Strategic plan for home health agency

Developing A Strategic Plan

The strategic planning process is essential for all organizations. Strategic plans help organizations’ leaders and stakeholders keep sight of their missions and visions, achieve their goals and objectives, and address their challenges and issues. As a health care leader, you must be able to develop a strategic plan and use it to drive your organizational decision making. For this Project, you develop a comprehensive strategic plan to address challenges that have adversely impacted a health care organization.

To prepare:

Review the Hillsboro County Home Health Agency, Inc. (HCHHA) case study in this week’s Learning Resources.

Note: Your Project should show effective application of triangulation of content and resources in your conclusion and recommendations.
The Assignment

HCHHA’s board of directors and executive leadership team have asked for your assistance with addressing some of the major issues that have adversely impacted the organization’s financial and operational performances. They have requested that you advise them on the following:

Strategies to help the organization address the absence of a Medicare-certified hospice, which has inconvenienced patients and their family members and has led to negative publicity for the organization
Strategies that might improve HCHHA’s overall financial performance
Strategies that might improve HCHHA’s operational performance
Strategies that might assist HCHHA with effectively addressing the various external factors that may potentially threaten its market share
In a 20-page strategic plan, include the following components:

Mission statement (provided in the case study)
Vision statement
Core values
SWOT analysis
Grand strategies or long-term strategic priorities
Operational and tactical plan
Key performance and evaluation indicators
Change management plan, including the following:
The size of the change and its impact on the community and the organization
The organization’s readiness for change
Change management strategy
Team structure and responsibilities
Sponsor roles and responsibilities
Planning and implementation
Communications plan
Change management resistance plan
Training plan
Incentives and celebration of successes
Timeline/schedule of activities
Budget for change management
The 20-page narrative plan should be written as if it were to be presented to the board of directors. The plan should also include the following pages that will not count toward the 20-page limit:

One-page Executive Summary
Tables, graphs, and/or charts
The plan should include at least 15 current (no older than 4 years) quality resources, with 10 of those resources being from peer-reviewed sources.

In addition to the paper, you must produce a PowerPoint presentation highlighting the key elements of the paper. The presentation should not be more than 15 slides, excluding the cover slide and the appendices. Be sure to include 100- to 150-word speaker notes to explain the content on each slide.

Resources:

Walston, S. L. (2014). Strategic healthcare management: Planning and execution. Chicago, IL: Health Administration Press.
Chapter 13, “Strategic Change Management” (pp. 291–307)
Al-Adwani, A. B. (2014). The extent to which human resources managers in KNPC believe in human resource investment. International Business Research, 7(4), 132–141. Retrieved from http://www.ccsenet.org/journal/index.php/ibr/article/view/31563/20091
Cocks, G. (2014). Optimising pathways for an organisational change management programme. TQM Journal, 26(1), 88–97.
Note: Retrieved from Walden Library databases.
Gopal, S., & Kumar, D. M. (2015). Strategic interventions in tackling poor performance of service departments: Study on Muhibbah engineering. Journal of Economics and Behavioral Studies, 7(4), 6–13. Retrieved from https://ifrnd.org/journal/index.php/jebs/issue/download/Issue_52/9
Henderson, S., Kendall, E., Forday, P., & Cowan, D. (2013). Partnership functioning: A case in point between government, nongovernment, and a university in Australia. Progress in Community Health Partnerships, 7(4), 385–393.
Note: Retrieved from Walden Library databases.
Kash, B. A., Spaulding, A., Johnson, C. E., Gamm, L., & Hulefeld, M. F. (2014). Success factors for strategic change initiatives: A qualitative study of healthcare administrators’ perspectives. Journal of Healthcare Management, 59(1), 65–81.
Note: Retrieved from Walden Library databases.
Martínez-Jerez, F. A. (2014). Rewriting the playbook for corporate partnerships. MIT Sloan Management Review, 55(2), 63–70.
Note: Retrieved from Walden Library databases.
Mutale, W., Stringer, J., Chintu, N., Chilengi, R., Mwanamwenge, M. T., Kasese, N., … Ayles, H. (2014). Application of balanced scorecard in the evaluation of a complex health system intervention: 12 months post intervention findings from the BHOMA intervention: A cluster randomised trial in Zambia. PLoS One, 9(4).
Note: Retrieved from Walden Library databases.
Ovseiko, P. V., Melham, K., Fowler, J., & Buchan, A. M. (2015). Organisational culture and post-merger integration in an academic health centre: A mixed-methods study. BMC Health Services Research, 15, 417–443.
Note: Retrieved from Walden Library databases.
Rajaram, S. S., Grimm, B., Giroux, J., Peck, M., & Ramos, A. (2014). Partnering with American Indian communities in health using methods of strategic collaboration. Progress in Community Health Partnerships, 8(3), 387–395.
Note: Retrieved from Walden Library databases.
Reid, M. F., Brown, L., McNerney, D., & Perri, D. J. (2014). Time to raise the bar on nonprofit strategic planning and implementation. Strategy & Leadership, 42(3), 31–39.
Note: Retrieved from Walden Library databases.
Shea, C. M., Jacobs, S. R., Esserman, D. A., Bruce, K., & Weiner, B. J. (2014). Organizational readiness for implementing change: A psychometric assessment of a new measure. Implementation Science, 9(7), 1–15.
Note: Retrieved from Walden Library databases.
Steinbauer, R., Renn, R. W., Taylor, R. R., & Njoroge, P. K. (2014). Ethical leadership and followers’ moral judgment: The role of followers’ perceived accountability and self-leadership. Journal of Business Ethics, 120(3), 381–392.
Note: Retrieved from Walden Library databases.
Traberg, A., Jacobsen, P., & Duthiers, N. M. (2014). Advancing the use of performance evaluation in health care. Journal of Health Organization and Management, 28(3), 422–436.
Note: Retrieved from Walden Library databases.

