The push to move beyond basic delivery and into equipment- and patient-management has been a long time coming in the home medical equipment industry. After all, providing the care and services that can optimize a patient's health seems like common-sense customer service.
But extra care does not entitle providers to extra dollars — which means there is little justification for extra time and money to be invested in salaries or training. Fast-changing market conditions are exaggerating the issue, and according to industry leaders, could leave some providers a little nearsighted when it comes to envisioning their role in home care.
But looking toward patient outcomes, they say, figuring out how to help meet customers' goals — and quantifying these actions for payers and referral sources — can justify providing the service and should, in the long view, help attract more business.
Beyond Delivery
“Outcomes are what make us all feel better about what we do. They are the reason we celebrate our work and the feeling we get when we have provided the right product for the patient,” HomeCare columnist Louis Feuer wrote in this year's April issue. “This is the message that lets your referral sources and patients know they have made the right choice in selecting you as their home care provider.”
What's more, Feuer says, hospitals, rehab centers and pharmaceutical companies are becoming involved in understanding and tracking outcomes. “Now it is our turn to develop outcome information that can be used as a selling and marketing tool.”
“It's time that DMEs stop looking at themselves as deliverymen,” agrees Jerold Cohen, vice president of chronic care for Catholic Healthcare Partners, Cincinnati, Ohio, and former president and CEO of CHAP (Community Health Accreditation Program).
Cohen suggests that focusing on long-term patient goals can help providers determine the correct product and care for each customer, and he recommends a series of questions that can help: Why are you choosing this product? What do you want to achieve? What does this patient actually need? For example, Cohen explains, if you're fitting someone for a specialized wheelchair, the intended outcome may be so the individual can be independent.
Another example is considering home oxygen. A provider looking at long-term goals, according to Cohen, would focus on how patients are using the oxygen, when they should use it and how they regulate it. Then, beyond safety issues, “What is the purpose for the oxygen? What do we expect the patient to be able to do as a result of using the oxygen? Do we expect them to be able to ambulate around the house? Do we expect them to breathe better, to eat their dinner or do simple tasks?” Cohen asks. “I don't think that most DMEs think about that. Instead, it's just that the doctor ordered it, and here it is.”
Informed Patients
In other words, meeting patient goals goes beyond the delivery of prescribed equipment, offering a cursory explanation of its safe use and performing regular maintenance.
“We call that the ‘drop and run,’” says Carol Anderson, MSN, owner of Advanced Therapy Surfaces, White Bear Lake, Minn., a DME company that concentrates on support surfaces and the clinical accoutrements that go with them. “Our core business, on the other hand, is the clinical view: What is the client's goal? The client says, ‘I not only need to heal, but I need to get out of bed and get my kids to school in the mornings.’” Providers can bring that expertise to the table, she says.
Anderson's staff looks at the patient's wound data along with nutrition offloading, wound management and what's going on in the wheelchair — what she calls a “comprehensive global view.”
“We can talk about all that in one swoop, then communicate [the information] back to the payer source and the referral source. We call this ‘touching the patient.’ We touch that account every 30 days so the payer source and clinician know they'll get an update — outcomes and any problems — every 30 days.
“We have clinicians making clinical decisions about medical equipment. We have connections with the hospital that gives us the referral. We see the patient at home and check on them 30 days later before they go back to the physician, so we can call the doctor and say, ‘Do you realize they have no home care?’ We can be the clinical voice back to the doctor.
“I thought doctors would say, ‘That's none of your business,’ [and] have a narrow view of the treatment, but that has not been the case. Instead, the doctors have appreciated the input.”
Besides, Anderson adds, “payer sources no longer let someone have a bed for wound healing without someone gatekeeping those dollars and outcomes.”
According to Simon Margolis, vice president of clinical and professional development for National Seating and Mobility, Chattanooga, Tenn., and president of RESNA (Rehabilitative Engineering and Assistive Technology Society of North America), it is particularly critical with mobility products that providers understand not only the patient's current diagnosis but also the prognosis, taking into account a disease or lifelong condition.
