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:
Make sure the patient understands the disease and the importance
of treating it, as well as how to use the equipment.
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.
Identify the appropriate heating and humidification system.
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.
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:
a needs assessment, which includes medical history,
demographics, ADL (aids to daily living) requirements, user and
caregiver goals;
a physical/clinical evaluation, which considers strength,
endurance, range-of-motion limitations, muscle tone, postural
requirements and sensation;
a home evaluation, to learn about the terrain the client will
encounter, entrances and exits;
an assistive-technology assessment [that] matches clinical and
functional requirements with appropriate equipment;
product simulation and prescription;
training in use of the equipment; and
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.
