As our industry confronts the multitude of forces that combine to prompt change in the home health model of the future, many providers and clinicians alike are seeking guidance as to how to modify their care delivery to fit proposed refinements and reductions in funding. Many questions and concerns currently heard throughout the home health world address programming requirements, the expectation of value-based care, and skilled, reimbursable service delivery. In addition, increased levels of audits and denials of Medicare claims seem to foretell the Recovery Audit Contractor (RAC) phase that will begin in 2009 and is scheduled to cover all 50 states by the end of the calendar year.

These currently elevated levels of audit and denials are derived from the Center for Medicare Services (CMS) appeals process with the involvement of Fiscal Intermediaries and Quality Improvement Organizations contracted by CMS. Combined with the prospect of an uncertain future based on national economic woes, it is imperative that, as home health providers and clinicians, we take time to examine the real-world value of the care and visits we deliver.

Clearly, the lessons of the Prospective Payment System (PPS) have been internalized by CMS, and future refinement plans have been accelerated by solvency questions that confront the Medicare benefit as a whole. For certified Medicare providers, these concerns serve to threaten their viability as business entities today and in the near future. For front-line clinicians, such as homecare nurses and therapists, new methods of care and efficiencies must be identified in order to continue their care mission. Ironically, home health agencies and their administrators often find themselves at a loss when approached for direction by their clinical employees.

Historically, home health claims have avoided audit and regulatory scrutiny that is present throughout nearly all other points of the continuum of care. The decided emphasis on decreasing hospital admissions that has been prevalent for nearly a quarter century has identified homecare services as the preferred model for care delivery. The installation of the PPS mechanism, as a replacement for the fee-for-service model, identified acuity-based payments as a means of care delivery that stressed quality outcomes based on caregiver/patient education and skilled content. Best practice guidelines were identified, and OASIS data helped CMS define desired levels of skilled care and progression.

In the not-too-distant future, increased audit scrutiny will force home health agencies and clinicians to re-examine what they do and what that is worth in terms of value to the Medicare program as a whole. Those striving to convert their agencies into efficient delivery models of the future will need to identify the contemporary value of a homecare program, or more specifically, the value of a visit. Clearly, the days of valuing a visit based on whether a home health clinician appears in the home are over. In today's homecare environment, the appearance of a nurse or therapist in the home does little to produce a billable visit. The nurse or therapist must provide reasonable and necessary care in a contemporary manner in order to produce both a skilled program and desired clinical outcome.

Only the objective demonstration of a PPS-based program and desired progress, evident in the clinical documentation, will result in a reimbursable program. If your agency or personal area of practice lacks these items, expect to struggle in the future as audits prompt denials of a greater percentage of your programs.

Progressive agencies realize the difficulty in expecting individual clinicians to produce reimbursable clinical programs and Medicare claims 100 percent of the time. They seek to aid their clinical staff by UR-managed programming, ongoing clinical rounds, constant best practice education, and discharge management and planning. Realizing the fluid future of homecare defined by the clouds on the horizon (OASIS-C, P4P, RACs, post-acute bundling, funding reductions), agencies understand that change is here to stay. Progressive clinicians study the contemporary protocols utilized by home health educators to re-wire care approaches in a continuing effort to evolve their skills and patient outcomes. We must remain mindful that in home health, the old adage applies, "If you're not moving forward, you're falling behind."