T he Hillsboro County Home Health Agency (HCHHA), originally named the Middleboro Home Health Agency, was founded in 1946 as a nonprofit home health agency to provide healthcare services to the area's population. Three years ago, in conjunction with establishing

an office in Jasper, the organization changed its name to reflect better its countywide orientation. Today, it is the only Medicare-certified home health agency in Hillsboro County. The Joint Com­

mission also accredits it.

MISSION

"The mission of HCHHA is co serve individuals in their usual environments and is concerned with well people as well as people with illness or disabilities. We strive co prevent disease or co retard its progress and to reduce the ill effects of unavoidable disease. We provide quality nursing and therapeu­ tic care co the noninstitutionalized sick and disabled. We also provide information and encourage­ menc to individuals and families, special groups, and the community as a whole for the promotion of health." (Approved by the board of directors, December 31, 2010.)

Case 2: Hillsboro County Home Health Agency, Inc.

GOVERNANCE

Overall responsibility for HCHHA rests with the board of directors. The 21-person board meets monthly to review the status of the corporation. Except as noted the board acts as a committee of the whole. All directors serve for a three-year term and may be reelected by the board. The executive committee nominates individuals for membership on the board. The new board then elects its officers. The election of directors is done by the full board at the June meeting. New directors and officers take their positions beginning July 1. Last year a consultant recommended that the board cease being self-perpetuating and establish mandatory term limits. The board is still considering this concept.

The executive committee (president, vice president, secretary, and treasurer) meets, as needed, with the executive director to resolve special issues and plan board meetings. In April of each year, the executive committee prepares a slate of nominees for new board members. The finance committee meets monthly with the executive director to review the financial status of the corporation. It also reviews and recommends the new annual bud­ get to the full board for approval. The professional advisory committee meets monthly to review issues related to clinical care and quality standards.

Membership on the current board includes Janet Myer, senior vice president at the Middleboro Trust Company. She is currently president of the board of directors and has one year remaining on her third three-year term. She lives in Middleboro. This is her fourth consecutive year as board president. It should be noted that Myer was instrumental in the reorganization of the agency three years ago. David Ruseski, owner of Ruseski Auto Sales in Middleboro and Jasper, is in his second year as vice president of the board. His first three-year term on the board will expire next June, but he has agreed co serve for another three-year term if he is nominated. During 2012 he chaired the firntnce committee. Ruseski lives in Miffienville. Mary Steel, JD, is the elected sec­ retary. She maintains her solo law practice in Miffienville and lives in Middleboro. Steel has been on the board for nine years. Steve Meadows is the elected treasurer. He is the senior partner in the accounting firm of Meadows and Associates in Middleboro. He has served on the b.oard for 14 years. As treasurer, he is a member of the finance committee. He lives in Statesville.

