The Florida Home Care Connection · within its own little silo but in an ACO, everyone is working together. McCann and Gilmartin explained that the goal of an ACO is to make sure

Home CareThe Florida

ConnectionThe Official Publication of the Home Care Association of Florida

Summer 2013

Home CareRenew

Yourself for the New Age of

The Home Care Association of Florida 5

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ecarefla.org

The Florida Home Care Connection is published for The Home Care Association of Florida 1363 East Lafayette Street, Suite A Tallahassee, Florida 32301 Phone: (850) 222-8967 Fax: (850) [email protected]

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©2013 Matrix Group Publishing Inc. All rights reserved. Contents may not be reproduced by any means, in whole or in part, without prior written permission of the publisher. The opinions expressed in this publication are not necessarily those of Matrix Group Publishing Inc.

11

In Memory07 Remembering Terri Santangelo

Features08 Examining the Future of the Home Care

Industry in ACOs

11 Increasing Referrals by Becoming a

Physician’s Trusted Partner in Care

13 Making Managed Care Work for You

15 The Future of Healthcare Delivery is in the

Home

18 Are You “Hip” With the New HIPAA Rules?

21 Buyers Guide

08

ContentsSummer 2013

July 31, 2013

Aug. 28, 2013

Sept. 25, 2013

Oct. 30, 2013

Nov. 20, 2013

Dec. 18, 2013

Jan. 29, 2014

Feb. 26, 2014

Mar. 26, 2014

Apr. 30, 2014

May 28, 2014

June 25, 2014

July 30, 2014

UPCOMING EVENTSRehabenings is a monthly forum for home health rehab professionals that is presented by HCAF,

in collaboration with Arnie Cisneros, P.T., President of Home Health Strategic Management.

Participants may join the webinars either online and by telephone, or via telephone only. All of these

events will be recorded and available online soon after each event... FREE with registration of the live

event! Live events are held 12:00 – 1:00pm (Eastern).

The Art of Coding for Home

Health

Tampa, Florida,

8:00am – 4:00pm

Beginning ICD-9: “Learning

to Paint by Numbers”

Sept. 10, 2013

Intermediate ICD-9:

“Creating a Diagnosis

Masterpiece” – Sept. 11, 2013

Advanced ICD-9: “Where

Art Meets Science:

Advanced Level Strategies

and Applications for Home

Health Coding Success”

Sept. 12, 2013

ICD-10: “Prepping

the Canvas for a New

Landscape” – Sept. 13, 2013

Blueprint for OASIS-C Data

Accuracy

Two full day OASIS-C Data

Collection Rules & Guidance

workshop, with optional

Certificate for OASIS Specialist-

Clinical Exam Administration.

• July 21 & 22 – Orlando (exam

July 23 or July 25, 2013)

• Sept. 25 & 26 – Miami (exam

Sept 27, 2013)

• Dec. 4 & 5 – Orlando (exam

Dec 6, 2013)


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OUr hOME CarE COMMUNITy has lost someone very special and someone very dear to many of us. Terri Santangelo was truly an unsung home care hero. She did not just work in home care—she was home care! She was always willing to do what needed to be done, in a prac-tical, caring and kind way. Home health was in the very fiber of her being and it surely was her passion.

For over 26 years, Terri worked in the community of South Florida. She was a dedicated home care profes-sional, earning the respect and admi-ration of those who worked alongside of her. Her passion, her knowledge and her experience led her to serve

up front

In lieu of flowers, her family set up a webpage in memory of Terri with the American Heart Association. The link is:

http://honor.americanheart.org/goto/santangelo

Remembering Terri SantangeloFlorida’s leading voice on home care goes silent

as the President of the Home Care Association of Florida. She was also an active member of the Association of Coders. Her deep caring was con-tagious and inspired many of us to be less cynical about the business of home health, and remember more often that it is the clinician serving, caring and healing the patient in their home that makes it all magic.

When a special soul like hers is unexpectedly taken from us, the void is great. Terri would have wanted every one of us to fill that void with our own renewed passion. She would have wanted us to rekindle our commitment and our resolve to follow her example,

putting the people that we love first, including the patients that we see every day.

Her beloved Matt and her kids, Chris, Matthew and Nick, will feel her absence the most and they will be in our prayers for a long time to come. Her husband Matt said it best, “My Terri had an enor-mously big heart, it gave and gave so much to others, but in that one moment, it was just not quite strong enough to give anymore.”

We were all blessed by Terri and will continue to be so. Our friend, colleague and leader will be sorely missed as we continue to follow her example, laboring with our hands and hearts. HC

TerriSantangelo1960-2013

Remembering

Summer 2013

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8

Home Care Industryt this point, it’s probably safe to say that everyone who works in the health-

care industry has heard of A c c o u n t a b l e

Care Organizations (ACOs). ACOs are a major part of the Affordable Care Act (ACA) because they represent the goal of the future of the healthcare industry to provide the best possible care to patients at the most affordable cost. ACOs are a collabora-tive effort between a group of healthcare organizations from different aspects of the industry, who are all working togeth-er and regularly communicating to make sure that each patient is getting coordi-nated care.