“For example,” he explains, “a person with multiple sclerosis comes into your office and says, ‘I want a scooter.’ At that moment, the client could probably use a scooter, but if you understand the natural history of the disease you know that client eventually will not be able to use the scooter. If you provide the scooter, the client has used up his benefit by having his insurance company purchase a scooter, and then he can't get a power chair.
“It's the supplier's responsibility to present that information; it's the patient's responsibility to decide which way to go,” Margolis continues. “Suppliers have to take responsibility for informing clients of anything that may affect the short-term or long-term benefits of the equipment; they can't simply take the order from the physician and fill it, because the consumer will suffer. And, in some ways, the provider will suffer because he will have to eat [the cost of] that equipment that didn't work.”
Patient education also plays an enormous role in meeting goals and providing positive outcomes.
In her area, Anderson says, virtually no one in the market was properly educating support surfaces clients. As a home care nurse, “I was really tired of patients not knowing how to operate the equipment, so I created a patient education tool that includes a checklist. My technicians know the insides and outsides of the equipment, and they use a checklist at the bedside.”
Anderson says she believes providers are doing some patient education as required for accreditation, “but no one is telling the patients the details. The delivery techs were doing the ‘drop and run.’ Nobody looked the person in the eyes and asked, ‘What can I do for you?’”
The Right Products
How do providers know what equipment is right for a particular patient and a particular condition?
Some home care companies rely on manufacturer claims about a product's clinical efficacy. Others rely on experience; patients have tried a product and given feedback on whether they liked it and whether it helped achieve their therapeutic goals.
However, neither method is foolproof. Manufacturer claims must be proven, and it could be costly to try various products out before finding the one that will do the job.
“Providers have to evaluate the products themselves,” says Vernon Pertelle, corporate director of respiratory/HME services for Apria Healthcare, Lake Forest, Calif. “In every product line, every manufacturer has a competitor with a similar product. You need to evaluate the products to make sure they meet the therapeutic needs that the manufacturers claim they do.”
Advanced Therapy's Anderson assesses the products she buys according to a three-point agenda: economics, safety and outcomes. “With safety, it doesn't matter if it's the Rolls Royce of equipment if the patient is falling out of it. If it doesn't show efficacy, it doesn't matter, because no one will pay for it and no one will use it clinically,” she says. “What's going out in the field is what I am recommending. I don't have an exclusive contract with any manufacturer. It's purely about those three pieces of data.”
As part of her assessment, Anderson requires potential vendors to supply recent, applicable, published clinical outcomes of the products. She also conducts real-time, blind demonstrations, working with nursing homes and home care agencies that will test unlabeled equipment and provide feedback.
Other providers work with third-party companies to assess the products they provide to patients. Apria's respiratory products, for instance, are evaluated by outside company Valley Inspired Products in Apple Valley, Minn. “Our goal is for the results of the evaluation to yield information that gives us the ability to make good decisions,” Pertelle says.
Apria's current focus is on products that involve invasive or semi-invasive care. “We know based on evidence that these products absolutely are a big component for … keeping patients out of the hospital and in the home. The question is, how do they stand up against one another? There are products that may get introduced into the market and, because they are new, tend to have certain appeal, but we need to know if those products actually meet the therapeutic needs of the patient.”
Apria also evaluates products using patient focus groups. “Health outcomes relate to what the patient feels: ‘I feel better. I am able to do more.’ It is essential to get the patient's perspective,” Pertelle explains.
Once patients begin using the correct product, providers can look at the product's benefits, assess the outcome of its use and provide associated service. While outcomes assessment is not normally required for HME providers (as it is for home care agencies and other health care providers), quantifying the value of products and services can be one key to home care companies' health.
Outcomes, by definition, must be measurable. “Clinical outcomes are health outcomes, and health outcomes are what the patients feel, not what we provide. [Outcomes are] the patient's perspective of the results of the treatment, as it relates to the service and the products provided, as it relates to the patient, as it relates to the cost,” explains Pertelle.
