Care at home organizations continue to search for ways to navigate industry changes and reimbursement cuts. Home care organizations can lean on the nuances of their industry to expand and diversify their business and increase revenue.

In an education session at the 2023 Axxess, Growth, Innovation and Leadership Experience (AGILE), Zaundra Ellis, Vice President of Hospice Professional Services at Axxess, and Guy Tommasi, Jr., Director of HCP Lifetime Care at Home, explained how home care leaders who wish to diversify their revenue streams should focus on adopting strong leadership strategies and partnering with other care at home and community organizations.

The Role of Leadership in Diversification

During the session, Tommasi advised home care leaders to concentrate on making home care valuable and local, focusing on the strengths of the industry and the needs of the specific community the organization serves. Leaders should avoid trying to compete with neighboring states and communities.

Ellis and Tommasi also encouraged care at home leaders to lean into innovation, partnerships and new initiatives. They believe adopting and maintaining a partner-focused and innovative mindset is the key to surviving in an ever-changing industry.

“In our industry, we need to get that partnership mentality,” Tommasi said. “It’s [really] hard to do anything alone today. And if you want to build scale, you build scale based on partnerships, because that then allows you to build those new programs.”

Ellis added that those partnerships can also help leaders address any gaps in their organization or services.

“[When] you’re thinking about being a disruptor, know your strengths and bring people along with you who balance things that maybe you’re not amazing at,” Ellis said.

Scale Operations With Partnerships

Ellis and Tommasi provided several examples of ways home care leaders can create partnerships to scale their business. While home care often focuses on skilled and non-medical care, organizations can partner with hospitals in their communities to help reduce readmissions, improve star ratings and maintain compliance with conditions of participation.

Tommasi advised home care leaders looking to partner with home health organizations to appeal to value-based purchasing and patient-driven groupings model (PDGM) needs. Leaders should lean on how home care helps improve patient satisfaction and functional impairment.

“If you step up and you go to a home health agency and you tell them, ‘I can help you with your value-based purchasing, I can help you with PDGM, I can give you examples if you’d like,’ you will see them sit up because they haven’t heard it,” Tommasi said.

Organizations should also use data to appeal to potential partners, focusing on the quality measures and performance data to be a differentiator in the industry.

“This [quadruple aim] isn’t really difficult but it is a differentiator,” Tommasi said. “This will add money to the bottom line, this will help you step up as a leader in your region and then you can scale it.”

With more than 250 attendees, more than 40 sponsors and countless connections made, AGILE 2023 was a massive success for everyone. Check out the recap video and mark your calendar for AGILE 2024, April 21-24 in Dallas.

Between reimbursement cuts and regulatory changes, the care at home industry faces many challenges. While these issues must stay top-of-mind for organizations, industry leaders should also begin to focus on developing the next generation. Ryan Klaustermeier, MSN, RN, Vice President of Professional Services for Axxess and Chair of the National Hospice and Palliative Care Organization (NHPCO) Next Generation Leadership Council, shared why developing the next generation of leaders is crucial to the care at home industry.

Developing the Next Generation of Leaders

Developing the next generation of leaders is essential to ensuring the survival and progression of the care at home industry. As staffing issues and turnover rates increase in the industry, leaders must ensure that they are attracting new people, resulting in a more sustainable leadership pipeline.

Klaustermeier noted that more senior leaders who are gearing up for the end of their careers don’t always take time to grow younger colleagues. “I think there’s been a lack of intention and ensuring that there is a smooth and successful transition of power within the industry,” Klaustermeier said, “which I feel is a disservice to the people we serve in our communities.”

According to Klaustermeier, the best way to be intentional with leader development and create an intergenerational culture is through active engagement, focusing on sharing practices, knowledge and experience.

“[Leaders should] leverage their expertise and knowledge to ensure that this industry continues to flourish for years and years to come.” Klaustermeier said.

Bridging the Gap Between Generations

Leaders set the tone on acceptable forms of communication and should individualize those needs based on their staff. For leaders looking for tangible ways to close the generational gap, Klaustermeier suggested looking into succession planning and mentoring toolkits. “Everyone in a leadership position should have a succession plan, in my opinion.” Klaustermeier said.

When building out a mentorship program, Klaustermeier stressed these programs should require contracts and set time limits so that participants experience the full benefits of the relationship.

“I think intentional and formal [mentorship programs] with guidance and boundaries will create more successful mentoring opportunities than random, informal ones, because accountability is important.” Klaustermeier said.