William Bond, vice president of finance at Master Tractor, was elected to his first term on the board two years ago. He chairs the finance committee and has indicated that he will be unable to serve beyond this coming June. He lives in Miffienville. Martha Logic, JD, is an attorney in the law offices of the Jasper Legal Assistance Clinic and has served on the board for five years. She lives in Jasper. Carl Fisher was elected co the board for his first term three years ago. He is a retired major general from the us· Army and is active in the local chapter of the MRP. He maintains farming ·interests at his family's farm in Boalsburg. Nancy Blau w� elected to the board for her first term two years ago. She is

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48 The Middleboro Casebook

a former county commissioner, a member of the regional school board, and a trustee at

Webster Hospital. She lives in Middleboro. She serves on the finance committee. Helen

Vosper, RN, was reelected ro the board four years ago. She was the director of nursing at

Middleboro Community Hospital until 2010 and recently retired as director of nursing

at Webster Hospital. She lives in Middleboro. Lois Metz, MSW, was elected to the board

lase July and is serving her first term. She maintains her independent practice as a social worker in Middleboro, where she specializes in marriage and family counseling. She lives

in Middleboro. Janee Doe was reelected to the board two years ago. She is a retired regis­ tered nurse and the former director of school nursing for public schools in Middleboro.

She resides in Middleboro and has been a member of the board for 16 years. Melissa Giles,

a recent law school graduate and alumna of the Middleboro school system, was elected to the board lase year. She is currently a legislative aide to US Representative James Giles, and

she specializes in elder issues. She resides in Jasper. Mary Care, RN, was reelec�d to che

board three years ago. She is the executive director of Valley Hospice and has served nine

years on the board. Cindy Donnelly has been a member of the board for 19 years. She is a

former reporter with the Midd/eboro Sentinel and lives in Miffienville. Walter Graham was recently elected co fill a board vacancy created by a resignation. His first term has cwo years

remaining. He is the senior administrator at Medical Associates, a multispecialry group practice located in Jasper and Middleboro. Matty O'Brien, OT, has been a member of the board for seven years. She is professor emeritus of occupational therapy at State University

and has lived in Middleboro for the past cen years.

Board Committees, 2014 Chair Members

Executive Myer Ruseski, Steel, Meadows

Finance Bond Blau, Logic, Giles, Martin

Professional Advisory Vosper Metz, Doe, Care, O'Brien, Ellis

Publicity and Public Relations Fisher Donnelly, Black

Building and Grounds Shields Graham, George

Mark Shields has been a member of the board for 17 years and is the chair of the building and grounds committee. He resides in Statesville, where he operates a large feed

and grain business and serves as an elected town official. Conner George has been a mem­

ber of the board for 13 years, lives in MifHenville, and has a professional background in

Case 2: Hillsboro County Home Health Agency, Inc.

landscaping. Dennis Martin lives in Jasper and is a retired superintendent of schools in Jasper. He has been on the board for four years. Frances Black lives in Middleboro, where she is active in civic affairs. She has been on the board for seven years. Jennifer Ellis lives in Jasper, where she maintains a private practice in speech pathology. She has been on the board for rwo years.

In 2001, the board created a community advisory council to provide advisory ser­ vices to each of the programs provided by the agency and to increase commw1ity participa­ tion without expanding the formal board of directors. Because of the increased possibility of conflict of interest in a competitive healthcare market, as well as declining attendance at quarterly meetings, the board abandoned this council in 2011. It should be noted that in 2010, the board passed a resolution that stated, "Board members represent themselves, not their employers."

Physician interest in serving on che board has been nonexistent since Maynard Cushing, MD, completed his service in 2010. Dr. Rita Hottle ofMiddleboro serves as the agency's medical director. For the past three years, the agency has experienced a decline in operating margin. In 2013 and 2014, the agency experienced its first losses from opera­ tions. The losses were funded out of net assets.

The finance committee is concerned by the downward trend in financial perfor­ mance from operations as well as the impending significant change in reimbursement for the agency, mandated by the changes in Medicare and Medicaid.

