With the new Medicare Conditions of Participation (CoP) regulation looming, home health agencies cannot be operating with a business-as-usual mindset.
That’s the message from Arlene Maxim, vice president of program development for Quality in Real Time (QIRT). Floral Park, New York-based QIRT was founded as a home health quality assurance and coding organization in 2006, and now provides a range of services in clinical, financial, educational and other domains.
“This whole issue with the COPs is a sea change for the industry, the biggest change we’ve ever had since I [joined the industry] in 1979,” Maxim told Home Health Care News.
Her urgency is shared by Marvin Javellana, CEO and founder of Des Plaines, Illinois-based agency Better Care Home Health Inc.
“Compliance with the CoPs means a total DNA change from top to bottom for agencies,” he told HHCN.
Maxim and Javellana recently gave HHCN a preview of the information and strategies that they plan to present at a two-day CoP prep event in Las Vegas on June 12 and 13, offering their take on the biggest CoP compliance challenges, providing a basic roadmap that agencies can follow for success—and some dire predictions for what might befall providers that cannot rise to this challenge.
No More ‘Mindless Drones’
The Centers for Medicare & Medicaid Services (CMS) published the final version of the new CoPs in January 2017. This was the first time in nearly three decades that the federal agency comprehensively updated the requirements that providers must meet to be Medicare certified.
Weighing in at 88 pages in the Federal Register, the rule contains a multitude of new provisions. A few stand out as especially challenging, particularly those regarding patient rights, plans of care and coordination of services, and new board of director responsibilities, Maxim said.
Agencies will have to communicate patient rights prior to the first visit, and then verbally communicate them prior to the second professional visit, and document that this has occurred, Maxim explained. The plan of care (POC) is going to have to be more unique and detailed for each patient, upending the current POC format and workflow.
“With the electronic medical records (EMRs) that are out there, clinicians have gotten used to checking boxes like mindless drones,” Maxim said. “They’ve learned which boxes to check for more money and there’s no uniqueness to the patient. That will have to go away. You can’t hold up an agency’s POCs and see all the same checkboxes marked for each patient.”
One particular facet of the new POC is that it must reflect a specific goal expressed by the patient. If the goal is not realistic, it will fall to the clinician to work with the patient to formulate one that is, Maxim said. For example, if a stroke patient sets a goal of running a 5K within six months, therapists and nurses will have to bring that person “back to reality.”
Agencies’ boards will also have new and more sophisticated roles and responsibilities, which Maxim also foresees being challenging, in part because it’s not uncommon for an organization to have a one-person board or a husband and wife team.
Roadmap for Success
With the status quo about to be upended, there is one overriding imperative for agencies, Javellana believes.
“It’s time for management to learn about change management and implement those skills,” he said. “The majority of people who have been in the inudstry have been used to a certain way and they don’t like to change their ways. ICD-10 was hard enough. Little changes in regulation were hard enough. This is a big, big change.”
Javellana is sending key managers and leaders with Better Care to change management seminars, to arm them with the tools they will need to guide the organization.
Once they have the needed skills, managers can more effectively shepherd their agencies through the specific changes demanded by the CoP rule, Javellana said. Maxim laid out a basic roadmap for moving forward:
1. Assign a lead person, such as the administrator or a compliance officer, to be the change agent.
2. Talk to the agency’s EMR vendor right away to discover what is being done to aid compliance, such as adding quality assurance and performance improvement (QAPI) information to the system.
3. Have the lead person attend a formal training on the new rules as they are currently understood, and then attend another training after CMS issues interpretive guidance.
4. Prep for the transition by creating a specific timeframe for compliance. This will look different for an agency with a 3,000-person census versus a 30-person census.
5. Perform a gap analysis. This should include a review of the org chart and all policies and procedures, to identify where compliance gaps exist.
6. Educate, support, and manage staff through making needed changes, with implementation meetings and special focus on areas that historically have been difficult within he industry, such as coordinating services with other types of providers.
7. Assess board strengths and weaknesses and address appropriately to ensure they can meet new mandates, such as reviewing QAPI initiatives.
8. Build a budget. The Congressional Budget Office estimated that implementing the CoPs would cost a total of $293.3 million in the first year. Consider how to use technology to help control costs.
Implementing the CoPs will require a culture change, and staff members who are set in their ways could prove unwilling to adapt, leading to turnover, Maxim warned. She recommended preparing for this eventuality and having a robust training program in place for new hires.
To get as much staff buy-in as possible and minimize turnover, involve every person in the agency in the change process by educating them on the stakes, Javellana advised.
“Everyone in my office understands why we need to change,” he said. “The whole office, from receptionist to administrator, needs to understand what is going to happen if we do not change. If they understand that, they themselves will be part of the change. I’m not afraid of turnover.”
A Natural Death
So what will happen if an agency cannot manage this change? It might have to shut its doors permanently.
Surveyors are going to aggressively check agencies’ compliance with the new CoPs, with special attention to some of the headline provisions such as patient rights, Maxim predicted. And if surveyors detect a problem, citations could start snowballing.
“So many of the new conditions touch one another,” Maxim said. “Once surveyors find one area out of compliance, you’re going to see multiple citations, because that one area will touch multiple standards and other conditions.”
Once an agency is facing sanctions to the tune of $10,000 or $15,000 a day, it won’t take it long to close up shop, she said.
And this outcome is a more likely than a struggling agency being acquired, Javellana said, particularly in the case of smaller operations that do not have well-established relationships with sought-after referral sources such as hospital systems or managed care organizations.
“They do not have anything to offer in a consolidation,” he said of these smaller agencies. “They die a natural death. I see a drop in the number of agencies. The M&As will happen at the higher level of operations.”
So, the stakes are as high as possible, meaning agencies cannot be complacent. This is not a time to wait for interpretive guidance to come out or hope that the compliance date will be pushed back.
“The top tip for a lot of the agencies out there is to start now,” Javellana said.
Written by Tim Mullaney