their  policies  and  procedures  manual  contains  written  statements  of their  mission,

philosophy  and  agency  objectives.  Their  mission  is to provide  quality,  professional,  and

support  services  to patients  in their  homes  to return  patients  to their  maximum  level of

health  and  independent  function.

The  philosophy  which  bolsters  their  mission  is that  home  health  services  should  minimize

negative  patient  illness  and  disability  outcomes;  maximize  potential  client  level-of-

independence  outcomes;  restore,  maintain,  and  promote  patient  health;  and  meet  each

patients  needs  to assist  them  in finding  the  meaning  of their  experience  and  to promote

self-actualization.  Their  philosophy  includes  a commitment  to educating  the  patient,  the

patients  family,  and  the  community.

c-lo  AMERICACNfmqINc. 
NEWBURG~  NY 
General  and  Background 
This  home  health  agency  is a proprietary,  non-affiliated,  organization.  It opened  in June, 
1988 and  was certified,  at that  time,  to serve  Medicare  beneficiaries.  It serves  a two-
County  area,  one  of which  is suburban  and  one  of which  is rural.  The  Newburgh  office 
serves  beneficiaries  in Orange  County.  In adjoining  Ulster  County  they  operate  a branch 
office  in New  Paltz  and  a new branch  opening  soon  in Kingston.  Ulster  County  is 
considered  rural. 
The  agency  is in the  process  of obtaining  accreditation  from  the  JCAHO.  They  consider 
accreditation  an asset  for marketing  purposes.  In addition,  the  agency  belongs  to the 
New York  State  Association  of Health  Care  Providers  and  the  National  Association  for 
Home  Care. 
Seventy-five  percent  of the  agencys patients  are  Medicare  beneficiaries.  The  remaining 
twenty-five  percent  are  Medicaid  (15 percent)  and  managed  care  (10 percent).  In  1993, 
their  average  reimbursement  per  beneficiary  was $1917.  That  figure  rose  slightly to 
$2022 in 1994, but  the  average  number  of visits remained  the  same  for both  years,  31 
visits per  beneficiary. 
How  does  the  Home  Health  Agency  ensure  the  people  they  are  seining  are  qualified  for 
Medicare  home  health  care  and  that  the  appropriate  number  and  type  of seMces  are 
provided? 
Every  referral  to the  agency  is processed  within  24 hours  or less.  A registered  nurse  is 
sent  to the  home  of a patient  to perform  an initial  assessment.  If the  RN  determines 
that  the  payer  is Medicare,  she follows Medicare  policies  to determine  what  services  to 
authorize.  The  RN  develops  a Plan  of Care  after  this initial  patient  assessment  is 
completed,  and  the  attending  physician  signs the  plan.  The  extent  of involvement  of the 
physician  in developing  the  Plan  of Care  varies. 
The  requirement  that  a Medicare  beneficiary  be  homebound  is strictly  adhered  to.  RNs 
continuously  evaluate  a patients  progress,  and  when  the  patient  is no longer  homebound, 
s/he  is discharged.  The  agency  only provides  services  to Medicare  patients  who  have  an 
acute  condition,  that  is, those  whose  condition  will improve.  The  agency  discharges  a 
patient  as soon  as he or she  is stabilized.  Chronic  care  patients,  that  is, those  whose 
condition  will not  or cannot  improve,  are  not  provided  home  health  services  reimbursed 
by Medicare. 
The  home  health  agency  believes  that  their  sexvicing RHHI  and  their  State  Department 
of Health  play  an important  role  in adherence  to the  conditions  of participation.  The 
RHHI  has  a good  working  relationship  with  the  agency.  Claims  for inappropriate 
services  or for patients  who  are  not  homebound  are  denied.  The  agency  controls 
C-n  appropriate  utilization  of home  health  aide  visits by using the  New York  State  Guide  to 
Home  Health  Aide  Training  and  Competency  Evaluation  and  Matrix  of Permissible  and 
Non-permissible  Activities:  Home  Health  Aide  Services. 
The  agency  has  an  easy-to-read,  large-print  brochure  which  contains  guidelines  for 
determining  if a patient  may be  eligible  for Medicare  home  health  care  services.  This 
brochure  makes  it clear  at the  onset  of services  what  the  Medicare  home  health  benefit 
includes.  It clearly  states  for what  services  Medicare  will pay and  for what  it will not  pay. 
For  example,  it states  that  Medicare  will not  pay for semices  which  are  considered 
custodial  or housekeeping.  The  brochure  also states  that  Medicare  provides  only 
intermittent  or part-time  skilled  services  generally  for a short  duration  and  that  the 
patient  must  be  confined  to his or her  home.  Examples  of what  constitutes  homebound 
are  also  clearly  illustrated  in the  brochure. 
How  does  the  Home  Health  Agency  attempt  to assure  quality  of semices? 
The  agency  believes  the  relationship  between  a caregiver  and  patient  is important  in 
assuring  that  the  services  are  of high quality.  When  a patient  or a patients  family 
complains  about  a staff  member,  that  person  is replaced  immediately.  The  agency  does 
not  force  a caregiver  on a patient.  The  agency  believes  that  working  together  as a unit 
affects  the  quality  of the  services.  They,  therefore,  work  had  to ensure  that  the  (1) 
patient,  (2) family  member(s),  (3) caregiver,  and  (4) attending  physician  are  in agreement 
as to what  is needed  and  appropriate. 
The  agency  employs  a variety  of techniques  to assess  and  ensure  quality.  Plans  of Care 
are  reviewed  by an RN  on a regular  basis.  A Utilization  Review  Committee  made  up of 
staff  members  and  professional  people  from  the  community  meets  quarterly.  Since  the 
agency  also regards  the  relationship  between  a caregiver  and  a patient  as the  key to the 
quality  of the  services,  they  are  very interested  in measuring  patient  satisfaction.  All 
patients  are  surveyed  verbally  when  services  begin  and  immediately  following  discharge. 
In addition,  a mail  survey is sent  monthly  to a random  sample  of patients. 
Patient  complaints  are  handled  formally  and  promptly.  A complaint  file is opened  and 
the  complaint  investigated.  Upon  completion  of the  investigation,  the  agency  meets  with 
the  complainant  and  tries  to resolve  the  problem.  Most  complaints,  it turns  out,  are 
misunderstandings  regarding  what  the  client  was to receive  from  the  agency. 
All professional  caregivers  and  aides  receive  an agency  orientation  and  periodic  in-house 
training.  All staff  are  credentialed  according  to their  position  and  references  are  checked 
prior  to hiring. 
C-12
 What is the philosophy  of the Home  Health  Agency? 
The  home  health  agency  has its written  philosophy  hanging  on the  wall.  It says 
Commitment  to Our  Patients 
Meet  the  Perceived  Needs  of Our  Clients  and  Employees 
Theagency  believes  that  honesty  isthe  best  policy.  Bycooperating  with  doctors,  hospital 
staff,  patients  and  their  families  to provide  appropriate  services,  they will get  more 
referrals.  They  believe  there  is too  much  to lose by providing  unnecessary  visits and 
services. 
C-13
 WESTCHESTER  COUNTY  DEPARTMENT  OF  HEALTH 
HAwmolmgNY 
General  and Background 
This  home  health  agency  is run  by County  government  and  is an official  home  health