Career Planning for the Next Generation

Younger employees who are looking for ways to move through leadership hurdles should focus on career mapping and planning. Like their more senior leaders, Klaustermeier suggests young leaders invest in a career pathing toolkit and tailor it to their desired position or discipline. Klaustermeier pointed out that the NHPCO Next Generation Leadership Council is currently working on this type of resource.

“If you were to start a hospice tomorrow, you could take our templates, have job descriptions pre-made, and have career pathing ready to go.” Klaustermeier said.

Younger employees can also lean on professional development resources like the Axxess Training and Certification Program, which provides industry-specific training to help users perform their duties at the highest level.

Ultimately, though, young leaders need to take their careers into their own hands. Klaustermeier advises young employees to continue learning and not be afraid to disrupt current systems. Young employees should also diversify their mentorship opportunities, connecting with peers as well as C-suite leaders.

“Don’t expect leaders to take you under their wing and help you grow,” Klaustermeier said. “You have to openly ask for that need and express your desire to grow within your organization or profession because if you don’t tell someone that and keep telling them, it’s just not going to happen.”

Anyone can create an Axxess Training and Certification Program account, giving them access to all certifications, continuing education and training courses across service lines. Together we will elevate care at home.

Diversity in the care at home industry is continuing to grow in importance. Organizations that promote diversity, equity and inclusion (DEI) can see benefits ranging from increased employee engagement to improved patient care.

Tom Codd, Chief People Officer at Axxess, joined Sonnie Linebarger, Co-Founder of IDEAL and CEO of Evoke Greatness, to discuss the importance of DEI at the 2023 Axxess Growth, Innovation and Leadership Experience (AGILE). Codd and Linebarger shared actionable ways care at home organizations can create and foster a diverse, equitable and inclusive culture.

Organizational Culture and Success

Codd noted there has been a cultural shift in focus from tolerance and multiculturalism to equity, inclusion and belonging. The addition of belonging to DEI stresses the importance of how people feel at work.

“Fitting in is about assessing a situation and becoming who you need to be to be accepted,” Codd said. “On the other hand, belonging doesn’t require us to change who we are; it requires us to be who we are.”

Many organizations with successful DEI programs have their framework built on three core pillars:

• Clearly defined and disseminated stance on DEI. Diversity, equity, inclusion and belonging permeate the company’s mission, strategies and practices in visible ways.
• Specific plans and programs to support DEI. This can include hiring and onboarding practices, DEI steering committees and cultural programs.
• Measuring and regular reporting on performance.

Organizations should not view DEI as just another program, but it should be part of the organization’s culture. Organizations must also consider whether their employees reflect the communities where they live and work. Linebarger underlined the need to represent diverse groups at all levels of an organization and address barriers that could hinder an inclusive work environment.

“Despite significant promotion of diversity, so many companies really don’t put that into play,” Linebarger said. “The idea is not to do the tick box. The idea is to really implement it richly in the fiber of the company.”

Actionable Steps for Organizations

Codd and Linebarger highlighted several actionable solutions care at home organizations can implement to create and grow DEI programs in their organization.

• Benchmark DEI and human resources data against industry peers.
• Provide a career development program for everyone in the organization, such as mentorship and training opportunities.
• Promote pay equity.
• Report DEI data within the organization.
• Leadership accountability for DEI initiatives.

Monitoring and Reporting on DEI Initiatives

Leadership accountability is essential for the success of DEI programs, and internal reporting on those programs can ensure progress and accountability across the organization.

“Beyond having ideas and launching DEI programs, mature companies have robust means for measuring and monitoring the performance of these programs, including supporting software and regular reporting,” Codd said.

Linebarger stressed the need for organizations to not only gather data but to also use it to drive actionable solutions and improvements within their organizations.

“When you think about measuring reports, what you measure, you move,” Linebarger said. “Driving sustainable changes requires effective monitoring.”

With more than 250 attendees, more than 40 sponsors and countless connections made, AGILE 2023 was a massive success for everyone. Check out the recap video and register now for AGILE 2024, April 21-24 in Dallas.

Many care at home organizations, especially hospice providers, are considering adding palliative care services as a separate business line. Community-based palliative care programs can address gaps in care for patients with a serious illness and serve as a referral source for other services.

Axxess hosted a recent webinar with Hospice News as part of the Palliative Care Conference Webinar Series. Amy Rose, Axxess’ palliative care product director, led a session on leveraging palliative care for seamless care transitions. Sarah Payne, medical director for Banner Hospice, and Rory Farrand, vice president of palliative care for the National Hospice and Palliative Care Organization (NHPCO), contributed their insights to the conversation.

