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Webinar Recap: Value-Based Purchasing & ACOs

Posted by Seth West on September 8, 2017
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Webinar Presented by:

Arnie Cisneros & Astrid Roeder

Home Health Strategic Management

ACO integration into Post-Acute Care calls for a shift in agency practice from volume to value, leaving many agencies wondering how best to begin their transition away from a ‘silo based’ care model. In their webinar on Value-Based Purchasing & ACOs: The Path of the Future, Arnie Cisneros and Astrid Roeder provide a comprehensive overview of the following issues:

  1. ACO Value Analysis for the Home Health Provider
  2. HH Value Programming Goals and HH Value Programming Changes
  3. Required Clinical Elements for Medicare Programming
  4. CMS Home Health Rehab Requirements:
  5. Required Rehab Elements for Medicare Programming
  6. Clinical Management of Home Health for Value-Based Care (Utilization Review)
  7. Clinical Targets for Home Health Value Programming


Arnie and Astrid highlight key issues in the traditional care model and suggest actionable and measurable steps to put your agency on the path to delivering a value based care model.

  1. ACO Value Analysis for the Home Health Provider:

In order to successfully transition to value based programming, Home Health providers must be aware of what the Accountable Care Organization is looking for, so that they can restructure accordingly.

  • Star ratings: Home Health providers must strive for 4 or greater.
  • Good HHCAPS scores re: patient satisfaction that is maintained over time.
  • Specific attention to 30-day readmit, ER visits
  • Average HH Length of Stay statistics
  • Liaison support for Care Transitions management: increased communication and collaboration with provider.
  • Start of Care capability
  • Minimal missed visits, anti-recertification culture: visits should be made up within the same week.
  • Progressive clinical delivery/programs, not volume-based: what did you do to add value to the patient’s care?
  • DC with goals met - culture of compliance: important that patients are discharged with goals met.


HH Value Programming Goals

HH Value Programming Changes

● Improvements in Quality of Care

● Patient centered, reliable, accessible, safe

● Improved outcomes for CMS Home Health clients

● Reduce the cost of quality healthcare

● Hold providers accountable for the quality of care they provide to Medicare beneficiaries

● Individualized Start of care Home Health Programs

● Managed on an In-Episode Basis for efficient care

● Fiscal Results tied to care quality performance

● Increased attention to Care Intrinsic required: properly managing intake, focusing on the start of care date.

● Traditional Care Approaches now defunct

● Clinician - managed care WON’T WORK

● Focus on Wellness, Independence, Acuity

● Increased Reporting, Communication

● Decreased Utilization - Decreased Payments



Required Clinical Elements for Medicare Programming

Clinical Documentation Requirements:

  1. Objective Clinical Programming - Mandatory
  2. Home Programming - Care between visits
  3. Patient Compliance - Mandatory
  4. Caregiver Participation - Mandatory
  5. Discharge Planning - Mandatory
  6. Qualified Short Term Goals
  7. Qualified Long Term Goals
  8. Caregiver Participation - Mandatory
  9. Discharge Planning - Mandatory
  10. Qualified Short Term Goals
  11. Qualified Long Term Goals


All patients in your care require you to outline care and treatment programs that:

  • Meet professional standards
  • Are based on objective tests and best practice measures within the professional practice
  • Include measurable goals that directly relate to the patient’s illness or injury.


CMS Home Health Rehab Requirements:

  1. Connecting the individual treatment modalities to the patient’s level of clinical or functional decline.
  2. Creating goals of improvement that are a direct result from the patient’s care plan.
  3. Documenting patient progress at every visit, to identify how the program is specifically addressing each of the areas. Documentation is used to justify more visits for the patient to achieve the measurable goals you’ve set in place. Failure to document can mean denial of coverage.

It cannot be emphasized enough that the patient care plan that is created must match the OASIS.


Required Rehab Elements for Medicare Programming
Below is a comprehensive overview provided by Astrid of the rehab elements that are required for Medicare programming. A breakdown is provided for each of the four elements so that providers may have a better understanding of what each element entails.