One of the major questions that remain regarding ACOs is what role the home care industry will play. The answer is: a major one. Home care agen-cies that haven’t started preparing them-selves to become a part of an ACO may find themselves getting left behind as the healthcare industry as a whole moves forward.

There are many naysayers who argue that ACOs will never achieve the grand results that they were designed to do. However, the ACO model will be put to the test on a grand scale and home care providers should not sit idly by.

“Health systems are partnering with home care companies today for the future. You have to start prepar-ing because if you wait, it will be too late. A wait and see approach could be disastrous. ACOs are the first in a series of changes in reimbursement,”

Examining the Future of the

in ACOsBy Scott Brashears, ContinuLink, LLC

Mark Francis, managing director of the Houlihan Lokey International Investment Bank, said at the Home Care and Hospice Financial Managers Association Leadership Panel in 2012.

Moving toward the futureWhile they were once just an

abstract concept, ACOs are now rap-idly spreading across the U.S. For example, Forbes magazine reports that more than half of the U.S. popu-lation lives in an area that is now served by an ACO. Furthermore, that number is expected to grow. A recent article published by MedPage Today called ACOs, “an increasingly popular shared-savings model.” The news source cited a report done by analyst David Muhlestein, who said that although the number of ACOs is currently fairly small, growth will undoubtedly continue.

This model of care delivery has benefits for several different aspects of the healthcare industry. For example, the goal of an ACO is to deliver qual-ity care at a less expensive cost. The idea is that the best way to do this is to foster greater communication among doctors, hospitals and all other health-care professionals who are involved in a patient’s care. Hopefully, this will lead to fewer unnecessary tests and lower hospital admission and read-mission rates.

Lowering readmission rates is key in controlling costs, since ACA provi-sions will crack down hard on hos-pitals that don’t get their numbers down. A recent report by the Robert Wood Johnson Foundation showed


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that one in five elderly patients is readmit-ted to the hospital within 30 days of dis-charge and 76 percent of these readmis-sions are preventable.

“They are the result of a fragmented system of care that too often leaves dis-charged patients to their own devices, unable to follow instructions they didn’t understand, and not taking medications or getting the necessary follow-up care,” said the study authors.

The news source stated that once patients leave the hospital, less than one out of five see any direct communica-tion between the hospital and their pri-mary care physician. This may be one of the reasons why patients end up back in the hospital. However, the Inquirer also pointed out that, thankfully, the ACA has suggested new delivery and payment models that aim to solve this problem namely, ACOs.

Research has also backed up the idea that ACOs may be just what the health-care industry needs to foster better com-munication and reduce costs. A report by researchers from Dartmouth University, published in the journal Health Affairs, pointed out that the current policies and approaches to performance measure-ment and payment reform in the health-care industry focus on individual provid-ers. This runs the risk of reinforcing the type of fragmented care that patients with chronic illnesses have become used to receiving, as they bounce from one care provider to another.

The major role home care playsTo shine a greater light on how home

care will fit into the ACO model, we spoke to Interim HealthCare’s Chief Executive Officer, Kathleen Gilmartin, and Chief Industry Officer, Barbara McCann. Interim is one of the nation’s leading home care, hospice and medical staffing companies, with more than 300 franchise locations.

According to Gilmartin, Interim has recognized ACOs as an important part of the ACA since the very beginning. They have been recommending that all of their franchisees educate themselves about what types of ACO models are emerg-ing. Furthermore, they provided their franchisees with information on all of the Medicare ACOs, as well as the Cigna and

United Healthcare ACOs, to help evaluate and determine how to participate in these organizations.

McCann explains that the process of becoming part of an ACO is different and challenging for each ACO. However, both she and Gilmartin insisted that becoming part of an ACO is well worth it. McCann added that an ACO encourages physicians to communicate more with home care staff about patient care. In an ACO, phy-sicians have re-focused on overall patient care, including the benefit of care in the home. This comes from the realization that the home care multi-disciplinary care team is spending a considerable amount of time with their patients. These kinds of discussions don’t happen in the tradition-al healthcare setting. Usually, each facet of a patient’s healthcare team operates within its own little silo but in an ACO, everyone is working together.

McCann and Gilmartin explained that the goal of an ACO is to make sure that patients only go to the hospital when an emergency arises. In order for this goal to be achieved, physicians need to work with home care agencies that can help monitor the patient outside of the hospital in the most affordable setting; their home. Who are you working with?

According to McCann, home care agencies take care of people with chronic diseases with the viewpoint of helping them live independently with their ill-ness, rather than inside the walls of a hos-pital. Home care workers get more face time with a chronically ill patient than any other healthcare provider. They visit these patients in their homes, where they make their healthcare decisions every day, giving them first hand knowledge to any barriers and behaviors that affect the adherence to the treatment plan.

