Value-based Purchasing (VBP) & Medicare Reimbursement
Medicare's Value-Based Purchasing (VBP) became effective for all certified home health agencies on 1/1/2023. Under VBP your Agency's Medicare payments are determined by three conditions: (1) CAHPS - patient satisfaction scores, (2) patient improvement on eleven (11) OASIS outcomes and (3) patient hospitalization rates.
Improving eleven (11) OASIS outcomes consistently and with predictability can be a reality for all home health agencies.
How Do You Consistently Improve Eleven (11) OASIS Outcomes?
Patients who should be classified as 'maintenance'.
Of course, not all patients are going to improve. Many patients are more appropriately managed under maintenance care. The duration and cost to try to get better outcomes is not in the best interest of the patient, the payer, the agency or the field clinician.
Maintenance care - i.e. intervention & teaching that prevents decline rather than improve outcomes, is the 'other' careplan. Patients with low or no rehabilitation potential - because of prior function, mental status and other co-morbidities - are not appropriately served with a careplan to make them improve.
Instead, a careplan that prevents further decline is Best Practice. For these patients, maintenance care can take on two (2) functions: short-term care to teach a caregiver the Home Exercise Plan, or long-term care for ongoing monitoring in the event that there is no teachable caregiver.
Medicare risk-adjusts the OASIS assessment.
The answers on the OASIS assessment should support the decision to provide maintenance care, thus removing Medicare's expectation that the patient can improve. Medicare risk-adjusts the OASIS assessment to reduce expectations of improved outcomes.
Patients who should be classified as 'potential for improvement'.
Patients who are alert & oriented or with mild cognitive impairment (M1700, M1710), with independent to semi-independent functionality prior to the home health admission (GG0100) are always candidates for the aggressive 'outcome-improving' careplan. Achieving the all-important improved outcomes is now highly likely and predictable.
The HHA can achieve the improved outcomes within budget and count the admission towards its successful outcome strategy.
Determining a Patient's Rehabilitation Potential
The two (2) most important indicators for rehabilitation potential are mental status (M1700) and prior functionality (GG0100). Download our 'VBP or Maintenance Worksheet'.
Of course there are circumstances where - for example, if a patient is severely confused - a dedicated caregiver can learn the Home Exercise Program and demonstrate improved outcomes in a timely manner. Or a patient's prior function was dependent, but is able to improve one or two outcomes with the assistance of a caregiver.
The case manager should always adjust the 'maintenance or VBP' formula for specific cases.
Recommended Strategy For Improving The Eleven (11) VBP OASIS Outcomes
Use a Systematic Approach To Determine Rehabilitation Potential
We recommend having policies and procedures in place to determine if a patient has rehabilitation potential. The OASIS assessment has all the questions needed to make this determination. Once the determination is made, the appropriate Best Practice careplan for maintenance or VBP can be implemented.
Implement an 'Outcome-Improvement' Careplan for Patients with Rehabilitation Potential
A VBP careplan frequency is always front-loaded looks something like the following:
- 3w2, 2w3, 1w4
- 4w1, 3w1, 2w2, 1w5
Implement a 'Prevent-Decline' Maintenance Careplan for Patients without Rehabilitation Potential
A maintenance careplan frequency looks like following:
- 2w1, 1w8