However, outcomes do not necessarily have to be clinical. According to Pertelle, providers also can measure outcomes related to cost and patient satisfaction, although all are interrelated.
The Ultimate Goal
Correctly and effectively documenting outcomes ensures providers are adequately reimbursed for home medical products and the care associated with providing them.
According to Cohen, outcomes also can demonstrate to payers that a provider is delivering higher-quality care than competitors. “We want to believe that, ultimately, people want high-quality [care], and that the payers are going to be looking at the quality of care,” he says. In addition, “we have to make the assumption that if what we're doing will result in a positive outcome for the patient, then that is what the payer is going to want.”
Ensuring the viability of providers' businesses, in turn, assures the viability of the entire home care industry.
“In this health care environment, we're under constant scrutiny to show that what we provide is not only value-added but absolutely vital,” Pertelle believes. “The industry needs to develop a framework to quantify outcomes so they are explicit, easy to follow and compelling to those who make decisions about reimbursement.
“It's our responsibility to provide evidence-based data that is duplicative over time so [government decision-makers] have the necessary information,” he continues. “The HME part of the continuum of care will have access issues or cease to exist, and costs will ultimately go up because patients who do not have access to care in their homes will end up staying in facility-based centers.
“When you look at the whole picture, what we do is an essential component of the continuum of care, a small spoke in the wheel. To make [the spoke] even smaller will ultimately cause that wheel to stop turning.”
An industry-wide call to provide quantified information currently extends to all providers.
“So many providers are so busy providing service that it's very difficult for them to stop and gather data, but as we become more sophisticated in communicating with Congress, we need the data,” says Kay Cox, president and CEO of the American Association for Homecare. The association has published a white paper detailing the cost savings and health benefits of long-term oxygen therapy in-home in the treatment of chronic obstructive pulmonary disease (COPD), and another study on the costs associated with inhalation therapy was forthcoming at press time.
“If we are not actively participating in creating data and outcomes, we have missed the boat in dealing with issues like accreditation, reimbursement and other items that affect our industry,” Cox explains.
Finally, a viable home care industry achieves the ultimate goal: its patients' health and well-being.
“If you get involved with clients, if you have some knowledge of disease process and some knowledge of product mechanics — who needs what kind of equipment and generally what works with what kinds of systems — you end up distinguishing yourself, which isn't a bad thing,” Margolis says. “And if you provide the right equipment, you can go home at night feeling good about yourself.
“With the amount of burnout in this industry, there has to be some other reason to stay in the business — one is knowing that you can help the individual and make a profit for your company.
“There has to be a bigger picture, and that [bigger picture] is taking care of the individual. That's one reason to jump in with two feet and be the client's partner, or even to take charge to make sure they get the desired outcomes.”
DO YOU NEED A CLINICAL EXPERT ON YOUR PAYROLL?
Many HMEs choose not to employ clinical staff, such as nurses or respiratory therapists. However, it is these clinicians who have the expertise to record and interpret patient data. So, should providers employ a clinician in order to measure patient outcomes?
Yes, according to Carol Anderson, MSN, Advanced Therapy Surfaces, White Bear Lake, Minn., at least when it comes to working with support surfaces. “I don't know how you can bill if you don't have a clinician because wound data has to be so tight,” she says. “How do you fight and debate your denials intellectually if you don't have a nurse? The people who are denying your claims aren't necessarily nurses, so you have to be smarter … about interpreting the data you get.”
In addition, she says, providers can “open doors” when a staff member is identified as a clinician. “If you have a clinician calling about denials, the payer source will back down if you know what you're talking about and will more likely reconsider. “We're not required to do what we do, but it's a matter of how many days it takes to turn your dollars. I have found that if we don't have a clinician, my [days sales outstanding] are huge because we couldn't get the data back in our hands. When we have a nurse, we are able to turn dollars around very quickly. Put a nurse where a nurse needs to be, pay the salary and the benefits.”
Nurses and other clinicians can be hired on a per-diem, per-event or per-account-touched basis, Anderson notes. But she is quick to point out that the company is careful about not stepping on the toes of the patient's wound care nurse.
