How Dru Evans Promotes Efficient Operations in Home Health

Name: Dru Evans, RN
Title: Administrative Director of Pardee Home Health
Home state: North Carolina
Company and specialty: Pardee UNC Health Care

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In February 2018, Pardee UNC Health Care brought Dru Evans aboard as administrative director of Pardee Home Health. Evans joins Pardee from Raleigh, North Carolina, where she served as the regional director of operations for Intrepid USA. For Intrepid, Evans was responsible for clinic operations of numerous home health agencies in Ohio, Pennsylvania, West Virginia, Virginia and North Carolina. These agencies achieved 4.5- and 5-star ratings with the Centers for Medicare & Medicaid Services (CMS), and represented more than $30 million in budgetary responsibility.

As administrative director for Pardee Home Health, Evans is responsible for integrating, progressing and accelerating home health services to bring advanced care to the home of each patient. In concert with Pardee’s physicians and staff, community partners and post-acute care facilities, Evans has to ensure patient engagement, clinical quality, innovation and affordability.

Pardee UNC Health Care is a not-for-profit community hospital founded in 1953 and is managed by UNC Health Care.

HomeCare: What path did you take to get to where you are today?

Evans: My nursing career began in the ICU at a level III trauma center. I greatly enjoyed the high-tech nature of the position but missed patient interaction.

In 2004, I started a homecare agency working with the local hospice agency to assist with keeping patients at home. The patients utilized long-term care insurance and private pay for CNA or LPN services. I loved growing that business. When we relocated to North Carolina in 2004, we had 50 patients. I sold the business to a dear friend and at last contact with her in 2017, she had more than 200 patients.

Being new to North Carolina, I was not sure where I would land as far as nursing opportunities were concerned. I interviewed at a home health agency and accepted a field clinician opportunity. This was my nursing fit—each day was different. I took care of nasty wounds, did infusions, educated on medications, and taught on disease process, as an educated guest in patients’ homes.

I remain grateful for the opportunity to work with patients in their home. I owe each patient I have cared for a debt of gratitude for the opportunity. Eventually, I became the OASIS RN, then preceptor and finally as a field clinician, I became the high-tech nurse caring for complicated wounds, high-tech IVs and case-managed other complicated patients.

In 2010, I was offered a clinical supervisor position, which was a blast. I taught clinicians to work in the challenging field of home health. I held them accountable and set high expectations.

In 2012, I received my first offer as administrator (director). I loved this position and soaked up knowledge as quickly as I could. I so enjoyed imparting vision, managing outcomes and figuring out how to be profitable in a very challenging market with Medicare reimbursement decreasing. We have to do more with less money every day.

HomeCare: What is dynamic about the home health care industry? Just how much have the nuts and bolts of good care changed over time?

Evans: It really depends on what part of the industry [you mean]. For example, the conditions of participation until January 2018 had not changed in close to 25 years. The constant changes in home health revolve around reimbursement, day-to-day operations and evidence-based practice.

We also see changes in the industry for bundled payment, the emergence of Medicare replacement policies, ACOs and pay-for-performance. Reimbursement has been on a steady decline since my involvement in home health leadership. We have to be patient-centered, frugal and responsible with the dollars we are paid to do business.

Some day-to-day operational changes I have seen in home health are the coming and going (thank goodness) of the therapy 13-, 19- and 30-day reassessment. When we had multiple disciplines, it was nearly impossible to track and maintain compliance.

I have witnessed the need for a face-to-face to qualify a patient for home health services, which I stand strongly against. Home health used to be able to care for patients who had little to no access to care; we now have to involve the physician at a visiting level. This decreases the high-risk patients’ access to home health services.

Evidence-based practice is our goal with every patient, and some treatment modalities have changed over time. When I first started in health care, the thing to do for wounds was Maalox and a heating lamp. When evidence-based practice evaluated Maalox and heating lamps, we found that this modality was ineffective. So, staying up [to date] with the latest and greatest is important in every aspect of patient care.

Some things have not changed. Patient-centered care with dignity, respect, integrity, responsibility and excellence should be what drives us every day.

HomeCare: You are described as a turnaround expert. Where and how should an underperforming organization develop turnaround thinking?

Evans: Situational leadership. Motivating, honest, positive, caring, determined and visionary. You have to know when your team needs prodding, when they need encouragement, when they need to be reminded of the goals, and when they need someone to listen. I am intuitive, so I can pretty easily read people and situations, which helps me to understand the needs of my team members and how to interact to meet their needs.

People also need accountability. Each of us has a role, and it is my responsibility to hold staff accountable. We have to raise the bar. Expectations should be achievable, but only if you give your best effort.