MANAGEMENT TEAM

Hired at the time of corporate expansion in 2010, Martha Washington, RN, MHA, is HCHHA's executive director. Prior to serving in chis position, Washington was the regional' director for a large for-profit chain of home health agencies, and she managed the affairs of 13 separate agencies. Before that, she was director of marketing for a large medical products firm headquartered in Capital City. She also has approximately ten years of experience as a visiting nurse with a large visiting nurses association located in a major midwestern city. Today, she is vice president of the Seate Home Health Association and maintains an active presence in the state legislature, lobbying for home care issues. After formal review, the board recently extended her four-year contract for another four years with an increase in salary.

Since her arrival, Washington has reorganized the agency into three divisions: Home Care, Private Duty, and Community Health. As approved by the .board prior to her appointment, she opened an additional office located in Jasper to support all pro­ grams. Under her leadership, existing services were expanded and new services were added. Above all else, she has worked co ensure that the agency continues to fulfill its mission.

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50 The Middleboro Casebook

Her management style emphasizes the delegation of clearly expressed responsibilities. She has delegated responsibility for operations to each full-time division manager, added a special assistant co the executive director co assist with projects related to human resources adminisrratio; and marketing, and upgraded the bookkeeper position to a professional position as controller.

In her first year at the agency, Washington-with the able assistance of select board members and consultants-selected and installed an electronic medical record and patient care planning system specifically designed for home health ca.re. The system has been operational for 18 months in the Home Care Division and 12 months in .the Private Duty division. The system required a significant financial commitment.

Ruch Marcin, RN, is che manager of the Community Health Division. Four years ago she asked the board co relieve her as executive director, a position she had held for three years. She asked to be retained by the agency as the program manager for the Co\Ilmunity Healrh Program, which upon reorganization became the Community Health Division . The board, after much discussion, agreed and then recruited Washington as executive director with the understanding chat Martin would be retained for at least three years. Prior to being appointed executive director, Marcin had been the assistant director for 12 years. During chis tenure she was responsible for beginning che high blood pressure and maternal and child health program initiatives. Prior co relocating to Middleboro, she was employed by the Capital City Home Healch Agency as a home care coordinator. She is a graduate of a southern university and has completed her graduate education in community health nursing.

Catherine Newfields, RN, is the manager of the Home Care Division. Washington hired her in 2011. She is a former assistant professor of community health nursing at Stace University. Prior to her faculty appointment, Ms. Newfields completed her graduate studies in community health nursing at a major southern university and has 17 years of experience in all aspects of home care, including a brief tenure as the executive director of a small visiting nurses association in another part of the state.

Michael Carlstcad, LPN, manages the Private Duty Division. He has more than 30 years of experience as a home health aide (HHA) and licensed practical nurse (LPN). He completed his nursing training 18 years ago and recently earned his bachelor's degree in business administration from a small college chat offers distance education opportunities for working professionals. Carlstead has been affiliated with the agency for 24 years and plans to retire in six months.

Steve Callahan is the controller. Washington promoted him upon completion of his bachelor's degree in accounting two years ago. He has worked for the agency for ren years. He was originally hired as assistant bookkeeper and then promoted to bookkeeper. He is currently matriculating part-time for his graduate degree in business administration

Case 2: Hillsboro County Home Health Agency, Inc.

at Seate University. Since his promotion, he has become very active in the State Home Care Association.

Judy Herman, RN, is the quality improvement and utilization review manager. Herman devotes most of her time to the Home Care Program and regulatory compliance with Medicare and Medicaid. She is also responsible for the electronic medical record sys­ tem. She is a graduate of State University and holds an MS in nursing quality improvement from a private university. She has approximately 15 years' experience in quality improve­ ment in home care and worked with Ms. Washington prior to coming to this agency.

Washington has indicated thac she is not yet satisfied with the agency's ability to qualify for Medicare reimbursement under the Home Health Prospective Payment Sys­ tem. "1he coordination between our clinical personnel and our business office needs to be improved. For example, last ye--a.r we had more than 20 cases where we failed to adhere to the 60-day physician review requirements. Also, too often we need to begin providing home care services before we actually have the signed physician's certificate, thereby jeop­ ardizing and delaying our qualification under Medicare. These remain some of the issues chat Steve Callahan and Catherine Newfields need to address. I am, however, delighted chat Steve has taken on an active role with our state association. We need someone who is on top of Medicare's Outcome and Assessment Information Set and in a position to represent our interests."

