This is the first in a series of blogs on the importance of HHCAHPS surveys and their value to helping improve patient outcomes and growing business. 

The Home Health Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) patient engagement survey impacts the bottom line of home health agencies, primarily through attracting referral sources and value based reimbursement.  The HHCAHPS survey is also important for engaging patients through the survey process and gaining insight from how patients rate the services received from your home health organization.

Patient Opinions Quantified

Patient opinion is the source of truth when rating organizations on the quality of care delivered.   Gathering perceptions of the patient’s care experience is tremendously valuable, and focuses on more than just their level of satisfaction.

The HHCAHPS survey was developed to standardize the collection of patient feedback. This makes it possible to measure the quality of care provided by home health agencies (HHAs) as rated by patients receiving care.

Surveying Mandatory to Improve Patient Choice

Since April 2012, the HHCAHPS survey has become mandatory and the results are publicly reported on Home Health Compare, allowing the general public to better understand the quality of care provided by HHAs and select services.

The Centers for Medicare and Medicaid Services (CMS) has introduced a number of programs to shift the healthcare system from fee-for-service (paying for volume) to value-based reimbursement (paying for value) through the introduction of various quality measures, which include the HHCAHPS survey.  Numerous payors and referral sources have also identified potential home health partners through the Home Health Compare data, which may potentially negatively impact home health agencies with lower HHCAHPS values.

Elements of the HHCAHPS Survey

The HHCAHPS survey consists of 34 questions. The first 25 questions serve as the core questions, and the remaining nine questions in the “About You” section are used for analysis.  It takes respondents an average of 12 minutes to complete the HHCAHPS Survey, and the core questions are summarized into the following five categories or domains:

• Care of Patients
• Communication Between Providers and Patients
• Specific Care Issues
• Rating of The Home Health Care (10 Point Rating Scale)
• Would You Recommend This Home Health Agency

These domains are publicly reported through the Home Health Compare, the Home Health Star Ratings program and the Home Health Value-Based Purchasing demonstration program.  Therefore, it is imperative for organizations to understand the HHCAHPS survey, how to improve each measure and how to use the domains for maximizing their organization’s long-term growth and sustainability.

Improving HHCAHPS Measures

A starting point for improving HHCAHPS measures is to ensure you are familiar with the survey, and the questions.  Next, educate your staff and clinical staff on the survey, and encourage them to mention the survey to patients.  Staff may highlight that a survey will be administered during the Start-of-Care and Resumption-of-Care, and patients may be surveyed by Axxess or your current HHCAHPS survey vendor.

CMS does not allow you to share a copy of the HHCAHPS survey with patients, tell the patient how to answer, or demand the patient provides a positive review. A great way to educate staff on elements of the HHCAHPS survey is to review a question at each staff meeting and discuss ways to improve processes to continually better patient care.

In our upcoming blogs, we will review each of the five HHCAHPS domains and questions asked to patients to provide more insight for improvement and better patient engagement.

While Axxess continues to work every day to create innovative solutions to address industry needs and make lives better, the company and its leaders have been recognized for their accomplishments.

Earlier this year, IDG’s Computerworld for the second consecutive year recognized Axxess as the Best Place to Work in IT and profiled our company with comments from several of our colleagues. That award complemented similar recognition Axxess received earlier in the year when Modern Healthcare recognized Axxess as a Best Place to Work in Healthcare.

More recently, the Dallas Business Journal honored Axxess’ Vice President of Operations Melody Lenox among its 2017 Women in Business, and Shradha Aiyer, Director of Mobile Technology, among its 2017 Women in Technology, respectively.

Axxess and company founder John Olajide were recent finalists for the Tech Titans’ Emerging Company Innovation Award and Emerging Company CEO Award, respectively. Tech Titans is the largest technology trade association in Texas, representing more than 250,000 employees through its 300 member companies.

In addition, Axxess’ Chief Technology Officer Andrew Olowu is a finalist for D magazine’s 2017 Chief Information Officer/Chief Technology Officer award, which will be announced in late October.