Susan McCaskill, Esq., CEO of Orlando-based HeartFelt Home Care, agrees that home care will play a major role in the future of ACOs. “Home care is uniquely positioned to be part of an ACO because we can go and see the patient in their home setting, [and] report back to the case manager to let them know if they need to step up the level of care a patient is receiving to avoid a hospitalization. This isn’t just about reducing readmission rates; it’s about keeping a patient from having to go into the hospital in the first

place. Home care can truly be an extension of the doctor’s office,” she said.

For decades, doctors have been focus-ing on helping people get well and spend-ing little time on disease prevention. This is something that ACOs aim to change. According to the American Medical Group Association (AMGA), in order for doctors to focus more on prevention, there needs to be a cultural shift within the healthcare industry. Doctors will need to be able to pay attention to their patients who need immediate care, while also reaching out to those who are working on preventing ill-ness. Home care workers are in patients’ homes to act as an extension of the doctor and make sure that preventative measures are being taken, as well as ensuring that those with chronic conditions are manag-ing them properly.

Will it pay off?From a cost perspective, if home care

agencies are interested in ACOs, they may have to make some investments to make sure that they are equipped to share all necessary patient data with other mem-bers of the ACO. This could include a new system that allows for data sharing to dif-ferent providers and settings.

However, these investments will pay off in the long run because an ACO is all about providing the best possible care at an affordable cost. McCann adds that the government is very generous to agencies that are part of an ACO. For the first two years of a typical ACO contract, agencies are reimbursed at the current episodic rates. After the first two years the Medicare ACOs move to a population based reim-bursement-predictive expenditure in a geographic area for a group of Medicare beneficiaries, often referred to as an At Risk model. This will most likely be fol-lowed by the Payer driven ACOs.

Under the At-Risk Model the savings are shared between the ACO participants, which include the home care companies.

Thank you to ContinuLink for being a major supporter of HCAF through-out the year! For more information and to thank them for their support, please visit www.continulink.com or call (866) 802-7704.

Continued on page 21


ery candidly, most agencies try to be all

things to all people,” says Rich Chesney, president of

Healthcare Market Resources, a market intelligence company

for home health agencies and hos-pices. “Everybody says they’ve got

a great quality agency, right?” Differentiation. It’s one of the most fundamental aspects of

marketing but also something many agencies never quite get their arms around. The oversight is natural. After all, we all know we’re unique… why doesn’t everybody else get with the program and see our uniqueness, too? That’s the trouble with differentia-tion. It must form in the mind of the buyer—the physician. And agency leaders and marketers are the ones who must shape it.

Differentiation is essential because competition is fierce. There are 67 counties in Florida, but more than 1,500 Medicare and/or Medicaid-certified home care providers. With so many agencies fighting for the same referrals, often a doctor will just say, “I’ll work with these five agencies.” Then, they’ll divvy up the referrals so each agency gets a handful. Maybe you’ve been in this situation and just accepted it as a fact of life. It’s not. It means the physician does not have clear enough differentiation to justify a more informed decision.

Chris Tillotson, president of Custom Home Health, learned the importance of differentiation during his years selling medical devices. “Everybody’s trying to sell to doctors all the time. They’re saying the same things as you but they might be better looking and they might speak better than you. How can you prove your agency is the best option?”

Creating your partnership storyBefore starting J.I.D. Consulting & Coding, Jill Dyer,

RN was the owner and administrator of a highly successful,

physician-friendly agency. Her husband, Bill Dyer, was the agency’s business manager. “You’ve got to determine your unique selling points,” says Jill Dyer. “For our agency, our differentiators were that we had HomeCare Elite status, had all full-time clinicians and therapists, and were locally owned. Every agency needs to figure out its story and why that story matters to the doctor you’re talking to.”

Bill Dyer quickly adds, “We wanted to be known as the educational home health agency. We were always bring-ing in information of specific value to our physicians, like, ‘What constitutes homebound status?’ or ‘What are the new regulations for face-to-face?’ It wasn’t just a ‘howdy call’ with doughnuts. We were partners.”

Creating a niche for your agency can help, too. Do you have great outcomes with heart failure patients? Do you provide cancer care? Those may be differentiators in your market that can set your agency apart. A niche allows you to walk in and tell the physician, “Doctor, we’ve built our agency to meet the needs of the patients you serve. We understand what’s involved and we’re here to be your eyes in the home.” But it must be true. Build your specialty pro-gram first, then go in and talk about it. False promises lead to disaster.

hello… Is it me you’re looking for?What are physicians really looking for? It’s a basic ques-

tion but answering it accurately will help you better align your agency’s value proposition to physicians’ needs and become a better partner.

David Tapia, MBA, FACHE, of Exegete Healthcare International, a consulting firm focused on home care, boils it down to five elements:• Great patient care – Physicians want an agency that

produces good outcomes and can prove them with pre-cise metrics.

By Chip Schneider, Kinnser Software

Increasing Referrals by Becoming a Physician’s

Trusted Partner in Care

Summer 2013

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• Credibility – Physicians want an agency that has a good reputation.