When interviewed, Steve Callahan indicated chat the agency is attempting to address some major problems including "our operating margin and days in accounts receivable. We have some specific challenges that are taking a great deal of attention."

Mary Bird is responsible to Martha Washington for special projects involving human resources administration and marketing, and she staffs the Jasper office when needed. She completed her baccalaureate-level studies in health services administration at State Uri.iversity two years ago, then returned to Middleboro, where she was born. Dur­ ing her academic career, she had interned under Washington when Washington was the regional director for the for-profit chain of home care agencies. She has told Washington chat unless her position is made full time in 2015, she will be forced to look elsewhere for employment.

Every two weeks the management team meets formally to review operations and to solve problems. The entire management team attends all monthly board meetings. Wash­ ington used the opportunity created by her recent performance review to share certain confidences with the board. She indicated chat the Jasper plan needed a complete reevalu­ ation and that she was unsure exactly what an office location in Jasper was. really gaining for the agency. She also noted that she had learned that Unicare Home�o, a national for-profit home care corporation, had recently completed a feasibility study to enter the Jasper market.

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The Middleboro Casebook

She indicated that more rime was needed to meet personally with major referral

sources and chat additional funds were needed for advertising. She also said chac she was not pleased with the overall decline in financial performance of the agency, par­ ticularly in the Community Health Division, and thac she foresaw a steadily declining revenue picture in char area. She mentioned co the board chat her relationship with Marrin, while professional, seemed co highlight the difference in their perspectives and the old versus the new approaches she was attempting to implement. She also stated that to continue expanding services, she would need more help and chat she felt chat the long-term care program offered by the Home Care Division faced an expanding market.

Washington also said that she faced some "productivity problems" with some of the older employees and alerted the board that some changes may need to be made. Repeat­ edly, rhe board emphasized to her that it wanes the HCHHA to remain the sole provider of Medicare-certified home care services in the county and chat it expected the public to so value the agency that they would continue co support the agency with their contributions. William Bond, chair of the finance comminee also indicated to her that he and the rest of the board felt comfortable with her at the helm. The board felt that she understood the finances as well as che dynamics of the home care market. Bond was cautiously optimistic about the financial future as long as the long-term care program matured counrywide

and as long as the agency could operate effectively under the prospective fixed-price reim­ bursement environment imposed by Medicare. Myer assured her of board support if the Community Health Division had to be resized and refocused to correspond better with its financial support.

Washington expressed her concern over the increased competition in the home care field as well as the changing reimbursement system. In addition co the interest expressed in the Jasper market by a national home care company, she noted char insurance companies and managed care organizations were expressing increasing interest in using home care ser­ vices. She pointed out the agency's relatively high dependency on government programs, particularly Medicare, in spice of reasonably successful efforts to establish contracts with managed care organizations. A recenr article published in the State Home Care Association Newsletter reported that the number of agencies consolidating or going out of business alrogerher had been increasing dramatically within the past six months, primarily as a result of rhe impact of reimbursement changes.

HOME CARE DIVISION

This program provides nursing (RN and LPN) and other services (e.g., occupational rher­ apy, physical therapy, speech therapy) to patients in their homes. Medicare, Medicaid, and self-pay and private insurance carriers provide funding for this program. Within the past

Case 2: Hillsboro County Home Health Agency, Inc.

five years, the agency has pursued contracts with local managed care organizations. As a result of these efforts, contracts are in place with Central Scates Good Health Network and one other commercial HMO. Medicare finances four categories of service: intermit­ tent nursing care; physical, occupational, or speech therapy; medical social services; and intermittent care provided by a home health aide.

RNs assess and monitor all patients. They are responsible for treatment planning, administering medications, and other nursing services. LPNs work as team members in implementing treatment plans and providing assistance with self-care activities within rhe context of Medicare and Medicaid regulations. Therapists and other contract professionals (e.g., physical therapists, occupational therapists, speech therapists, social workers, nutri­ tionists) are available as consultants and to implement treatment plans.

