FOR HOME MEDICAL, a Medford, Ore.-based home medical equipment provider, going through the accreditation process was demanding enough. But in 1999, on its third accreditation review since 1993, it ran into serious difficulties meeting established standards on patient compliance. The accrediting organization wanted to know whether Home Medical's patients were using their HME as prescribed by their physicians.

Almost from the beginning, the home oxygen provider knew it would do poorly in that area because providers have little control over that aspect of patient care and services. It turned out "we really got dinged on it," recalls Kathy Lasota, director of patient care.

Home Medical isn't unusual. Almost all HME providers that undergo reviews don't do well in meeting the patient education and compliance portions of the accreditation standards, according to accrediting organizations.

Under the Microscope

Although it is only one of several standards under which home care providers are scrutinized, patient education and compliance represents a significant part of the review process, says Jerold Cohen, president of the Community Health Accreditation Program in New York, one of three national home care accreditation agencies. The other two are the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, Ill., and the Accreditation Commission for Health Care in Raleigh, N.C.

Compliance "is the one area that providers can't control," Lasota says. A provider might do a good job of documenting whether patients are following their prescribed medical regimens and using the equipment properly, yet it can be the least able to control whether the patient is always in compliance. Knowing this, accreditation agencies are apt to look more closely at how providers are working with patients to encourage compliance, experts say.

"Compliance is an extremely tricky situation," says the president of a small oxygen provider in Philadelphia that recently underwent a successful JCAHO accreditation review. She asked not to be identified for this article. "It's extremely difficult because a patient can be in compliance one day and be noncompliant the next day."

However, accreditation agency officials maintain that the review process doesn't necessarily focus on whether a provider is ensuring compliance. Ultimately, the process involves questions on what the provider is doing to educate the patient and the caregiver to achieve proper compliance. The emphasis is on how carefully and accurately the provider is monitoring the noncompliance and what it is doing about it, not necessarily the results it is achieving, experts say.

In general, accrediting agencies look at the extent to which a provider is keeping track of the patients' use of the equipment, says Bob Thornburg, a Seal Beach, Calif.-based consultant and former accreditation surveyor.

The key lies in documentation. The surveyor will look for documentation in a patient's chart to determine how well the HME company is monitoring the patient's condition and the use of the equipment. "The charting must reflect an accurate, ongoing and long-term record," says Cohen.

With oxygen patients, concentrators and respirators have gauges that indicate oxygen usage. "If a technician can calculate the rate of oxygen consumed by a patient in one month based on the gauges and amount of deliveries, an accreditation surveyor can do so, too," says Carl Allison, president of Baya Home Care in Lake City, Fla., which two years ago underwent a JCAHO review.

In fact, the accreditation surveyor will look at the difference between the number of hours per day that the patient has been on the concentrator and the number of hours prescribed by the medical provider. The surveyor will compare that difference with what was documented in the patient's chart by the nurse or HME technician during each home visit, Allison says. According to officials, the site surveyors will ask to visit five to 10 patients' homes to make these evaluations.

Although the process varies slightly among the three accrediting bodies, officials say each makes patient education and compliance a priority. Thornburg says they look mainly for the same things during visits to the HME provider's offices and patients' homes.

However, JCAHO maintains that its patient compliance standards are folded into two sections of its manual: Patient Education and Care, Treatment and Services. "We don't have a separate [free-standing] set of standards on patient compliance," says spokesperson Janet McIntyre. Neither does the ACHC.

Setting the Standards

On site visits, the agencies use their own teams of surveyors. They also publish their own lists of standards bound in official manuals, which are available to providers. JCAHO's standards, for example, are published in the 1999-2000 Comprehensive Accreditation Manual for Home Care.

In general, Thornburg says, the agencies are interested in four broad areas to see whether providers are:

• complying with federal, state and local regulations regarding the delivery, operation and maintenance of the equipment;

• correctly following the HME manufacturers' guidelines for safe use and operation;

• using national clinical standards and best practices delivered by qualified therapists and technicians during home visits; and

• monitoring performance improvements through policies and procedures that are in place and being followed at all times.

To some extent, all four areas overlap into patient education and compliance, Thornburg says.

At Home Medical, the JCAHO surveyor asked managers for dozens of randomly chosen patient records. The surveyor meticulously inspected each one, looking closely at chart entries and comparing them with HME prescriptions, Lasota said.

The surveyor also asked to see several patients, especially the most acutely ill.

During Baya Home Care's site visit, the surveyor reviewed several charts and asked probing questions about whether the entries were timely and how well the oxygen technicians knew the patients' medical conditions.