agency.  It serves  the  entire  County  of Westchester,  a suburb  of New York  City.  The

agency  has been  certified  by HCFA  to provide  Medicare  home  health  semices  since

1966.  In addition  to the  main  office  in Hawthorne,  home  health  services  are  provided

from  5 district  offices  located  throughout  the  County.

The  agency,  being  part  of a County  public  health  department,  provides  a wide variety  of

public  health  services.  In the  early  1970s they  received  home  health  referrals  from  every

hospital  in the  County.  At that  time  there  was very little  competition.  Now proprietary

agencies  have  entered  the  home  health  market  and  are  very aggressive  in seeking

Medicare  home  health  referrals  from  hospitals  and  physicians.  Medicare  referrals  have

steadily  been  declining  in this agency  as a result  of this increased  competition  from  for-

profit  home  health  agencies.

In  1993 the  agencys  average  reimbursement  per  beneficiary  was $1724, and  the  average

number  of visits was 20.  In  1994 those  figures  increased  slightly to $2188 and  25 visits.

How  does  the Home  Health  Agency  ensure  the  people  they  are  serving  are  qualified  for

Medicare  home  health  care  and  that  the  appropriate  number  and  type  of seMces  are

provided?

This  home  health  agency  has no incentive  to provide  unnecessary  visits since  they  are  a

government-run  agency.  However,  despite  the  absence  of a profit  motive,  the  agency

takes  definite  steps  to ensure  appropriateness  of care  and  to control  utilization.  They

evaluate  a patients  condition  and  situation,  teach  a patient  and  his/her  family, whenever

possible,  how to perform  the  same  services  and  tasks  as agency  personnel,  and  discharge

the  patient  as soon  as possible.  They  perform  all three  tasks  simultaneously  so that  they

may terminate  care  in the  shortest  possible  number  of visits, while  providing  quality  care.

Discharge  planning  occurs  at the  commencement  of services.  Staff  see  discharge

planning  as a contract.  That  is, agency  staff tell patients  what  they  should  expect,

approximately  how many  visits they will likely receive,  and  for what  period  of time.  They

seek  an understanding  and  agreement  from  both  the  patient  and  the  family  at the