Communication in Palliative Care

Communication is a central tenant of palliative care delivery, and it’s critical for continuity of care.

“In palliative care, we’re one piece of a very complex puzzle that is the care delivery for a patient,” Rose said. “It’s so important not only for our referral pipeline and making sure that our community is comfortable referring to us, but also just general care coordination and transition, to maintain really deep relationships and communication channels.”

Farrand noted that telehealth can provide an additional connection between providers, the patient and the family. However, telehealth use needs to be based on the needs of the community and the team providing care.

“[Telehealth] helps improve access and equity, especially for rural or other marginalized populations in general,” Farrand said. “In areas that are resource scarce, [telehealth] helps extend those palliative care services where folks may not have a local provider…If you have a significant coverage area, you don’t want to have your expensive, smart, wonderful clinicians behind the wheel of a car all the time.”

Internal communication among the provider team is also critical. Many palliative care providers use the hospice interdisciplinary group (IDG) approach of bringing the team together for regular meetings about patients.

“The care team has to be connecting regularly,” Payne said. “If they don’t, nuances get lost along the way, the communication starts to break down. So bringing that internal team together at least biweekly is important.”

Leveraging technology can enable more clinicians to come together easily and share information with the team.

“In this space, we tend to be just a little bit walled off technologically,” Rose said. “Finding a tech partner that can speak that language and send and receive information in a way that makes your job so much easier is really integral.”

Patient Transitions Between Palliative Care and Hospice

Palliative care’s focus on symptom management and patient goals lends itself to discussions about next steps for the patient, such as hospice. With consistent and accurate communication, palliative care teams can ease those transitions of care.

“A thing that I see a lot are silos between how the hospice team operates and how the palliative team operates,” Rose said. “As we transition patients, [we need to make] sure that we’re on the exact same page about what those teams are doing. That communication can be a challenge, especially if you’re working on different systems that aren’t communicating with one another.”

Patients receiving hospice care may improve and no longer meet eligibility criteria for hospice, but they will still need continued healthcare support.

“If we don’t have a safety net for [patients transitioning out of hospice], and hopefully that’s community-based palliative care or some other way to address those needs, they get lost and they’re going to have a lot of trouble,” Farrand said. “Making sure that person has a path back to palliative is really critical.”

Education and Support

Early education on the resources and services available to the patient and family can also support transitions. Farrand encouraged providers to use simple language, talk up the benefits of palliative care, explain that patients have a choice at every step and connect using stories rather than statistics.

“This is really just humanizing that discussion,” Payne added. “It’s humanizing the experience throughout while also making it very custom and using language that’s digestible to patients and families rather than coming to the table with our own intention.”

Educating referral sources, especially front office staff who have direct communication with patients who are struggling, can also be helpful.

“If [referral sources] can tell me that the patients have symptom burden or caregiver strain, then those are the low hanging fruit right out of the gate that we should be talking to for palliative care,” Farrand said.

Payne agreed, adding, “Whenever someone has a serious illness, it would be very prudent to involve palliative. Palliative will wrap their arms around that individual [and] help support them through the journey, no matter the outcome.”

Axxess Palliative Care, a cloud-based palliative care software, was built for flexibility with streamlined workflows from intake to claim submission.

Over the past two years, we have seen a dramatic increase in the use of remote care technology in clinical practices of all kinds. With recent reports that the cost of COVID-19 social isolation has reached nearly $7 billion, we may soon see remote care monitoring (RCM) in the home expand exponentially. RCM may soon be considered the “seventh discipline” on many home health plans of care.

Face-to-Face Compliance with Remote Care Monitoring

In home health, we must secure documentation of a face-to-face physician visit with the patient for the same reason we are seeing the patient in the home. The documentation secured for compliance with this rule includes a brief narrative that describes how the patient’s clinical condition, as seen during that encounter, supports the patient’s homebound status and need for skilled services.

How can an organization comply with this requirement when patients are unable to, or refuse to, leave the home due to fear of contracting the virus?

Remote care monitoring is a logical answer to this dilemma.

In fact, CMS directs physicians through documentation, indicating “the face-to-face encounter can be performed via a telehealth service.” For home health organizations struggling to comply with the face-to-face rule, it is in their best interest to make this technology available to all admitted patients who require clinical care and are unable or unwilling to leave their home.

Providers and multiple professional organizations, such as the National Council on Aging, the American Medical Association and the National Association for Home Care and Hospice (NAHC), are attempting to work with Congress to gain support for remote care monitoring reimbursement. Now that the Medicare Payment Advisory Commission (MedPAC) is showing significant interest and getting involved in the conversation, it would appear that we are getting closer to meeting that objective.