We are incredibly proud of these recognitions both nationally and locally because they reflect the quality of the culture and the caliber of the leadership team Axxess has built as we strive daily to help grow the home healthcare industry and meet the needs of our clients.

We encourage you to take the time to read the linked profiles to get a better sense of Axxess and some of our key leaders.

Centers for Medicare and Medicaid Services (CMS) recently announced that home health agencies (HHAs) operating in areas affected by Hurricane Harvey will allow agency staff to focus on patient care while in the midst of recovery.

On August 31, 2017, CMS announced that blanket waivers had been issued for several provider types, including HHAs, in Texas counties and Louisiana parishes declared disaster areas by the Federal Emergency Management Agency (FEMA).

Waivers to HHQRP

The waivers include an exception to Home Health Quality Reporting Program (HHQRP) requirements, or “pay for performance,” for the second and third quarters of 2017. Other waivers will delay or suspend re-certification and revisit surveys, allowing additional time for providers to submit plans of correction among other helps.

Current HHQRP regulations, including 484.20(c)(1), require HHAs to achieve at least a 90 percent compliance rate when exporting matching OASIS assessments to create a quality episode within the reporting period. Quality episodes begin when care is initiated and end when care ceases.

Agencies who do not meet the 90 percent quarterly compliance rate typically see a two percent reduction across the board of final claims payments. However, for agencies in declared disaster areas, this threshold has been waived for the second and third quarters of 2017. The state or impacted provider should forward provider information and waiver requests to the CMS Dallas Regional Office for tracking purposes (see contact information below).

Other Waivers

CMS-issued other blanket waivers that may impact HHA practices in Harvey impacted areas:

• Waiving requirements that critical access hospitals must limit the number of beds to 25, and length of stay is limited to 96 hours;
• Lifting of Part B Medicare Non-Emergency Ambulance temporary enrollment moratoria in Texas;
• Waiving the three-day prior hospitalization for coverage of a skilled nursing facility stay; the 1812(f) waiver allows nursing facility admission without the three-day hospital stay and also waives the spell of illness requirement for evacuees and others impacted by the hurricane who need skilled nursing facility care;
• Waiving of timeframe requirements for Minimum Data Set (MDS) assessments and transmission; this waiver is limited to identified impacted counties and geographical areas; and
• Loosening of Medicaid and CHIP enrollment requirements.

Blanket waivers apply to the following counties in Texas and Louisiana:

HHAs in these counties should be aware of the following information impacting care delivery:

• According to the Survey and Certification FAQs, Medicare-approved HHAs have the following modifications to the comprehensive assessment regulation at 42 CFR 484.55 may be made, and will support reimbursement when billing is resumed to help ensure appropriate care is provided:
  • Start of Care assessment (RFA 1) may be abbreviated to include the Patient Tracking Sheet and the 24 payment items;
  • Resumption of Care assessment (RFA 3) and the Recertification assessment (RFA 4) may be abbreviated to the 24 payment items;
  • Discharge assessment (RFA 8 or RFA 9) and Transfer assessment (RFA 6, RFA 7) are suspended during the waiver period;
  • HHAs should maintain adequate documentation to support provision of care and payment; subject to the public health emergency declarations under section 1135, for HHAs that are located in the emergency areas that serve evacuees, the SOC Assessment (RFA 1) may be abbreviated to include the Patient Tracking Sheet and the payment items;
  • Abbreviated assessment does not have to meet the five-day completion date or the seven-day lock date;
  • OASIS transmission requirements at 42 CFR 484.20 are suspended for those Medicare approved HHAs that are serving qualified home health patients/evacuees in the affected areas;
  • Agencies are expected to use this policy only as needed, and to return to business as usual as soon as possible.
• Instructions for how to handle situations where documentation to support payment has been lost or destroyed can be found in CMS’ Program Integrity Internet Only Manual in Publication 100-08, Chapter 3, §3.8, “Administrative Relief from MR During a Disaster.” A note should be entered and dated in the medical record that the documentation was destroyed in the hurricane. This will include medical records for ADRs, CERTs, RACs, etc.
• Face to Face requirements, which are a condition of payment, cannot be waived under Section 1135 of the Social Security Act. If conditions related to the emergency cause a provider to expect to be unable to meet the face to face encounter timeframes, that provider should contact the CMS Regional Office to allow for tracking and completion of this encounter as soon as conditions allow.