beginning  regarding  what  they will provide.  If a patients  condition  and  needs  change 
b	
during  the  course  of care,  agency  personnel  re-evaluate  the  situation  with  the  patient  and 
his/her  family. 
The  agency  adheres  to the  homebound  criterion  for Medicare  patients.  Beginning  at the 
time  of the  referral,  agency  staff have  lengthy  discussions  with the  referring  physician  or 
hospital  regarding  whether  a patient  is homebound.  In situations  where  a Medicare 
C-14
 patient  is not  homebound  but  needs  home  care  services,  the  agency  will find another 
payment  source  besides  Medicare  rather  than  terminate  services. 
The  home  health  agency  provides,  with few exceptions,  home  care  to patients  with  acute 
illnesses.  When  determining  whether  to provide  home  visits to chronic  care  patients, 
they  follow the  HCFA  guidelines. 
Initial  screening  is a key factor  in assuring  appropriate  services  and  controlling  utilization. 
A lot of information  is gathered  by the  agency  during  the  initial  referral  contact,  which  is 
typically  by telephone.  Referrals  are  always handled  by professional  staff rather  than 
clerical  staff.  Staff  obtain  detailed  information  regarding  the  patients  condition, 
homebound  status,  and  what  should  be  included  in the  Plan  of Care.  This  initial 
telephone  conference  helps  reduce  a lot of unnecessary  steps  and  gets  an  attending 
physician  more  involved  in the  patients  Plan  of Care. 
The  home  health  agenq  believes  that  the  policies  and  procedures  of their  servicing 
RHHI  help  control  utilization.  The  RHHI  provides  valuable  training,  technical 
assistance,  and  consistent  and  clear  guidelines.  The  RHHI  is diligent  in reviewing  Plans 
of Care  against  claims  submitted  for reimbursement,  particularly  with  regard  to the 
necessity  for visits.  Rarely  does  their  RHHI  request  additional  information  on claims 
submitted. 
The  agency  carefully  controls  the  number  of aide  visits to a patient.  It strictly  adheres  to 
the  Plan  of Care,  providing  what  a patient  needs  as opposed  to what  a patient  or his/her 
family wants.  They  regard  aide  services  as an extension  of skilled  setices,  not  a semice 
unto  itself.  As a result  of tight  controls,  only 20 percent  of all their  visits in a year  are 
aide  visits, as compared  to an  average  of 47 percent  nationally.  Aides  are  paid  by the 
hour  rather  than  by the  visit. 
The  patient  is always assigned  a case  manager.  The  case  manager  is the  RN  who  makes 
the  initial  visit to a patients  home.  If it is determined  that  a patient  needs  the  services 
of a skilled  therapist,  the  therapist  must  report  to the  case  manager.  A therapist  must 
contact  the  case  manager  within  24 hours  of making  a visit to discuss  a patients  therapy 
needs  and  to obtain  approval  to continue  providing  semices. 
How  does  the Home  Health  Agency  attempt  to assure  quality  of seMces? 
All professional  caregivers  and  aides  receive  an agency  orientation  and  periodic  on-going 
training.  All are  certified  and  references  are  checked  prior  to hiring.  Therapists  under 
contract  with  the  agency  must  provide  documentation  that  they  have  at  least  one  year  of 
experience;  are  licensed  to provide  home  care;  are  immunized;  have  been  trained;  and 
have  liability  insurance. 
A Utilization  Review  Committee  meets  quarterly  to review  home  health  records.  It is 
made  up  of people  from  the  staff and  professional  people  from  the  community.  Patient 
C-15
 complaints  are  given top  priority  by the  Main  office  in Hawthorne.  Upon  completion  of 
an investigation,  the  patient  or the  complainant  is notified  of corrective  actions  taken. 
What is the philosophy  of the Home  Health  Agenq? 
They  refer  to themselves  as the provider  of last resort.  This  public  health  agency 
provides  home  health  services  to anyone  in need  regardless  of insurance  status,  location 
of neighborhood,  and  severity  of illness. 
C-16
 SPOHN  HOME  HEALTH 
CORPUS  ~  TX 
General  and Background 