• Reliability – Physicians want an agency that is dependable and honest.

• Great follow up and communica-tion – Physicians want an agency that will communicate effectively, efficient-ly and accurately at all times.

• Exceptional customer service – Physicians want an agency whose staff is friendly and professional at all times. “A low readmission rate means a lot

more than how interesting your logo is or

even how long you’ve been in business,” says Tapia. “If your outcomes are not as good as the average, you need to address that immediately.”Great marketing doesn’t start with marketing

A partnership-focused marketing strategy doesn’t begin with marketing at all, and most of it has very little to do with your marketer. It starts with opera-tional processes that are focused on patient outcomes and customer service.

“Focus on operational things, like having one nurse and one therapist

seeing the patient,” suggests agency owner Chris Tillotson. “Having four dif-ferent people in that patient’s home in one week doesn’t support quality out-comes and is a terrible experience for the patient. I know this isn’t ‘marketing,’ per se. It’s more important than that. It’s about being the agency that you’re mar-keting. When your agency is high qual-ity, it’s a lot easier for your marketer to prove that it’s true.”

Seeing the world from the physi-cian’s perspective can help you iden-tify inventive ways to engage him or her. Tillotson’s agency has had great success by developing special programs and pro-tocols with referring doctors. “It really connects them to our agency, because it’s something we do together.”

Jill and Bill Dyer’s agency enhanced physician partnerships in a very direct way by the agency referring patients to physicians. “We had patients who’d come home from the hospital having been treated by hospitalists, but they didn’t have a primary care physician. We could refer them. The patient and their family were happy because they got a great doctor and the doctor was happy because we gave him a patient. That established a very real partnership.”

When you communicate to a physi-cian that you understand and can solve the problems he or she faces, that physi-cian is much more likely to value you as a person and to value your agency as a partner in care. As David Tapia says, “It’s a relationship based on trust.” Building that trusting relationship is one of the most important keys to succeeding in home health. HC

chip schneider is the creative director for kinnser software. thousands of home health agencies and therapy companies use kinnser´s web-based solutions every day to increase back office efficiency, enhance collaboration and improve clini-cal outcomes.

Thank you to Kinnser Software for being a Gold sponsor of HCAF’s 2013 Annual Conference! For more information and to thank them for their support, visit www.kinnser.com.


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anaged care generally refers to a way of organizing doctors, hos-pitals and other providers into groups in order to enhance the quality and cost-effectiveness of health care. Managed care organizations include Health

Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Point

of Service (POSs), Exclusive Provider Organizations (EPOs), etc. Accountable Care Organizations (ACOs) are different from the

managed care and capitation models that were prevalent in the 1990s but there are similarities, especially when it comes to the goal of cost savings.

The ACO model is designed to achieve savings through improvements to care quality and population health care, as opposed to restricting utilization of health care services. Under the Medicare ACO model, patients retain all the rights of free (traditional) Medicare patients.

Several major national insurance carriers, such as Aetna, WellPoint/Anthem and UnitedHealthcare, have announced that they will be rolling out or supporting the development of ACO networks across the country, creating, a path to operational con-vergence of traditional managed care and the ACO model.

adapting to home health managed care In contrast to Medicare and Medicaid, managed care is char-

acterized by shorter treatments, more frequent admissions and discharges, and a tighter grip on the amount of services authorized.

To successfully operate a home health care agency in a man-aged care environment, the agency must maximize efficien-cies and reduce turnaround times, while controlling costs and improving outcomes.

With tighter margins, to achieve profitability agencies must service a larger numbers of patients while carefully managing costs and resources. The advances in information technologies have enabled agencies of all sizes to stand on equal footing with large multi-agency chains.

Maximizing efficiencies and controlling costsEfficiency and cost control are crucial to the success of an

agency that wants to provide managed care home health services. You need to implement internal processes to handle such a fast

paced environment and information technology is a key aspect to achieve a cohesive, consistent process that can address with equal ease Medicare/Medicaid patients and managed care patients.

Make sure that your software is designed for efficient pro-cesses and operations. Some solutions will require a much small-er ratio of non-medical staff per active patient, while others just mimic the inefficiencies of a paper based operation, and not all solutions are well suited for non-Medicare operations.

Implementing processes to have a tight control on pre-autho-rizations for treatments will significantly reduce risk and increase profitability. The proper software will ensure that you don’t schedule or provide un-authorized services, and that you provide the totality of authorized services to your patients.

Managing authorizations also means making sure that you obtain the right number of authorized services for you patients’ needs. Often you will find that you need to provide clinical sup-port and appeal for additional services. Make sure you have the right resources in place to tackle such processes.

One way to control expenditures while operating with tight margins is to minimize fixed-costs while trying to convert as many cost centers as possible to variable costs. Many agencies are already applying this strategy with field clinicians, where clini-cians are contractors paid for services actually provided.