I need to look at what my direct reports are accomplishing every day. My direct reports also have to hold their staff accountable. One responsibility I take very seriously is to make sure each person working for me is in their best role. I have to make sure if someone has a particular title that it is a great fit for them.

This level of leadership and accountability is often hard. I definitely do not like the conversations about, “Are you sure the role you are in now is a good fit for you?” Especially when I know it is not a good fit. It takes honesty, yet kindness and compassion, to have the difficult conversations.

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It’s Not All Business

What cool apps have you discovered?

Evans: We recently moved to Hendersonville, North Carolina, which is near Asheville in the mountains. I just downloaded AllTrails and a GPS tracker. AllTrails is awesome! It has difficulty ratings, directions and star ratings for tons of hiking and biking trails.

What podcasts are you listening to?

Evans: I love TED Talks.

What are you reading?

Evans: I enjoy all types of leadership books. Right now, I am reading “The Practice of Management” by Peter Drucker. I also enjoy reading fitness and running books.

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HomeCare: What are the foundational elements of efficient operations in home health?

Evans: Patient-driven care and outcomes. I am a nurse by trade and my philosophy of nursing revolves around “caritas,” which loosely defined means caring with love. Sometimes it is a balancing act between financials and patient care, so if I have to drop a ball, it is the financial ball. If responsible patient care comes first, along with understanding the reimbursement structure, the money will come. It is my responsibility to be a good steward of the money Medicare, Medicaid and private insurance pays.

There are two types of outcome measures: patient satisfaction and patient care. Patient satisfaction comes from surveys patients have filled out and returned to an outside firm. Patient outcomes have two sets of measures: quality and process measures. Quality is related to the functional questions: shortness of breath and pain. Process measures have recently changed to no longer include the percentage of patients receiving the flu vaccine during flu season.

HomeCare: As an operations leader, how would you approach setting and achieving strategic goals if you were operating a home health agency today?

Evans: The first thing I would do is evaluate the current system. I would pour over financials, OASIS answers to pertinent questions with focus on functional questions, shortness of breath, pain, timely initiation of care and medication management. Other considerations are visits per episode, therapy utilization and nursing utilization.

I would look at the pay model of the clinicians and their productivity. I would evaluate the staffing model both for field clinicians and back office staff. I would make sure each person was performing at a high level, and make adjustments as needed.

Some job descriptions would likely need to change, especially in the back office, and some positions may need to be eliminated. Territories may need to change based on patient demographics and clinical coverage situations. If I want to get somewhere in the most efficient manner possible, I need a map. It is the same thing when turning around an office. I do a thorough investigation of the situation, then I write an action plan and execute.

HomeCare: What about OASIS is hard for home health agencies?

Evans: According to the NIH, “Empirical findings indicate the validity and reliability of the OASIS range from low to moderate but vary depending on the item studied.” So, the questions may not be the best. The way the questions are asked may not be worded to elicit the most accurate answer.

We need to look closely at every OASIS question, read the literature on how to correctly answer and then educate and re-educate our clinicians. My constant reminder to my clinicians is to answer the questions based on patient safety, not on what they do or what they tell you they can do.

HomeCare: What do you predict for the financial future of home health businesses over the next three to five years?

Evans: We are at a crossroads in home health. We are the least expensive of all treatment systems, including hospitals, skilled nursing facilities and rehabilitation post-hospital stay. Patients are known to learn better in their homes. It is time for home health proponents to educate our legislators about the benefits of home health care.

We have the opportunity for exponential growth, not only from CMS, but from bundled payments, ACOs and relationships with private insurance groups. I predict the opportunity for great financial growth, if we take great care of patients.

HomeCare: How do you lead organizational change?

Evans: Communicate vision, be a barrier buster, stay calm, focus on the important, make a decision, lead my team, live with integrity, recognize accomplishments, encourage effort, care about success, never be afraid of failure, be a resource, always tell the truth, be prepared and celebrate achievements.

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On Accreditation

Some reasons to obtain accreditation: It shows a commitment to excellence in quality, it can bring in referrals, and it provides an opportunity for education, training and improvement. I personally have experience with ACHC, Joint Commission and CHAP.

Each accrediting body looks for essentially the same things, including accurate documentation of patient care, employee training and safety, and a clean and safe working environment. In order to accomplish this, the accrediting body will review organizational structure; policies and procedures; compliance with state, federal and local laws; compliance with patient rights and responsibilities; fiscal operations; and human resources management, to mention a few.

Does accreditation increase referrals? It certainly does indirectly, if an agency is compliant with the expectations of the accrediting body, that agency has strong practices, policies and procedures in place, which lends itself to stability, which improves outcomes, which in turn increases referrals.”