Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

OPERATING PRACTICES OF LOW-COST


HOME HEALTH AGENCIES


Seven Studies 

#-

2.

v ~> JUNE GIBBS BROWN 

Inspector General 

~ Ac 

q> FEBRUARY 1997 ‘%,,~~ +!$ 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.


OEI’S 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 
Medicare’s minimum conditions of participation requirements regarding training 

and orientation. 

F	 All Seven Emphasize Discharge Planning. Discharge planning is required by 

Medicare’s 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 patient’s 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 . . . . . . . . . . . . . . . . . . ...”””””””””””” “.-” ”””” ”””” .””s”””””5


. Staff Training . . . . . . . . . . . . . . ..”” ”.”” ”OO”0.”” ““”” ”””” s””” ”””” ”..5 

. Discharge Planning . . . . . . . . . . . . . . . . . . . . . ..”o. ””oo”ooo”os. ”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 ““o”co””o”””o””o”””oc-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 

person’s 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 

Administration’s (HCFA’S) 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, forprofit 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 

HCFA’S 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 HCFA’S 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 HCFA’S 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 High3 
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 President’s 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 nation’s 

Medicare and Medicaid beneficiaries and program expenditures. 

We conducted this inspection in accordance with the Qualizy Standards for Inspections 

issued by the President’s 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 HCFA’S Conditions of Participation for 

Medicare home health agencies. The agencies’ staffs emphasized that home health care 

should be tailored to a patient’s needs, and it should be terminated when a patient is 

capable of independent living. Typically, when commencing service, selected staffs 

evaluated a patient’s 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 patient’s 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 patient’s


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


patient’s 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 patient’s 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 patient’s condition is the key to


assuring appropriate services and number of visits. As a patient’s 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 patient’s


homebound status after each visit.


Supemisory Reviews: In addition to constant evaluation of each patient’s 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 patient’s 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 agency’s 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 

SELECI’ED 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: HCFA’S 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 

HHA 

Premier Health Connection 

Mid-Florida Home Health Services 

Holy Cross Home Health Services 

Westchester County Dept. of Health 

American Care, Inc. 

Spohn Home Health Care 

Linden Municipal Hospital Home 

Health Systems 

1993 1994 

Average Visits By I Average Visits By 

HIM I STATE I HHA I STATE 

24136123139 

27 I 57 I 28 I 60 

20140124145 

20 I 42125139 

31 I 42 I 31 I 39 

+--F--F


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


Westchester County Dept. of Health


Holy Cross Home Health Services


Spohn Home Health


Linden Municipal Hospital Home Health


Mid-Florida Home Health Services


Premier Health Connection


American Care, Inc.


NATIONAL AVERAGE


1993 1994 

Average Visits Average Visits 

9.3 10.9 

10.4 11.4 

10.5 14.4 

System 10.6 15.7 

12.5 14.0 

14.5 14.4 

16.7 15.8 

21.5 25.1 

B-4

APPENDIX C 

SITE VISIT Stnmowms

HOME HEALTH AGENCY 

Mid-Florida Home Health Services


Premier Health Connection


Holy Cross Home Health Services


American Care, Inc.


Westchester County Department of Health


Spohn Home Health


Linden Municipal Hospital Home Health Systems


PAGE 

c-2 

c-5 

C-8 

C-n 

C-14 

C-17 

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 agency’s 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 agency’s Medicare beneficiaries usually come from a hospital into


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


however, a patient, patient’s 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 person’s 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 agency’s 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 person’s 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 person’s 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 

patient’s 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 agency’s 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 patient’s 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 inhouse 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 agency’s 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 person’s 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 agency’s 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 organization’s 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 agency’s 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 beneficiary’s 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 person’s 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 patient’s care is empowered to call a 

supervisor or any other discipline to discuss a patient’s 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 patient’s records reflect needs, conditions, problems, goals, 

services, diagnoses, and evidence of medical necessity that each discipline’s 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 agency’s 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 multidisciplinary 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 agency’s 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 agency’s 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 Department’s 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 agency’s 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 patient’s attending 

physician, if the referral source was a non-physician, to verify the person’s 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 patient’s eligibility for Medicare home


health setices is obtained, including the Medicare number, skilled care needs, physician’s


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 patient’s attending physician, if the referral source was a non-


physician, to verify the person’s 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 person’s 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


patient’s 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


patient’s family, and the community.


c-lo 
AMERICANCfmqINc. 

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 twoCounty 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 agency’s 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 patient’s 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 patient’s 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 

HAw’molmgNY 

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 1970’s 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 agency’s 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 patient’s 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


b	 beginning regarding what they will provide. If a patient’s condition and needs change 

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 patient’s 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 patient’s 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 patient’s 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 patient’s 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 agency’s 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 agency’s 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 physician’s 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 patient’s 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 Agency’s 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 patient’s 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 inservice 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, inservice 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