Consider outsourcing activities for which a fixed resource will have low utilization or it will be difficult to manage efficiently. The activities you define as low utilization directly depend on the volume of services provided by your agency under Medicare/Medicaid and managed care. As the volume of managed care ser-vices that your agency provides increases, you will have to peri-odically reevaluate your decisions.

reducing turnaround times while improving outcomes

Managing home health clinical data is challenging. Traditionally, agencies have to wait several days for clinicians to turn in clinical progress notes. Case managers have to wait to see if the services rendered are working as expected in the initial plan of care or if there is a need to adjust the treatment.

By implementing point of care technologies, case managers have real time access to the patient progress notes to monitor quality and, if needed, immediately adjust visitation frequencies, schedules and treatments.

Making Managed Care

By Pablo J. Buki, Igea Software

Work for You

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Point of care technologies provide clinicians with instant access to patient charts (EMRs) in the field; this is a great enabler of outcomes’ improve-ment and should not to be overlooked.

Point of care is also good for back office employees that can bill for ren-dered services faster and more accu-rately, while potentially detecting any mismatch early on, maximizing revenue and minimizing losses.

Coordinating careCoordination of care is paramount

to achieve improved outcomes as well as to obtain the proper level of autho-rizations. The most important aspect is having the primary care physician involved in the progress of his or her patients. Make sure to establish fric-tionless channels of communication. If possible, primary care physicians should have access to patient charts and progress notes in real time, as well as efficient tools to communicate with your agency in a seamless way while documenting the interaction.

One organizationMany organizations create silos when

providing Medicare/Medicaid and man-aged care services, while others create different legal entities to mitigate risk and focus on each type of service. This might be a reasonable approach but you have to keep in mind that having separate legal entities doesn’t mean that you have to duplicate the operational roles. To oper-ate efficiently and achieve maximum resource utilization, consider providing the common organizational services for both lines of business in an integrated way. You can achieve it by implementing the right technological solution and an organizational structure to support it.

The path aheadManaged care creates additional

opportunities for the home health care industry. With an increasing number of homebound patients under care, man-aged care organizations are becoming an even more important alternative to traditional Medicare and Medicaid. Additionally, with the ACO model many

of the practices that are common to manage care are going to be implement-ed by ACOs across the healthcare con-tinuum. The marriage of healthcare and technology opens the door for a great path ahead. Agencies that can achieve the efficiencies and the coordination of care required by managed care organi-zations will be in good shape to face the challenges of this new era. HC

for more information about implementing the right technological solution for man-aged care and medicare/medicaid in home health, contact pablo j. buki, ceo of indura systems, inc., maker of igea software for home health care, at [email protected] or by phone at (415) 226-1206.

Thank you to Igea Software for being a Silver sponsor of HCAF’s 2013 Annual Conference! For more infor-mation and to thank them for their support, visit www.indurasystems.com.


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2

1apid advances in health-care technology and the

economics of healthcare delivery are creating unprecedented opportunities for more healthcare services to be delivered in patients’

homes. This is happening not a moment too soon; all stud-ies point to growing fiscal pres-

sures on our healthcare system as Baby Boomers age.

I’ve often asked fellow boomers, “If you had a choice between receiving qual-ity healthcare at your home or in a hospi-tal, which would you choose?” Nobody has answered “hospital!”

Baby Boomers, like me, are used to fast food, online services and convenience of service delivery. This already established trend promises to emerge as one of the primary drivers for the home health indus-try’s prosperity.

Home care is essential but histori-cally, it is an under-utilized and under-appreciated piece of the healthcare puzzle. However, as the overall healthcare com-munity is coming to understand, not only does home healthcare reduce the overall cost, it also improves the quality of life for patients and families.

As Teresa Lee, CEO of the Alliance for Home Health Quality and Innovation puts it, “Not only is home health the least expensive form of healthcare delivery, home care is the patient’s preference.”

hospital readmissionsTo curb rising health expenditures and

improve patient outcomes, part of the Affordable Care Act that went into effect on October 1, 2012, introduced financial penalties for hospitals with excessive read-missions through the Center for Medicare and Medicaid Services Readmission Reduction Program. The Medicare Payment Advisory Commission submitted a report to Congress in 2007 showing that 17.6 percent of hospitalizations resulted in

often-avoidable readmissions within 30 days, costing taxpayers a whopping $12 billion each year.

Some of the top reasons for hospital readmissions include:• Patients not fully understanding what’s

wrong;• Patients being confused over which

medications to take and when;• Hospitals not providing patients or

doctors with important information or test results;

• Patients not scheduling follow-up appointments; and

• Family members lacking proper knowl-edge to provide adequate care.

CommunicationGenerally speaking, effective coordi-

nation of the communication of pertinent information is the key to reducing read-missions. Hospitals, physicians, patients, patients’ families and especially home health professionals, can have a positive impact on the rates of readmission when home health takes the lead in implement-ing a strategy for communication between all the parties involved.