Allison believes the questions went too far. "What we were asked for went a lot beyond the scope of what we were supposed to do," Allison says.

In her 1999 review, Lasota says, the JCAHO surveyor seemed to be "digging for problems and asking the [oxygen] patients specific questions about quality as if intent on getting them to answer no" to certain questions.

In the end, "they weren't very helpful," Lasota complains. "They came in like the 'Feds', gave us the standards, but didn't help us to meet them."

A Helping Hand

JCAHO says it offers help and advice to providers at every step of the process. And other HME companies that have worked with the organization say it does help with advice and doesn't impose specific instructions or requirements in correcting flaws. Officials were supportive about helping companies bounce back from a low Type I score, they say.

Part of the process does involve recommendations, especially when a provider is doing poorly in patient compliance. "If the patient isn't in compliance and it's reflected in the documentation, we expect to see exactly what the provider has done about it," says Cohen.

He adds, however, that "we don't tell an organization how to dot the I's. We tell them, 'This is the standard. This is how you might want to meet it.' But how they go about it is up to the individual organization."

All three accrediting bodies say they request information about the provider well in advance of a site visit to give the provider a chance to prepare. ACHC officials typically request copies of the company's policies and procedures up to four months before a visit.

Almost always, the policies and procedures offer surveyors early clues to the company's practices in following up on patient education and compliance, Cohen says.

Cindy Hardin, R.N., the ACHC's director of education, agrees. "It gives our surveyors an idea of what the organization is like and how it is run, and a chance to actually compare them to their policies and procedures during the visit," she says.

The agencies are reluctant to compare themselves with each other regarding home visits. But some providers believe that JCAHO can be more demanding during home visits. Thornburg says few differences exist among the three.

Home Medical ultimately won its accreditation from JCAHO for the third time. But management is questioning whether the process is fair or even helpful. Lasota says she's considering switching to another accrediting organization when Home Medical's accreditation comes up for renewal in two years.

Allison says Baya Home Care might not seek accreditation again. In Florida, "it's becoming less important to hospitals and payers," he says.

Overall, the process is beneficial, according to the Philadelphia HME company president who asked not to be identified. "Yes, it is an expensive proposition," she says. "But we now know how to work with compliance issues, and that's made us a better company."

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The Technology Solution

FirstHealth of the Carolinas had a problem. As an integrated health care system with three hospitals, 200-plus physicians, 16 ambulatory sites, two home care agencies, a hospice, an emergency medical service system and five home medical equipment branches, it needed a way of communicating information about patients to whoever in the system needed it. But the Pinehurst, N.C.-based company was hampered by a database that was accessible only inside its flagship hospital, Moore Regional.

"We ran into problems every time we transferred a patient from the hospital to home care because our home care nurses didn't have access to our notes," says Cindy McDonald, FirstHealth's director of outcomes. "Our case managers needed a low-cost, user-friendly tool to bridge the communications gap between ourselves and our patients, patient families and the care team both inside and outside the hospital."

The answer, McDonald says, was a Web-based case management solution. Working with a technology company, FirstHealth put together an easy-to-use, point-and-click system accessible via the Internet. The question, says McDonald, was how to make it "so the case manager can go into the home, assess these patients -- and how is that information going to keep up with these patients?"

The company first tried the new system on a group of 200 rural patients for whom it has a grant to provide whatever medical care is needed, be it HME, nursing, physician care or immunizations. Armed with laptops, case managers set out to see if they could monitor and manage these patients.

The new system worked. "[The case manager] can be at any location and pull up information on that patient," McDonald says, adding that case managers more accurately and easily assess patients, prescribe treatment and track their progress after they have gone home from the hospital.

It was so successful that FirstHealth started beta-testing the system in January in its hospitals. It will then phase it in throughout the system, including HME providers.

Once in place, the system should help answer some ongoing HME provider questions, McDonald says. "If we send a patient home on oxygen, the home medical equipment dealer would be able to look up the information and find out exactly what has been going on with that patient," she says.

As well as better patient care and smoother communication among FirstHealth entities, McDonald expects the Web-based care solution will bring other benefits. "I think it will save us time, save the physicians and other health care providers time -- and we hope to see a cost savings," she says. "If you have less time doing paperwork, you have more time to spend with the patients and effectively case-manage them.

"The biggest frustration that we have had has been the way we have to fax and send so much information," McDonald adds. Now, with the click of a mouse, FirstHealth's health care experts can pinpoint the patient information they need.

-- Susanne Hopkins