Remote Care Monitoring as the “Seventh Discipline”

As we work through the process of using remote care monitoring for ordered virtual visits, we need to understand what is required when surveyors and other auditors review documentation.

We currently have little direction from CMS. However, we have experienced survey and auditor reviews requiring documentation that is strikingly similar to rules now existing for the current six billable disciplines of skilled nursing (SN), physical therapy (PT), occupational therapy (OT), speech therapy (ST), home health aide (HHA) service and medical social work (MSW).

By treating the use of remote care monitoring itself as the “seventh discipline” on the physician’s care plan, we can satisfy the requirements that we see evolving.

Three Tips for a Compliant RCM Plan of Care

1. Orders should be very specific in frequency, use and duration. For example, an order may look like this: Remote care monitoring by RN 2 x week x 9 weeks. Remote care monitoring to assess patient’s compliance with current medication regimen, evaluate reported pain level and log being kept by patient for tracking of blood sugars.
2. The quality assurance staff within the organization should track RCM visits the same as the frequency and content of other visits.
3. Work with your electronic medical record (EMR) vendor to ensure RCM visits are appropriately identified as such. At this point, we cannot bill for RCM visits. If billed, it could be considered fraudulent billing.

RCM is quickly becoming adopted by all healthcare organizations as an alternative treatment of choice in caring for patients in the home. More frequent touch points could significantly change reported outcomes, improving star ratings. Be certain to research the best RCM program for you and your organization.

Axxess Home Health, a cloud-based home health software, includes HIPAA-compliant documentation capabilities on all devices, even without internet access.

With the implementation of the Notice of Admission (NOA) at the beginning of 2022, we have seen some issues occur with each Medicare Administrative Contractor (MAC) and their acceptance of the NOA.

These issues should be reviewed at each of the MAC’s websites (Palmetto, CGS/NGS) for continued tracking and updated instructions to alternative workflows.

As of today, we have seen three common issues occurring nationwide. Billers need to be aware of these known issues to ensure timely and accurate claim submission.

Reason Code 32114

First, providers were seeing reason code 32114 regarding missing ZIP codes for NOAs. The Centers for Medicare and Medicaid Services (CMS) is aware of this oversight, primarily affecting NOAs that were submitted in a batch (multiple NOAs in one electronic submission).

CMS has instructed providers to enter NOAs manually in Direct Data Entry (DDE black screen) to ensure pending acceptance. In DDE black screen, providers can access the claim in the Claim Center by entering the nine-digit ZIP code and resubmit by hitting F9.

It is important to review the status of your NOAs daily. However, if an NOA is late because of this issue, use the Remarks section of your final claim to include: “Jan 2022 Issue RE 32114.”

Reason Code 19960

For reason code 19960, organizations were seeing their claims in TB9990 status/location with a condition code of 15 added to NOAs that were not entered by the organization. This issue occurred primarily for Palmetto GBA providers.

Palmetto has instructed providers that there is no additional action needed to submit these NOAs and when the MAC removes the condition code, a new received date will be applied. Since this cannot be overridden, some NOAs may be considered late.

Just as with reason code 32114, if this issue causes an organization’s NOA to be untimely, the final claim associated with the NOA should include a KX modifier and remarks: “Late due to CC 15 release.”

Reason Code U537F

Currently an open issue at the time of publication, reason code U537F is one to be reviewed closely as some NOAs may be correctly editing for this reason code. Organizations should ensure that the claim does not have an open home health episode on file from a different organization, regardless of billing period date.

If the previous organization has not closed billing (DOLBA is blank), your organization’s NOA should include condition code 47.

Another instance in which providers will see NOAs in Return to Provider (RTP) status is when duplicate NOAs are submitted. In this scenario, one of the duplicate NOAs will receive this reason code. In this instance, the NOA marked with U537F should be suppressed by the provider as no further action is taken.

If your NOA does not fall under these scenarios, Palmetto GBA and NGS have advised organizations to monitor their websites for additional information. There are currently no resolutions implemented, but a fix is in process.

Axxess has created a resource page where updated information will be housed for industry partners and Axxess users to find more information on all things NOA. Be sure to continually review each MAC’s claims processing issues log for peace of mind and guidance directly from CMS.

Axxess Home Health, a cloud-based home health software, provides built-in billing updates for accurate claims, as well as a resource page with frequently asked questions on the NOA.