For the overall healthcare industry, focusing on home health care presents an obvious solution. A study by the Alliance for Home Health Quality and Innovation took historical data to forecast potential savings of $10.3 billion over ten years (2014 to 2023) by reducing regional hospi-tal readmissions through the use of home health as the first line to handle post-acute care episodes. The cost driver for these savings is the cost of a patient/day in com-parison. Hospital stays cost 43 times more than home health care in terms of patient days cost in dollars—not a 43 percent more cost, 43.67 times more costly! And this is using data from five years ago!

TechnologyA key element in determining which

agencies will survive, is the application of

technology. Here are four areas in which technology is making a real difference.

One: Improved medical team communication and coordination. Patients are often treated by multiple providers and health professionals and technology is enabling real-time team communication. This could mean giv-ing a home care nurse the ability to pull up the patient’s entire record (including hospitalizations and visits to primary care providers) on multiple windows, simulta-neously, on a tablet during a visit.

There are many different ways that smaller agencies can utilize up-to-date technology to efficiently share patient records that qualify as Continuation of Care Documents. For example, there is a new cloud based system that enables the digital transmission of patient referrals, doctors’ orders and other key medical information, without the involvement of a Health Information Exchange.

Two: Improved communication with the patient. Technology makes it possible for home care professionals to check real-time drug interaction updates, or to share videos with their patients, teaching them about new treatments, in the language of their choice. Patients can link up in telemedicine consults with their doctors and nurses and obtain instant responses to in-home situations, often avoiding costly doctor visits and hospitalizations. For instance, in 2007, the Veterans Health Administration was able to achieve a 19 percent reduction in hospital visits and other cost savings through a program that provided tele-health services, including videophones, digital cameras and vital sign monitors to patients in their homes.

There are also new technologies for patients to communicate with their healthcare team by not only using secure messages via email and texting, or enter-ing personal information into patient portals, but transmitting physiological

Hospital readmission rates will plummet as this future unfolds

The Future of Healthcare Delivery is

in the HomeBy Sam Smith, Home Health Evangelist and Vice President, Axxess, using core ideas of John Olajide, CEO, Axxess Technology Solutions

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4

3information through home monitoring systems.

Three: Shift from “fee-for-service” treatment to holistic Accountable Care Organization (ACO) model. When patients can stay home, hospital personnel can focus on the most acute cases. Studies performed by The Joint Commission in 2011 show that patients prefer to receive healthcare in the comfort and dignity of their own homes. By integrating healthcare into daily life, instead of limiting contact with the medi-cal system to a few office visits or hospital-izations, the dynamic of treatment chang-es to emphasize self-management. Home health agencies must adopt software that is HL7 compliant in order for them to be able to partner with ACO hospitals for seamless, 360-degree patient care. The agency accepts some of the risk for that patient’s well-being in the ACO model, with the focus on outcomes. This makes the use of technology even more crucial.

Four: Increased efficiency and competitiveness for even the small-est home health agencies. Not only is advanced, web-based software now

available to help agencies work more efficiently and effectively than ever, there are also affordable choices for agencies of all sizes. With the proposed 2014 deadline for agencies to adopt electronic medical records approach-ing, the jump into the 21st century can be pain-free if agencies invest the time to conduct thorough software demos, including for clinicians in the field and administrative staff in the back office, to find the option that is best for them. I have heard many prognosticators say that there will be a reduction in the sheer number of home health agencies, with the implication being that the smaller agen-cies will be eliminated. The data suggests differently. The agencies that thrive in the coming years will survive due to their pro-ficient use of technology. Technological sophistication, not size alone, is an impor-tant determinant of survival.

With the availability of cutting-edge models in care coordination, prescription management, disease management and behavioral education for patients, tech-nology providers are helping home health agencies incorporate innovative and

cost-effective approaches to deliver high quality, patient-centered, well-coordinat-ed care. All these factors, with proactive steps taken by home health agencies, can begin to significantly reduce readmissions. Patient outcomes are improving and over-all health expenditures can decrease as a result. The market is moving toward new technology and will bring with it a new, and welcome, focus on the role of home health care.

This role of home health in the contin-uum is destined to become pre-eminent. Patients will thrive and hospitals will ben-efit. The result: avoidable readmissions are decreased. HC

sam smith is vp-business development for axxess, a leading supplier of quality technol-ogy solutions for the health care industry. contact him at [email protected].

Thank you to Axxess for being a Gold sponsor of HCAF’s 2013 Annual Conference! For more information and to thank them for their support, visit www.axxessconsult.com.

Summer 2013

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inal rules regarding the Healthcare Insurance

Portability and Accountability Act (HIPAA) were published in the Federal Register on January 25, 2013, and were

effective on March 26, 2013. Covered entities and business associates must comply with the final rules by September 23, 2013. Following is

a summary of major changes included in the final rules.