Spohn  Hospital  Home  Health  Agency  is a hospital-based,  not-for-profit  agency.  Spohn 
Hospital  is a private,  Catholic  hospital,  operated  by the  Sisters  of the  Incarnate  Word. 
The  home  health  agency  seines  the  Corpus  Christi  metropolitan  area  which  is largely 
urban  with  a few rural,  isolated  pockets. 
At the  time  of the  site visit, the  agency  was settling  in from  a very recent  reorganization. 
Despite  some  small  confusion  with new titles  and  some  change  in roles  and  reporting 
lines  of authority,  this agency  clearly  understood  its mission  and was focused  on 
delivering  quality  patient  care.  The  central  theme  of reorganization  was total  quality. 
However,  it was apparent  from  discussions  with staff that  the  agency  was steeped  in a 
tradition  of quality  services  prior  to organization  changes. 
The  home  health  agency  operates  under  the  general  direction  of the  Spohn  Hospital 
board;  however,  they  are  physically  separated  from  the  hospital  and  operate  quite 
independently.  The  hospital,  the  largest  in Corpus  Christi  (about  500 beds)  provides  the 
agency  with  patients  as well as a variety  of other  resources. 
Spohn  Home  Health  Agency  is a member  of the  Texas  Home  Care  Association.  They 
are  also  members  of the  National  Association  of Home  Care. 
A variety  of home  health  agencies  accept  patients  who are  discharged  from  Spohn 
Hospital.  While  patients  have  a choice  of home  health  agencies  upon  discharge,  staff at 
Spohn  made  clear  that  they  hold  a certain  competitive  edge  when  it comes  to Spohn 
Hospital  patients.  These  patients  make  up the  preponderance  of the  agencys patient 
census. 
Finally,  the  hospital  serves  as a teaching  facility for home  health  employees.  Spohn 
Hospital  has  an  active  staff development  component  and  also offers  seminars  which  the 
staff can  attend.  This  hospital  resource  is an important  part  of the  agencys in-service 
training  program. 
How  does the Home  Health  Agency  ensure  that  the  people  they  are  serving  are  qualified 
for Medicare  home  health  care  and  the  appropriate  number  and  types  of setices  are 
provided? 
Eligibility  is treated  seriously  at  Spohn.  When  referrals  come  in, the  supervisory  nurse 
ensures  that  there  is a physicians  order  and  that  the  order  is clear.  Then  a registered 
nurse  makes  an evaluation  visit.  This visit involves  a complete  physical  assessment, 
including  a judgment  of whether  the  patient  is homebound.  Homebound  is interpreted 
in a serious  manner  by employees  at Spohn  Home  Health,  and  is based  on written 
instructions  from  the  Regional  Home  Health  Intermedia~. 
C-17  The  most  important  question  in determining  eligibility  is whether  this patient  is actually  a 
candidate  for home  health  care.  In other  words, will home  health  care  benefit  this 
patient  by restoring  or improving  their  ability  to function  independently. 
Discharge  planning  begins  at the  point  of referral.  From  the  assessment  visit through 
discharge,  Spohn  emphasis  is on moving  the  patient  to the  point  of independent  living. 
The  Patient  Care  Coordinator  (PCC)  is a BSN degree  nurse.  The  PCC  carefully  follows 
the  notes  on patient  progress  and  compares  them  to the  plan  of care.  Discrepancies  are 
noted  and  adjustments  to the  plan  of care  are  made. 
There  is no arbitrary  limit put  on the  number  of visits.  Staff expressed  some  surprise 
that  they were  in the  Low Visit category  as they felt  they were  allowing  as many  visits 
as are  consistent  with  the  goals  of the  Medicare  home  health  benefit.  In fact,  two 
respondents  stressed  that  even  when  the  patient  has  progressed  as far  as possible  from 
the  perspective  of independent  functioning,  they  may continue  visits to stabilize  other 
aspects  of that  patients  life, such as helping  them  to cope  with an undesirable  home 
environment. 
Central  to the  process  of managing  care  is the  critical  element  of continuous 