Non-Waiver Facts

Other important information, not tied to blanket waiver programs, that HHAs need to know include:

• CMS will advise Medicare Administrative Contractors (MACs) to pay claims for beneficiaries who have been displaced due to disasters, and the MAC will work with agencies that have transferred or received patients due to the disaster or emergency. However, normal HHPPS procedures will apply, including application of Partial Episode Payment (PEP).
• Under the temporary and extraordinary circumstance of a declared emergency or disaster, place of residence can include services provided at temporary locations like a family member’s home, shelter, community facility, church or hotel. A hospital, SNF or nursing facility would not be considered a temporary residence.
• For HHAs impacted, CMS is instructing the Regional Home Health Intermediaries (RHHIs) and MACs to temporarily cease and to automatically cancel the RAP for episodes that have already begun.
• HHAs should report condition under code 47, which indicates transfer from another HHA, on their RAPS for patients who were displaced by a declared emergency. This will ensure that Medicare systems do not reject their RAP due to an overlapping episode at the prior HHA. No other special indicators are needed on these RAPs.
• A Medicare-approved HHA that is able to provide home health services beyond its current geographic service area may do so on a temporary basis during the emergency period, provided that the HHA is in full compliance with state and local law, if the HHA is able to ensure that staff is competent and able to provide appropriate care, and that the purpose of the expansion is to provide care to the patients affected by the emergency. This means beneficiaries who have been receiving home health services and cannot obtain emergency-related treatment during the emergency (such as medication, vaccination, etc.) from HHAs within their service area can be seen by out-of-area HHAs.

Additional waivers are being considered and agencies in areas across the US who are impacted by hurricane damage should monitor for changes at the Hurricane Emergency website, under the “Administrative Actions” section of the page found.

Questions from providers can be sent to the Dallas Regional Office (RO) at RODALDSC@cms.hhs.gov or providers may also call their MAC for additional clarity or questions.

Additional Resources:

MLN Matters SE17020 regarding Hurricane Harvey and Disaster Related Claims, including disaster waiver program Q&A links.

Additional information regarding waiver programs for Hurricane Harvey.

For more information on home health quality reporting and quality episodes.

CMS recently published  proposed updates to the Home Health Prospective Payment System (HHPPS) for 2018. The proposal outlines updates to market basket, national 60-day episode payment, per visit rates and any rebasing changes.

It also outlines changes to Home Health Value Based Purchasing Model (HHVBP) and Home Health Quality Reporting Program (HHQRP) standards, and introduces a plan to remove the number of therapy visits as a payment calculation factor.

Highlights of proposed updates:

• 60-day national episode payment rate reduced by 0.97 percent to account for nominal case-mix growth;
• Annual market basket adjustment increased by 1 percent for agencies that submit required quality data;
• P Calendar year (CY) 2018, national standardized 60-day episode payment is $3,038.43;
• P Annual market basket, for agencies that do not submit required quality data, is offset by the 2 percent penalty, resulting in a -1 percent adjustment on all final claims and supply payments;
• PCY 2018 national standardized 60-day episode payment for agencies not submitting quality data is $2,978.26;
• Rural add-on, currently an added 3 percent for care provided in areas defined as rural locations, expires December 31, 2017, with no extension of the rural add on in 2018;
• Overall impact of HHPPS 2018 payment rate updates totals a decreased $80 million in payments to home health agencies;
• Case mix tables have been adjusted again as required. Grouping categories remain the same (early with 0-13 therapy visits; early with 14-19 therapy visits; later with 0-13 therapy visits; later with 14-19 therapy visits; and all episodes with 20+ therapy visits);
• Eight new variables have been added to the proposed 2018 grouper model, 12 variables that are dropped, 14 current variables increased in value, 48 current variable decreases and 50 remain with the same variable points values;
• No changes made to the 2017 outlier calculation revisions;
• New Home Health Grouper Model (HHGM) for 2019 is proposed to replace the current Home Health Prospective Payment System;
• For the HHVBP model, it is proposed to require a minimum of 40 completed HHCAHPS surveys to receive a performance score for all HHCAHPS measures and to remove OASIS measure “Drug Education on All Medications Provided to Patient/Caregiver during All Episodes of Care;”
• Removal of one quality measure and adoption of two new quality measures for HHQRP, in addition to reporting standardized patient assessment data in five categories described under the IMPACT Act.