Business associatesWith regard to Business Associates,

the new final rules clarify whether “con-duits” of protected information are Business Associates. Specifically, enti-ties that provide transmission services only, including any temporary storage of protected health information (PHI) inci-dental to transmission services, are not Business Associates. Entities that provide storage are considered to be Business Associates, even if the agreement with the covered entity does not contemplate any access, or access on a random or inciden-tal basis only. In short, the “test” under the new final rules is length of custody; not access.

The new final rules also address the issue of whether “downstream contrac-tors” are directly responsible for com-pliance with the Business Associate requirements of both the Security Rule and the Privacy Rule. According to the final rules, all entities are directly respon-sible for compliance, even if the par-ties do not enter into a written Business Associate Agreement. Providers are not required to enter into Business Associate Agreements with all downstream contrac-tors. They must sign a Business Associate

Agreement with the entity with which they do business directly. Providers’ Business Associates are then required to obtain written “satisfactory assurances” from each of their immediate subcontrac-tors. In the event of a breach, all “down-stream contractors” are required to report up the chain to providers.

An example of these requirements is a provider who contracts with a shred-ding company to dispose of records that include PHI. The provider must enter into a Business Associate Agreement with the shredding company. The shredding com-pany, in turn, contracts with a trucking company to pick up the records and deliv-er them to the shredding company. The shredding company is required to obtain “satisfactory assurances” of compliance from the trucking company.

The new final rule also clarifies that Business Associates are directly respon-sible under the Privacy Rule for:• Limiting uses and disclosure of PHI

to requirements of Business Associate Agreements in the Privacy Rule;

• Disclosing PHI to the U.S. Department of Health & Human Services (HHS) for investigation of business associates’ compliance with HIPAA;

• Disclosing PHI to covered entities or individuals in response to requests for electronic copies of PHI;

• Compliance with the minimum neces-sary requirements of the Privacy Rule; and

• Entering into Business Associate Agreements with subcontractors.

Disclosures and revised notices of privacy practices

The new rules allow covered entities to disclose information about deceased

patients to family members and others, in addition to personal representatives. Information may be disclosed to family members and others involved in the care or payment for the care of decedents prior to their deaths, unless such disclosures are inconsistent with prior expressed preferences of decedents known to providers.

Providers are now required to make changes to notices of privacy prac-tices and to distribute new notices that include changes required by the final rules. Providers are required, for exam-ple, to include uses and disclosure of PHI but should not specify a list of all circumstances in which authorization is required. Instead, covered entities can list categories that require authorization, such as:• Psychotherapy notes;• Marketing; or• Sale of PHI.

Revised notices must include a state-ment that other uses and disclosures not described in the Notice of Privacy Practices will be made only with autho-rization from individuals. Notices must also include statements related to indi-viduals’ right to opt out of fundraising communications and the right to restrict disclosures of PHI to health plans when individuals pay out of pocket in full for items or services.

access by individualsAccording to the final rules, indi-

viduals may request electronic copies of PHI that are maintained in an electronic health record or another electronic desig-nated record set. Providers are required to provide an electronic “machine read-able copy.” This is digital information

By Elizabeth E. Hogue, Esq.

Are YouWith the New HIPAA Rules?Hip” “


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stored in a standard format that permits PHI to be processed and analyzed by a computer. Providers have flexibility with regard to the exact format, since sys-tems may vary. Providers must, however, accommodate requests from individuals to receive information in specific formats, if possible.

The final rules also address requests to send information to third parties. When individuals request that providers send PHI directly to other individuals, provid-ers must send the information as request-ed. Requests from individuals must:• Be in writing and signed by the indi-

viduals making requests; and • Clearly identify persons designated

to receive the information and the address to which copies must be sent.If providers already require requests

for access in writing, then they can use the same requests to access individuals’ PHI or require separate written requests. Providers need to establish and imple-ment policies and procedures to verify the identity of persons who request PHI and safeguards to protect the information that is used or disclosed.

The final rules also make it clear that labor costs for copying PHI can be sepa-rately identified in both paper and elec-tronic form as part of fees charged. HHS acknowledges in the final rule that there are labor costs for searching and retriev-ing PHI. Providers may also include the costs of paper and any supplies used to provide electronic copies, including CDs or USB flash drives. Providers are also allowed to charge for postage to send portable media at the request of individu-als. Fees related to maintaining systems, infrastructure, and storage are not con-sidered reasonable, cost-based fees and cannot be passed along to patients.

The final rules also remove the 60-day time frame for retrieval of records. When the rules become effective, providers will have 30 days to provide records to indi-viduals in all circumstances. Providers may still utilize one 30-day extension. States may, however, have more stringent requirements.

Breach notificationThe final rule also includes modifica-

tions to the interim final breach notifica-tion rule published on August 24, 2009.

Although the interim final rule was final-ized without change in the new HIPAA rules, there was one significant exception. The definition of “breach” was clarified by removing the “harm standard” for dis-closures and substituting a more objec-tive standard of whether PHI has been “compromised.” The Office of Civil Rights (OCR) clarifies its “position that breach notification is necessary in all situations except those in which the covered entity or business associate, as applicable, dem-onstrates that there is a low probability that the PHI is compromised.”