communication,  This  includes  communication  between  Spohn  direct  care  staff  and  the 
patient  and  other  caregivers,  between  the  Spohn  direct  care  staff  and  Spohn  support  and 
administrative  staff,  and  between  Spohn  staff and  the  physician.  Open  and  frequent 
communication  is key to managing  patient  care  and  ensuring  the  best  outcomes  in the 
shortest  time  frame. 
How  does the Home  Health  Agency  attempt to assure quality of seMces? 
Medicare  home  health  is the  standard  for home  health  care  given by the  agenqq 
however,  patients  are  treated  by this standard  regardless  of who the  insurer  is.  Several 
direct  care  staff  reported  that  they  are  not  aware  of whether  the  patient  is Medicare, 
Medicaid,  private-pay  or charity.  The  Spohn  Home  Health  Agency  is accredited  by 
JCAHO. 
The  single  most  important  element  in providing  quality  services  is to assure  a quality 
staff.  Spohn  hires  only experienced  nurses  and  pays them  by the  hour.  These  nurses 
come  to Spohn  with  excellent  assessment  skills and  the  ability  to work  independently. 
Spohn  nurses  understand  that  there  is no quota  for numbers  of visits and  no advantage  in 
making  as many  as possible. 
Spohn  hires  only experienced  aides  and  pays them  by the  hour.  They  require  that  the 
aides  be  listed  on the  Texas  Aide  Registry.  The  agency  has  a very low turnover,  which 
suggests  staff  satisfaction  and  contributes  to semice  continuity.  Aides  average  five to six 
patients  per  day and  the  Aide  Coordinator  stressed  that  more  than  that  would  diminish 
service  quality. 
C-18
 The  final  point  on quality  of service  is the  Spohn  culture  of problem  identification  and 
amelioration.  As soon  as a problem  becomes  apparent  or even  suspected,  staff begin  to 
focus  on how to solve that  problem  before  it gets  out  of control.  This  timely  intervention 
reduces  serious  problems. 
What Is the philosophy  of the Home  Health  Agency? 
The  Spohn  Home  Health  Agencys philosophy  is clearly  embodied  in its Mission 
Statement.  The  mission  of Spohn  Home  Health  is to collaborate  with professionals  and 
others  in an  attempt  to provide  specialized  care  and  education  based  on patients  human 
response  to their  illness.  We  perform  quality  care  in the  patients  environment  with the 
family and  primary  caregivers.  We  promote  health  care  and  the  patient  is the  focus  of 
our  efforts. 
This  mission  statement  goes  on to emphasize  four  important  points.  These  are  to help 
the  patient  realize  optimum  potential,  to be supportive,  to enhance  independent  living 
and  to extend  a caring,  Christian  attitude. 
The  Spohn  Home  Health  Agency,  despite  its low number  of visits, does  not  focus  on 
utilization  in any of its philosophical  underpinning.  Rather,  they  accept  HCFA  guidelines 
in a literal  sense,  approaching  each  patient  from  a perspective  of patient  and  caregiver 
education.  They  make  it clear  to all involved  that  this sewice  is time-limited  and  goal 
oriented. 
C-19
 LINDEN  MUNICIPAL  HOSPITAL  HOME  HEALTH  SYSTEM 
LINDEN,  Tx 
General  and Background 
Linden  is a small  town  of about  2400 people,  which  is the  county  seat  of Cass County,  in 
rural,  northeastern  Texas.  The  hospital  is a small  (40 bed)  facility, operated  by a 
municipal  hospital  authority.  The  agency  is located  in a building  adjacent  to the  hospital 
and  operates  under  the  general  direction  of the  hospital  administrator. 
The  hospital,  itself,  faces  many  of the  problems  typical  of small,  rural  facilities,  such as 
low occupancy.  Both  the  hospital  and  the  home  health  agency  have  dropped  JCAHO 
accreditation  in a cost  cutting  exercise.  The  Office  of Evaluation  and  Inspections  has 
reported  on similar  problems  to those  observed  in Linden,  in detail,  in its series  on 
Hospital  Closures  (the  latest  being  Hos~ital  Closure:  1994 (OEI-95-O4-OO1OO). The 
hospital  has  maintained  its membership  in the  Texas  Hospital  Association  and  the  home 
health  agency  is a member  of the  Texas  Hospital  Home  Health  Association. 