The division manager is responsible for the development of the treatment plan when a patient enters the active caseload. Case management is then delegated i:o the appropriate staff member(s). The responsibility for timely patient discharge and case find­ ing rests with the division manager. The division manager is also responsible for the design and implementation of an appropriate quality assurance system. For the past three years, the staff has reported chat patients served by this program immediately following a hospital discharge required more intensive services than they had in the past.

This division also provides pediatric services to children who are born prematurely, who are recovering from surgery, or who are experiencing a chronic disease. Special therapy services are also available. Typically, these types of services are covered by medical insurance plans, Medicare, and Medicaid.

When interviewed, Catherine Newfields, division manager, said "staff turnover was a real and-sometimes-a critical issue." Specifically, she indicated that a primary diffi­ culty with this program was her staff's reluctance to provide N therapy to cancer patients who routinely require 24-hour, seven-day-a-week coverage. She also scared that she was somewhat concerned that hospitals in Capital City were referring their patients living in Jasper to rhe Capital City Visiting Nurse Association (VNA), not HCHHA, which had been the practice until 2012. She mentioned being annoyed that almost every time she drove into Jasper, she heard a radio commercial extolling the services of the Capital City VNA. She felt an office location in Jasper was needed more for the Community Health Division than for this division since most of "her staff" lived in the Middleboro area and traveled from the Middleboro office of the agency. She also indicated that getting the required physician recertification every 60 days for Medicare patients was a frequent chal­ lenge. Medicare�s changing definitions and rules (e.g., definition of homebound) were also mentioned as a source of stress and fruscrarion.

Newfields has recently obtained the following national data and is considering whether it might be appropriate in special benchmarking studies.

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54 The Middleboro Casebook

National Utilization Statistics-Home Health

Patients currently being served by home health agency

Patients under 65 years of age

Patients 65 years or older

Home health care patients discharged past 12 months

Under 65 years of age

65 years or older

At time of discharge, patient. ..

Remained in community

Transferred to another setting

Is deceased

Unknown

NOTE: Discharge means when a case is closed by the home health agency.

Rate per 10,000

population

16.4

91.0

1,439.3

Percent

71.5

20.5

2.3

5.7

Newfields indicated char her division's experience closely parallels the national

Medicare percentages by International Classification of Disease Codes (ICDA) and chat­

similar to the national data-few cases extend over a long time, making the division's mean

service time significantly higher than the median values. Current efforcs are under way to compare this division's service rimes with these national statistics.

A recent study done by a student ac the scace university indicated that on aver­ age every Medicare home visit involved an average (round trip) of 11.2 miles. Over the past five years the study showed that one of the hidden costs of services was the price of gasoline.

When asked about her assessment of the agency, Newfields indicated chat she had questions about the impact of the three-division model. She indicated chat "her Medicare patients" needed stronger nutritional counseling, flu and pneumonia prevention programs, and chat formal programs in pain management, fall prevention, and diabetes education needed to be considered but chat "these type of programs typically end up in the Com­

munity Health Division." As she said, sometimes "our silos get in our way." She seated that her division needed the opportunity co expand its emergency preparedness. She also

Case 2: Hillsboro County Home Health Agency, Inc.

indicated that Medicare's rule that client eligibility requires a patient to be "homebound" continues to prevent meeting the needs of a number of individuals. "Too often we have to

explain co senior citizens that they do not qualify for Medicare Home Care because they are nor homebound as defined by Medicare," she said.

PRIVATE DUTY DIVISION

This program began in 2012. Its primary intent is to assist patients with activities of daily living and to provide other services as needed. Medicare does not provide payment for these services. All funds come from Medicaid, self-pay, and private insurance. The division

and its programs began for both service and financial reasons. A formal marketing study completed in 2011 indicated a strong demand for these types of services. To date, demand

has surpassed expectations. All services are purchased based on an hourly, daily, or weekly charge. Medicaid sets its own hourly rates by service.

PRIVATE DUTY SERVICES

Under chis program professional LPNs can be hired to provide assistance with nursing care including medication assistance and blood pressure screenings. RNs provide skilled nursing care under a physician's order, administer medications, and provide other specialized services. As needed physical, occupational, and speech therapy, and social work services are also available.