The following language was added to the interim final rule:

(2) Except as provided in [the existing exceptions to the definition of breach], an acquisition, access, use, or disclosure of PHI in a manner not permitted under subpart E is presumed to be a breach unless the covered entity or business associate, as applicable, demonstrates that there is a low probability that the PHI has been compromised based on a risk assessment of at least the following factors:I. The nature and extent of the PHI

involved, including the types of identifiers and the likelihood of re-identification;

II. The unauthorized person who used the PHI or to whom the disclosure was made;

III. Whether the PHI was actually acquired or viewed; and

IV. The extent to which the risk to the PHI has been mitigated. The practical effect of this change is

that providers will undoubtedly report more breaches, since they are required to do so whether or not patients have been harmed by the breach. If PHI is com-promised, providers must now report a breach. It is also important to note that the new rules eliminate the regulatory exception for limited data sets that do not contain any dates of birth or zip codes.

With regard to notification to indi-viduals of breaches, the new rules provide clarification that covered entities acting as business associates by providing bill-ing services, for example, should respond to breaches as business associates. The covered entity, not the business associ-ate, will be required to disclose in these situations.

The new rules also make it clear that notice has not been given if written notic-es are returned as undeliverable. If more than ten notices are returned as unde-liverable, providers may take a reason-able period of time to search for correct addresses for affected individuals but must provide substitute notice as soon as reasonably possible within the original 60-day time period for notifications.

The final rules say the following with regard to notification to the media of breaches:• Providers are not obligated to incur

the cost of media broadcasts regarding breaches;

• Media outlets are not obligated to publicize every notice of breach received and the failure to do so does not make notices insufficient; and

• Providers must deliver press releases directly to the media. Posting a gener-al press release on a website, for exam-ple, does not meet the requirements of the final rules.As OCR becomes increasingly com-

mitted to enforcement actions, provid-ers must continue to be serious about compliance. Now is the time to com-ply with new requirements in order to protect patients’ privacy and to avoid enforcement action. HC

copyright, 2013. elizabeth e. hogue, esq. all rights reserved. no portion of this material may be reproduced in any form without the advance written permission of the author. used with permission by hcaf.

This article was kindly sponsored by Ponce de Leon, the nation’s first Risk Retention Group created to serve long-term care facilities in the state of Florida. Ponce de Leon provides liabil-ity insurance, professional risk man-agement and aggressive defense of unfair claims for home care agencies and other long-term care providers. Thank you to Ponce de Leon, RRG for being a Platinum sponsor of HCAF’s 2013 Annual Conference. For more details about their services, please visit www.poncedeleonrrg.com and thank them for supporting HCAF so generously!


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What is not settled at this point is how the savings will be distributed between the participants of the ACO.

McCann adds that even if an ACO fails, the home care agency working with that organization has created a strong relation-ship with physicians and hospitals in their area that will continue to be beneficial to them.

“I can honestly say that I don’t see a downside to being exposed to other ways of thinking about patient care,” she said.

Time for changeMcCann and Gilmartin say that they

believe ACOs have a greater chance of sig-nificantly changing healthcare, compared to HMOs and other plans of the past. ACOs center around overall patient care where HMOs centered around overall cost containment. McCann explains that ACOs use the term “patient-centered care.” This involves individualizing the care plan to the patients’ goals instead of the generic disease care plan like an HMO. Due to the personalized time spent with the patients, the goals and careplan adherence rates tend to be higher.

As more ACOs are created across the country, home care agencies need to eval-uate themselves and determine if they are ready to be a part of this important aspect of the future of healthcare or if significant changes need to be made. If they don’t, they may get left behind. HC

scott brashears is the chief technology offi-cer of continulink, llc, a boca raton based company that provides web-based software solutions serving skilled home care, non-skilled home care, staffing, aco and hospice providers.

ACCOuNTING SERvICES AND CONSuLTING Walters Financial Services Inc. ............................12

ACCREDITATION Accreditation Commission for Health Care Inc. ...14

CONSuLTING Woodrow Healthcare Consulting LLC ..................20 Health Care Professional Consulting Services .....21 JMM Consulting ..................................................16 John S. Ryan, ARNP, MSN ...................................21 Rowan Consulting Associates Inc. .......................16

HEALTH CARE CAPITAL PROvIDER Doral Healthcare Finance ....................................21

HEALTHCARE ORGANIzATION Molina Healthcare Inc................ outside back cover

buyers guideHEALTHCARE PLANS Molina Healthcare Inc................ outside back cover

HOSPICE CARE Vitas Healthcare Corporation .......inside front cover

INSuRANCE Warren Insurance ................................................22

RECRuITING Almost Family Inc. ...............................................10

SOFTWARE Allegheny Software Publishers Inc. .... inside back cover Alora Healthcare Systems .....................................3 ContinuLink .........................................................17 OMS2 Software .....................................................4 Stratls Business Systems Inc. ...............................6

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