I highly encourage industry professionals to review the proposed changes and thoughtfully submit comments and questions, as requested by the authors of the proposed rule. When CMS does not hear from professionals, it assumes the industry agrees with the proposals as stated.

Comments can be submitted one of four ways:

Electronically by visiting www.regulations.gov a the “more search options” tab.

By regular mail, using the following address ONLY:
Centers for Medicare & Medicaid Services,
Department of Health and Human Services,
Attention: CMS-1672-P,
P.O. Box 8016,
Baltimore, MD  21244-8016

By express or overnight mail, using the following address ONLY:
Centers for Medicare & Medicaid Services,
Department of Health and Human Services,
Attention: CMS-1672-P,
Mail Stop C4-26-05,
7500 Security Boulevard,
Baltimore, MD  21244-1850

By hand or courier to either of the following addresses:
For delivery in Washington DC—
Centers for Medicare & Medicaid Services,
Department of Health and Human Services,
Room 445-G, Hubert H. Humphrey Building,
200 Independence Avenue, SW.,
Washington, DC  20201

For delivery in Baltimore, MD—
Centers for Medicare & Medicaid Services,
Department of Health and Human Services,
7500 Security Boulevard,
Baltimore, MD  21244-1850
(If you plan to deliver to this address, please call (410) 786-7195 in advance to schedule your arrival with one of the staff members.)

Axxess will continue to provide information on the proposed changes via future in-depth blogs on the HHGM, HHQRP and HHVBP proposals.

For home health agencies (HHAs) serving Medicare and Medicaid beneficiaries in the coastal Texas region, there is an unseen benefit among preparations for the looming Hurricane Harvey.

Projected to strengthen to a category 3 hurricane with 110 mph winds before making landfall late Friday or early Saturday morning, Harvey promises to test the preparedness of residents in its path. Heavy rain in flood prone coastal areas is a major concern and Governor Abbott has declared a state of disaster for numerous counties along the Gulf of Mexico.

Hurricane Harvey is driving HHAs in the projected area to deploy their emergency preparedness (EP) plans, and begin last-minute preparations for their patients, staff and physical locations.  While residents in the hurricane region prepare, home health agencies and hospices must care for some of the most frail and vulnerable people, and therefore take extra precautions.

Federally-mandated EP regulations were instituted for situations such as Hurricane Harvey, so that patients who may have mobility issues or scant resources are relocated, or potentially have the choice to shelter in-place and are tracked and cared for as needed.

One potential perk to the upcoming storm is the opportunity for your HHA to complete requirements for EP.  Agencies who experience an actual natural or man-made emergency that requires activation of the emergency plan are exempt from engaging in a community-based or individual, facility-based full-scale exercise for one year following the onset of the actual event.

Agencies in the pending disaster area should record and document actions during the hurricane response. Once the HHA recovers from Hurricane Harvey, processes should be reviewed and policies updated per their experiences. After execution of the EP through Hurricane Harvey, the HHA will only need an additional table top exercise and review, rather than a coordinated, community-wide exercise, before November 15, 2017 to be compliant with the new regulation.

Compliance with emergency preparedness regulations are now tied to Conditions of Participation (CoPs) for Medicare and Medicaid HHAs, which become effective January 1, 2018. Agencies who do not follow the minimum standards of care, safety and quality in the CoPs are at risk of losing their ability to bill Medicare and Medicaid for services delivered.