The  home  health  agency  serves  a wide  geographic  area  of five counties,  in which  an 
estimated  25 physicians  practice.  Despite  the  relative  scarcity  of trained  health 
professionals  in the  area,  there  is no paucity  of home  health  agencies.  The  nearby  town 
of Atlanta,  Texas  (pop.  6100)  lists six such agencies  and  there  are  others  located  in and 
or serving  the  geographic  area.  Therefore,  despite  the  very rural  nature  of the  area,  the 
market  is seen  as extremely  competitive. 
How does the Home  Health  Agency  ensure that the people  they are serving are qualified 
for Medicare  home  health care and the appropriate number and type of seMces  are 
provided? 
Eligibility  is treated  seriously  at Linden.  Eighty  (80) percent  of the  patients  come  from 
the  Linden  Hospital  Clinic.  Most  of the  remaining  patients  are  discharged  from  Linden 
Hospital.  Every  Linden  patient  comes  with a physician  referral  and  virtually  all of their 
patients  have  been  seen  by the  referring  physician. 
Respondents  maintain  that  the  role  of the  physician  is growing  increasingly  more  active. 
They  attribute  this to two factors.  The  first is that  physicians  have  become  increasingly 
more  aware  of home  health  care  over  time.  The  second  is the  fact  that  physicians  can 
now be  paid  for  developing  and  monitoring  home  health  plans.  Despite  having  more 
knowledge  of the  services,  physicians  continue  to have  more  problems  with understanding 
and  accepting  limitations  of services  such as the  need  for skilled  visits and  of eligibility, 
such  as homebound. 
Linden  staff  carefully  follow the  homebound  criteria,  found  in the  Regional  Home  Health 
Intermediary  manual.  Respondents  reported  that  in a small  town  such  as Linden,  it is 
relatively  simple  to determine  that  this provision  has been  met.  Nevertheless,  they  also 
C-20  reported  that  many  of their  competitors  do not  interpret  the  homebound  provisions 
strictly. 
Discharge  planning  begins  at the  time  of referral.  From  the  assessment  visit, Linden  is 
focused  on moving  the  patient  along  the  plan  of care  to discharge.  The  Scheduling 
Nurse  is critical  to that  objective.  Although  respondents  did not  use the  term,  case 
management,  that  term  would  perfectly  describe  the  activities  of the  Scheduling  Nurse. 
Her  duties  include  reviewing  the  original  nursing  assessment,  completed  on the  first visit, 
reviewing  the  plan  of care  that  is developed  following  the  assessment,  reviewing  patient 
progress  and  comparing  it to the  plan  of care.  Any discrepancies  are  noted  and  the 
Scheduling  Nurse  has  authority  and  flexibility to make  necessary  changes.  Such  changes 
might  include  changing  nursing  staff  or aide  assignments,  or convening  a team  to review 
the  case. 
The  Scheduling  Nurse  ensures  that  the  plan  of care  is appropriate  to the  specifics  of the 
situation.  She  questions  deviations  in services  and  any apparent  failures  of patients  to 
respond.  She  ensures  contact  with  the  referring  physician  at the  first  sign of a serious  or 
unusual  problem.  Agency  staff report  that  keeping  a patient  too  long can be  detrimental 
to that  patient. 
The  key to the  management  of services  at Linden  is the  daily review  of services  and 
progress  notes.  Staying  on top  of each  case  that  has  received  service  is an  effective 
strategy  for ensuring  that  no patient  gets  too  far  off course,  in areas  that  the  agency  can 
control.  This  tight  case  management  works well. 
The  goal  is to move  the  patient  out  of the  service  as quickly as feasible.  However,  we 
observed  the  average  number  of visits per  beneficia~  increased  by over  50 percent 
between  1993 and  1994.  This  increase  could  have  resulted  from  recent  pressure  from  he 
affiliated  hospital  for the  home  health  agency  to increase  visits for economic  reasons. 
The  home  health  agency  is considered  a profit  center  for the  hospital.  According  to 
