Mary Ellen Conway, RN, BSN, is president of Capital Healthcare Group, LLC, Bethesda, Md., which provides health care management expertise in accreditation preparation and survey follow-up, operations assistance, design of quality improvement programs and outcome measures. She can be reached at (301) 896-0193 or through capitalhealthcaregroup.com.
The post-acute care world has changed dramatically during the past 10 years, and continues to grow and change each day. We have experienced extensive reimbursement cuts with even more to come, while post-acute care spending continues to rise. Between 2006 and 2010, CMS’s expenditures in this area rose by 45 percent, with an annual growth rate of approximately 10 percent. This sharp increase was driven by a variety of factors, including the increase in the elderly population (baby boomers entering the above age 65 population), as well as an increase in the chronically ill—more people living longer with more chronic diseases.
Hospitals also played a role in this increase in response to reduced DRG payments. Acute care discharged patients as soon as possible into post-acute settings with very little follow-up. Now that we have the 30-day readmission penalty in place for hospitals, we see this trend reversing and the need for more care in the community, either after the acute care stay or in lieu of it. Patients with chronic conditions such as diabetes, CHF and chronic obstructive pulmonary disease (COPD), represent about 20 percent of the CMS population but account for up to 85 percent of expenditures. Much of that cost is driven by expensive acute-care episodes.
The 30-day readmission penalties have forced hospitals to take a closer look at their discharged patients and to become increasingly more selective about how and to whom they discharge. In addition, bundled payments, in which reimbursement is paid for an entire episode of care (acute and post-acute), have further encouraged collaboration between acute and post-acute organizations.
CMS is also experimenting with ways to reduce the overall cost of care for these individuals by changing the care paradigm. Several of these experiments have demonstrated (specifically those in a patient’s residence) that increasing the level of care provided in nonacute settings can result in a significant reduction in acute-care expenditures. Thus, CMS is encouraging the development of the “medical home,” in which patients—particularly the chronically ill—are cared for by a primary care physician who is supported by a range of professionals (such as PAs, NPs, social workers and more) to create a trusting, managed relationship between the patient and the medical home staff in order to address the medical, social and economic issues that often surround these patients and exacerbate their conditions. These medical home-associated staff have become familiar with devices used in the home and will play an increasingly significant role in helping patients select the devices that work best for them. The noncompliant and nonparticipative patient can no longer be left alone to manage their condition.
How Does Accreditation Fit Into This?
As the market and reimbursement for post-acute services changes and many suppliers fade away, the networks providing post-acute services will only be contracting with those accredited organizations that are well-established and provide high-quality programs and services. Realizing that an accredited organization must meet standards that are above and beyond routine business practices, maintaining accreditation shows the organization’s quality commitment.
As all providers know, accreditation is not a one-time thing. Your organization is expected to be accreditation-ready every day. Accreditation renewal occurs at least every three years and gone are the days that an organization can gear-up for renewal only as that renewal survey approaches.
Because renewal work can bury your organization when performed all at once, it is important that you keep your accreditation activities in manageable, or as one accrediting organization (AO) puts it, in “bite-sized” pieces so that you and your staff can accomplish these tasks as a portion of your daily routine and not have to stop your activities to get tasks done. Below lists some of the accreditation tasks that you may need to perform daily, quarterly and annually, depending on your AO requirements.
Make sure that your records are being collected correctly, daily. Records must be kept in a secure location that is easily accessible for survey. They must include a form (paper or electronic) that acknowledges the patient/caregiver received all of the necessary, required items. These include such forms as the 30 Supplier Standards (or the language of how to find them online and how to request a copy in writing—see sidebar above), written proper use of equipment and troubleshooting instructions, Patient Rights and Responsibilities, the assignment of benefits, inexpensive or routinely purchased items (Medicare requirement), home safety information and more.
Check your accreditor’s standards to find a list of the items you must provide to all patients and make sure you have the complete acknowledgement of receipt from each patient on file.