Updated federal EP  regulations became effective November 15, 2016, and highlight standards for HHAs to implement, drill, review and update their emergency preparedness plans yearly. Agencies are required to hold two EP exercises to fulfill this regulation by November 15, 2017, including a community-wide exercise and a table-top exercise.

Both exercises must be executed and reviewed to find possible improvements to processes. Agency EP policies must also factor in federal, state and local regulation to ensure the HHA collaborates with authorities to coordinate evacuations, transfers and home checks for persons who may have sheltered in place and cannot be accounted for, for example.  EP policies must be reviewed and updated at least annually.

Updated EP regulation requirements include, among other points:

1. Each patient has an emergency plan as part of their comprehensive assessment;
2. Agency informs state and local officials about HHA patients who need to be evacuated from their place of residence due to medical or psychiatric conditions;
3. Follow up with staff and patients to determine services needed in the event of interruption of services during or due to an emergency;
4. Agency staff, whether directly employed or contracted, are trained on the agency’s EP plan and individual responsibilities when the plan is deployed;
5. Plans ensure communication and protection of patients’ medical records.

For more information on the updated Federal Emergency Preparedness regulations, go to Axxess’ on-demand video.

The importance of the home health aide, as part of the patient care delivery team, is formally recognized in the updated Medicare Home Health Conditions of Participation (HH CoPs). For those of us who have worked on a team with an aide in the home health industry, we have long recognized this fact. CMS has now recognized the importance of aides and developed new requirements.

Home health aides performs important tasks, including:

• Taking and recording vital signs;
• Caring for the patient’s environment;
• Recognizing changes in the patient’s body functions or cognition;
• Reporting changes to the supervisor;
• Bathing, grooming, dressing and assisting with toileting;
• Assisting with turning, positioning, transfers and mobility;
• Providing skin care;
• Using assistive devices properly;
• Reminding patient of medication and hydration; and
• Assisting with safety precautions.

Due to the intimate nature of the aide’s duties, they often form a special, trusting relationship with patients. In my experience as an aide, many reminiscent stories and exchanges of laughter, among other things, have been known to occur during bath time. This rapport lends itself to patients sharing information with the aide that might not otherwise be shared with the clinical team. For example, aides have an ongoing opportunity to assess the patient’s skin for changes more readily than the other team members.

The newly updated HH CoPs recognize the significance of the home health aide’s role in the overall team of care delivery. Due to this shift, new requirements for aide training have been developed. According to 484.80(b)(3), aides must be trained in communication skills, including the ability to read, write and verbally report clinical information to patients, representatives, caregivers and other home health agency staff. They must also be trained on recognizing emergencies, and how and when to implement emergency procedures. Lastly, in 484.80(b), aides must be trained to recognize changes in patient skin condition. Aides are not to function as trained clinical professionals and stage pressure ulcers, but rather to be aware that changes in skin appearance are important to monitor and changes must be reported to supervisors.

The updated HH CoPs create a new interdisciplinary team requirement, which will impact aides’ job function. According to 484.80(g)(4), requirements state that home health aides must be members of the interdisciplinary team, report changes in the patient conditions to a registered nurse or other appropriate skilled professional, and complete appropriate records in compliance with specific home health agency policies and procedures.

Agencies are given flexibility on how aides function within the interdisciplinary team, and since this interdisciplinary team is a new standard, agencies must decide how they want to model this approach. Some may choose to model teams after the hospice interdisciplinary team model, for example each agency’s needs and populations served will need to be taken into consideration, and employees will need to be educated on new policies and procedures.

Home health agencies must ensure aides, whether full time, part-time or contracted staff, are trained on the new regulations prior to the implementation date of the new HH CoPs. Training may be done through routine in-service training, and agencies should maintain documentation that demonstrates meeting requirements. I recommend filing a copy of the in-service training and sign-in sheet in the agency’s in-services binder, as well as a copy in each aide’s personnel records. However, once the HH CoPs Interpretive Guidance Manual for Surveyors is published, we will know precisely what surveyors will be looking for when assessing compliance.