“We rely on the wound care nurse's data, while the [wound care] nurse relies on us for product data. We are the pressure-management side of that equation; they are the wound-management side of that equation.”
DOCUMENTING OUTCOMES FOR OSA PATIENTS
According to Vernon Pertelle, national respiratory manager for Apria Healthcare, Lake Forest, Calif., one of the greatest challenges in providing care for obstructive sleep apnea (OSA) patients is adherence to therapy. Providers should focus on the goal of the therapy — patient compliance — and then on documenting the outcomes of the therapy: Because of the service rendered and products used, the patient complied and, therefore, improved.
Pertelle suggests these steps to meet, and prove, the goals of treating OSA:
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Make sure the patient understands the disease and the importance of treating it, as well as how to use the equipment.
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Identify the appropriate interface, the mask. Unlike sleep labs, which see the patient briefly over one or two visits, providers can spend the time to assess the patient's condition and preferences and make recommendations based on instruction and set-up.
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Identify the appropriate heating and humidification system.
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Conduct follow-up at regular intervals. Schedule a telephone, in-clinic or home visit after two weeks. Use the visit to assess whether the patient has been using the CPAP by using the hour meter reading on the machine, which shows actual usage. Also, perform an Apwar sleepiness score before and after therapy.
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Conduct a patient-satisfaction survey. Ask the patient if he or she feels that the therapy is working.
Once these steps are completed, compile the data, interpret it, document it, report it, then share the results. “These are simple steps that can be taken. Providers can do short-term (six-month or a year) or long-term (five-year) studies,” Pertelle explains.
“However, the short-term results are most compelling, because you know that once the patient has been compliant, there will not be much change in the patient's adherence to therapy, unless the patient no longer needs the therapy.”
MOBILITY OUTCOMES Q&A
To find out what it takes to obtain good health outcomes for patients with mobility needs, HomeCare spoke with Michael Babinec, OTR/L, ABDA, ATP, a licensed occupational therapist with more than 25 years' experience in rehabilitation, seating and mobility. Babinec is currently manager of rehab training and education for Elyria, Ohio-based Invacare Corp., a RESNA-certified assistive technology practitioner and senior disability analyst/diplomate on the American Board of Disability Analysts.
Do you have to be a clinician or have certification in order to conduct a wheelchair evaluation?
A good “wheelchair evaluation” is not just one evaluation, but several. Team approaches, where each member contributes within his or her area of expertise, are recommended. Some funding bodies will not provide payment for rehab wheelchairs without an evaluation by a physical or occupational therapist and a certified Rehabilitation Technology Supplier (RTS) who provided the equipment.
Evaluations considered within a wheelchair assessment include, but are not limited to:
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a needs assessment, which includes medical history, demographics, ADL (aids to daily living) requirements, user and caregiver goals;
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a physical/clinical evaluation, which considers strength, endurance, range-of-motion limitations, muscle tone, postural requirements and sensation;
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a home evaluation, to learn about the terrain the client will encounter, entrances and exits;
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an assistive-technology assessment [that] matches clinical and functional requirements with appropriate equipment;
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product simulation and prescription;
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training in use of the equipment; and
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follow-up to make sure the equipment provided is, in fact, meeting the desired goals.
Follow-up visits not only assure the equipment continues to meet the goals identified initially, but allow providers to adjust the equipment to meet the user's changing needs or advancing skills, as well as help prevent future problems by heading them off at the pass.
What aspects of a wheelchair evaluation are most frequently overlooked by DME providers?
Providers often overlook the physical assessment, which includes the mat evaluation. A common question is, “Should every wheelchair user receive [a mat evaluation]?” and my favorite answer is, “Look what might be missed if they don't.”
Asymmetrical postures that are flexible need entirely different approaches and seating geometries compared with asymmetrical postures that are fixed. Knowing when and how much correction to provide is expertise only a skilled practitioner can provide. Limitations in hip flexion less than 90 degrees, which is more common than most people expect, require special considerations for either the wheelchair cushion or wheelchair back angle. These cannot be identified without the physical evaluation.