agency  staff,  the  hospital  has  suggested  that  appropriate  visits do not justifi  the  overall 
economic  status  of the  parent  organization.  Agency  staff advised  that  hospital 
management  has  suggested  that  the  home  health  agency  staff could  benefit  from  in-
service  training  with  home  health  agencies  that  make  considerable  higher  numbers  of 
visits per  bene~iciary.  For  example;  one  lesson  that  could  be  learned-is  to never  waste 
skilled visits by delivering  more  than  one  skilled  service  per  visit.  While  the  staff is loyal 
to the  hospital,  it is not  clear  to what  extent  the  increase  in visits per  beneficiary  was 
affected  by the  pressure. 
How  does  the  Home  Health  Agency  attempt  to assure  quality  of seMces? 
Quality  home  health  at Linden  begins  with  a high quality  staff.  Nurses  are  experienced, 
often  coming  from  other  agencies  whose  practices  with regard  to utilization  they 
questioned.  Aides  are  experienced  as well.  They  come  from  the  Texas  Aide  Registry. 
Turnover  for both  nurses  and  aides  is low, which helps  ensure  continuity  of care. 
C-21
 The  second  element  of quality  is the  tight  case  management  discussed  in the  preceding 
section.  The  skills of the  Scheduling  Nurse  allow Linden  Home  Health  to develop 
appropriate  treatment  plans  which  have  also resulted  in fewer  visits. 
In addition  to case  management,  two activities  are  focused  on improving  the  quality  of 
home  services.  First,  Linden  managers  make  supervisory  home  visits with  nurses  and 
independently  to  assure  that  the  quality  of care  is up to their  standard.  Second,  in-
service  training  is required  of all care  staff.  This  keeps  their  skills current. 
Recently  when  studying  the  operations  of other  agencies,  Linden  managers  were  struck 
by standard  care  plans which  dictated  a certain  set number  of visits for  the  first cluster 
of weeks,  another  set number  of visits for the  second  cluster  of weeks  and,  finally another 
set number  of visits for a final  cluster  of weeks.  Further,  these  agencies  insisted  on no 
more  than  one  skilled  service  per  skilled visit.  These  types  of formulae,  which  are 
reported  to be  common  practice  in the  home  health  industry,  result  in higher  utilization 
without  improved  results. 
Linden,  by contrast,  insists on individualized  plans  of care  rather  than  stock  formulae  and 
considers  these  individual  plans  to be  keys to quality.  Linden  staff  deliver  as many  skilled 
services  in one  visit as are  appropriate.  Linden  Home  Health  Agency  managers  also 
report  their  belief  that  paying  staff by the  hour  (rather  than  by the  visit)  is a way to 
ensure  a better  quality  service. 
Finally,  Linden  conducts  phone  and  mail  surveys of discharged  patients  and  their 
physicians.  They  use  these  to measure  quality  of service  and  to identify  problems  areas. 
What Is the philosophy  of the Home  Health  Agency? 
Linden  Home  Health  Agency  has  neither  a formal,  written  philosophy  nor  a mission 
statement.  However,  discussions  with Linden  staff  produced  similar  responses  which 
centered  around  giving patients  an appropriate  level of care  to assist them  to realize 
their  maximum  level  of independent  functioning. 
Respondents  from  Linden  expressed  some  surprise  that  their  average  number  of visits in 
1993 placed  them  in the  lower  third  of the  nation.  However,  staff  realized  that  many 
agencies  in their  area  make  many  more  visits to Medicare  patients,  and  they  expressed 
their  belief  that  in most  cases  these  high numbers  of visits were  unnecessary  and 
unethical.  Several  members  stated  that  the  overriding  Linden  philosophy  is to do the 
right  thing! 
Linden  Home  Health  Agency  staff are  likely to know  how the  patient  is paying  for home 
care.  While  they  are  increasingly  aware,  due  to growing  financial  problems  with the 
hospital,  staff  denied  that  they would  treat  a patient  differently  based  on how a patient 
was paying  for home  care.  They  did state  that  they  no longer  accept  any charity  cases. 
c-22