Members of the Public Health Committee of the Madison County Board of Supervisors and the Madison County Public Health Board heard an update on a home health care study conducted over the past three months.

Consultants reviewed three options open to the county but say the Health Department can hold onto its home health care and long-term home health care programs and make them more profitable. One of those services – the certified home health agency – made money, but long-term home health care saw a loss.

Timely documentation and comprehensive billing seem to be the key to helping those services pay for themselves.

In addition, some streamlining would allow the Health Department to up the number of individuals served, thereby increasing profits without increasing overhead.

Jane O’Connell of Boucher & Associates said certified home health agencies (CHHAs) are the engines that drive all other home care programs. She said CHHAs were established under Medicare law, but licensing requirements were left to each state. The CHHA designation is required to get paid by Medicare for services rendered.

It also is the mother program that allows the county to provide long-term home health care (LTHHC) services and bill Medicaid. LTHHC is targeted at keeping people out of nursing homes when a comprehensive care plan can be executed outside the institutional setting. According to O’Connell, the system for payment has changed several times, and each one of those changes has improved reimbursements.

Efficiently run CHHAs are very favorable because they can improve you bottom line, O’Connell said.

O’Connell’s co-presenter, Dave Boucher, said with the CHHA making money and LTHHC losing money, the end result was a loss for the combination.

Expenses continue to trend up, revenue drops, and negative operating margins increase over time, Boucher said.

Staff productivity, management staffing and support staffing were among areas that could use improvement, Boucher said. O’Connell said the other counties surveyed during their study were comparable rural counties, but Madison County’s cost for benefits was greater. She said staff productivity is just below mean, the department needs an additional management staff, and support staff is way above benchmark.

The department was worried about the results of a recent state audit, which indicated inadequate supervision among its findings; however, the primary problems revolved around documentation. O’Connell said absenteeism can be a factor in some of the staffing issues, but training for the computer system is critical, as the OASIS system requires a tremendous amount of documentation.

Other benefits would be training specifically targeted for the home care nursing experience, as many of the staff have hospital-based nursing experience, O’Connell said.

That training, she said, would help nurses work effectively in patients’ homes.

Peer groups billed $1,678 against Madison County’s $1,552 for those services. Nationally, payments for the same program services were $2,200, even after adjustment for local wage rates, Boucher said.

You can improve your reimbursement just by improving documentation, O’Connell said.

The pair suggested budgeting $15,000 for overtime over about three months to correct the records backlog cited by the state.

That also assumes that other documentation will be kept up-to-date, O’Connell said. Nurses need to complete the record at the time of service or by the end of that service day, and it is important to do that because of the complexity of the OASIS system.

Commercial insurance payments were very modest, Boucher said, and with increased payments and expanded volume, the county could see improvements of $200,000 to $300,000 annually.

In addition, the county’s PREVENT program for maternal and child health, which requires a CHHA to supervise, provides almost no third-party reimbursements opportunity, O’Connell said.

As a county, you want to try and cover the overhead costs of that program through other programs that do provide Medicaid reimbursement, O’Connell said.

We recommend the CHHA be retained by the county, Boucher said. It supports mandated programs and supports overhead expenses that would otherwise have to be covered through additional taxpayer dollars.

Consultants’ recommendations included:

Adding one management position for training and quality assurance issues for which the state cited the county;

Organizing and streamlining support staff functions;

Establishing productivity standards for nurses and home health aides;

Providing training on better and timely documentation;

Increasing the case payment rate for Medicare;

Increasing commercial insurance payment rates;

Recruiting a physical therapist to help improve the numbers served.