Astrid emphasizes the importance of ensuring that the measurements of your ROM and MMT are specific.


CMS HH - Objective Testing

● Establish Measurable Baseline via tests

● HH Focus has been on Fall Risk Tests

● Functionally related tests completes program

● Connected to objective delivery

● ROM/MMT – no gross tests – RLE – ⅗

● ROM/MMT – focus on area of decline

● Tendency to overscore geriatric MMT levels

● Establishes baseline for care delivery

CMS HH - Home Exercise Programs

● Required for all licensed HH clinicians

● Allows for efficient progress/improvement

● Instituted on first visit

● ROM, Strengthening, Function

●  MUST address underlying weakness

● Underlying weakness must relate to function

● Re-performance NECESSARY for progress: should be reperformed and progressed every visit.

● Progressive Element = Skilled care (PREs): Progress, resistive exercises must be included and documented.

CMS HH - Compliance/Caregiver

● Compliance required for qualified program

● Related to value reforms in healthcare

● Minimal value for non-compliant care

● Compliance based on therapist (NOT patient)

● Stated every visit re patient performance

● Caregiver issues are identical to Compliance

● Restated every visit for value management

● Non- compliant patients – value/coverage


CMS HH - Short/Longterm Goals


● STG/LTG – CMS HH requirement

● Must relate to objective & functional declines

● Must be labeled STG/LTG w date to achieve

● Must have finite time to goal achievement

● The primary cause of rehab denials in HH

● Content less valuable than format

● Helps clinical staff objectify care

● Helps measure value in care programs


Clinical Management of Home Health for Value-Based Care (Utilization Review)

  • U.R.C.H © Awarded Innovative Care Model 2016 VNAA Annual Conference

Service Utilization Review for Care in the Home helps you to manage doctors and clinicians to deliver best practice programs to get the patients better and out faster.


Clinical Targets for Home Health Value Programming

Arnie and Astrid identify the following clinical targets required for Home Health Value Programming. There are several issues that are highlighted in the chart below that providers will need to address in order to create care plans. 

1242: Pain

● Pain that interferes with activity or movement

● Usually tied to subjective scale only

● No functional walk

1400: SOB

● Delivery of DBE on the OASIS visit

● Interview question

● No functional walk

● Bedbound patients are asked, not functionally assessed.


1810: Upper Body dressing


● 3 part question

● Ineffective use of response section of guidance manual

● Interview versus functional assessment

1820: Lower Body dressing


● 3 part question

● Ineffective use of response section of guidance model

● Interview versus functional assessment

1830: Bathing


● 3 part question

● Ineffective use of response section of guidance model

● Interview versus functional assessment

● Entire body

● Medical restrictions


1840: Toilet Transfer

● 4 part question to/from on/off

● Ineffective use of response section of guidance model

● Interview versus functional assessment

● Can’t asses safety with equipment if equipment is not in the home

1845: Toilet Hygiene


● If ostomy: Includes cleaning

● Ineffective use of response section of guidance model

● Often interview versus functional assessment

1850: Transfers


● Use of minimal assistance or device to transfer safety

● 1 = One or the other to perform safely

● 2 = Requires both

● Ineffective assessment of transfers from one level surface to another versus guidance: In the bed; Supine; Up, Out of the bed; Transfer to another regular surface.

● Ineffective use of guidance manual response section

1860: Ambulation


● Regardless of need of device

● Response section of OASIS:  2 = Intermittent supervision; 3 = Continuous supervision

● Functional walk – something for accuracy

● Not an interview

● Homebound status needs to present Answer of 1

Sought ED Treatment without admission


● Ineffective scripting of how to utilize agency versus ED

● Agency call numbers not posted and reviewed

● Protocols for disease process and techniques are required to lower ED visits.



Topics: Home Health, Post-Acute Care, Medicare, ACO

Seth West

Written by Seth West

Seth West, Director of Marketing & Communications with PlayMaker, has extensive experience in advertising and promotion, equally astute in both print and web environments. He has lent his creative talents to a variety of Fortune 500 companies, helping to develop corporate branding, multi-tiered marketing campaigns, and engaging media communications.