Quality/Performance Improvement Activities and Tracking Measures
When it comes to HME accreditation, AOs receive multiple inquiries regarding how to monitor quality continuously and improve the performance of their organization. One of the first questions you should ask yourself is, “How do I select the area I would like to improve?” Most responses center on the Medicare Quality Standards and their guidelines. Medicare requires certain areas be reviewed, so be sure to follow the requirements, but also decide what will be the most beneficial to your operation. The concept of monitoring quality continuously is to locate, identify and correct any company weaknesses you can improve.
Customer Satisfaction Surveys
Every accreditor requires that you poll your customers for satisfaction. Distribute your surveys in the method that works successfully for you. If you send the survey to the customer to be returned, be sure to include a postage-paid return envelope for the most success in getting those completed surveys back to you. Total your results each quarter.
The annual education standard is often found deficient on re-surveys, especially for small suppliers, as they often forget to create their calendar. Even when they do, suppliers may not implement the schedule as planned. The CMS Final Quality Standards require that education be provided to all HME technical staff. Technical staff includes any staff member who delivers or instructs items in person or troubleshoots equipment over the phone. Your particular AO standard may list a yearly requirement of hours (and sometimes topics) of education that you must provide to technical staff. Make sure you are getting your educational requirements accomplished each quarter.
There are many methods to accomplish this requirement. Education can include in-person program attendance, such as regional association meetings, Medtrade and other conferences. It can also include participation in educational teleconferences. Both VGM and The MedGroup offer online HME-specific education that also can be easily implemented.
Check your on-call (or afterhours) log every month, but at least quarterly. Surveyors often ask to see your log for two reasons: 1. To make sure you have one. (It’s a Medicare requirement.) and 2. To look for troubles or problems they can investigate, especially repeat problems.
Read your log as a surveyor would, looking for repeating problems or recurring issues that happen afterhours. Make sure you have documented the time from the receipt of the call to the time of the response, then check your accreditor’s requirements to make sure that you are responding within their required time limit.
Your surveyor may ask for a census or an organizational chart to select files for review, or he or she might give you the option of pulling files yourself. He or she will usually ask to see the file of a newly hired staff member. Often these files have forms that have not been filed yet because the staff member is new. Make sure all of your files are current and complete for all new hires.
Competency is a basic tenant of accreditation and required by all oraganizations. Competency assessments have become crucial to ensuring that staff—particularly those providing direct patient care—have the necessary training and skills to perform their job correctly. Supervisors (or peers in the case of licensed RTs) need to observe the performance of tasks (assess the competency) to ensure that the staff member is capable of performing them on their own. A typical HME delivery technician might perform dozens of different deliveries of equipment needing set-up, all of which must be competency tested. Ensure that observation of these tasks is completed during orientation before sending the new staff member out into the field independently and again annually (or when required), to ensure that bad habits are not developed, keep skills sharp and to maintain product skill knowledge levels. You can document competency evaluations individually by item, or in an overall competency evaluation that includes all of the items that the staff member teaches or troubleshoots. Use a form that can be kept in the staff member’s personnel file. Ongoing assessment activities should be planned at regular intervals every year.
Ensure that you have documentation, report your quarterly results annually to leadership and have reviewed for policies and procedures for any changes. You also want to make sure that you test your emergency and disaster plans each year and that you conduct a safety review, including a yearly fire drill that is documented. Finally, always read your last survey report. This is what your surveyor does to see what was going on at the time of your last survey, what your deficiencies were and what steps you were taking to correct them. Make sure all of those deficiencies have been corrected and that you are compliant with each issue previously cited.
The 30 Supplier Standards
- If you want to remove a page of written information from the materials you give to your patients with each new item, you can satisfy the requirement listed in Supplier Standard 16 by providing the following text provided by the NSC in lieu of providing a copy of the 30 Supplier Standards:
- The products and/or services provided to you by supplier legal business name or DBA are subject to the Supplier Standards contained in the Federal regulations shown at 42 Code of Federal Regulations Section 424.57(c). These standards concern business professional and operational matters (e.g., honoring warranties and hours of operation). The full text of these standards can be obtained at http://ecfr.gpoaccess.gov. We will furnish you a written copy of these standards upon request.