COMPANION AND HOMEMAKING SERVICES

This service provides trained staff for light housekeeping, grocery shopping, meal prep­ aration, laundry, and similar duties. Homemaker/housekeeper aides provide in-home services.

PERSONAL CARE SERVICES

Clients are provided assistance with bathing and other activities of daily living as well as respite care. Services are provided by personal care attendants.

Overall this program provides a menu of services (and prices) clients can select to meet their rreeds. No medical authorization is needed. When interviewed, Carlstead stated, "We never seem to have enough staff to meet our clients' needs:' He.attributes this

to the low pay and benefits and says that "not everyone is. really suited to provide these types of services." He also stared that the paperwork really "gets me down. Over the past

20 years the paperwork has just increased and increased-it never seems to end." He did

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56 The Middleboro Casebook

say that his loyal staff is great and that he really enjoys working with them and will miss them when he retires.

Clients contract for a specific number of hours per week and are billed at the end of the week. Most clients pay by credit card, although some pay with cash or check. Any client with an outstanding balance for more than two weeks is reviewed and potentially dropped from the programs. For Medicaid to pay, the client muse be Medicaid-eligible and the service plan muse be approved by Medicaid before services are provided.

Carlstead stated concerns about the human resources dimension of the agency: "le is essential that we have current information of the professional status of all of our employ­ ees, but sometimes we don't. Credentialing and background checks are an issue that could gee us into trouble." He also indicated that "work rules" need to be the same within each of the divisions and char the current employee handbook was old and out of date, having been published in 2006. "Ocher issues we face include the poor and potentially unhealthy condition of the client's home sometimes created by a client's inability to car� for (coo many) family pets," he said.

COMMUNITY HEALTH DIVISION

Unlike in che other divisions of HCHHA, the manager of this division must apply for grants for private, scare, and local funds and attend town meetings co secure funding for services.

TELEHEALTH PROGRAM

This program provides home monitoring for individuals with a chronic iJlness who pres­ ent a high risk of rehospitalization. It is a cooperative program between the home health agency and both hospitals. Hospitals and attending physicians identify potential patients who are then offered this service free of charge. An HCHHA nurse works with each patient to help him develop self-care skills.

MATERNAL AND CHILD HEALTH PROGRAM

The Maternal and Child Health Program provides educational, direct services, and health screening programs to expectant mothers and their children who are less than one year of age as well as child home care visits for qualifying children up co one year after birch. As-needed bilirubin photo light therapy services are also available. Funding is provided by the state through an annual grant and from Medicaid. All recipients of state public assis­ tance are eligible (without charge) for this service. Ochers may receive service for a modest contribution. Classes and clinics are also held in Middleboro and Jasper based on funding

Case 2: Hillsboro County Home Health Agency, Inc. 57

received from scace, county, and cown grants. The agency's prenatal program includes a home visit from a maternity nurse co evaluate the health of both the mother and the child,

and to provide counseling on breast-feeding, diec, and infant care. This program has been very well received in the community.

HIGH BLOOD PRESSURE SCREENING PROGRAM

This program provides screening for high blood pressure and makes referrals to physicians as required. Screenings are done in public locations, such as shopping centers, churches, and schools throughout the area. Funding for chis program is from the United Appeal and is based on an annual application for continued funding. Recently, the United Appeal has requested a comprehensive assessment of the cost effectiveness of chis program as a condi­ tion of continued funding.

COMMUNITY HEALTH ACTIVITIES PROGRAM

The Community Health Activities Program provides physicals, immunizations, drug and

alcohol testing, smoking cessation programs, and health education services, as needed, co high-risk individuals. All services provided under this prog.ram are done at the agency's offices in Middleboro and Jasper. Physicals and immunizations required for public elemen­

tary and secondary schools are provided free of charge to any resident of che area. Special classes are held in several areas, including nutrition, foot care, and for stroke patients and their families. Financial support for chis program comes from annual appropriations from

each town. These appropriations are voted on annually in each town.

I

SENIOR HEALTH CLINICS

These clinics provide services chat include foot care, blood pressure monitoring, earwax removal, injections, medication management support, immunization, and ocher basic pre­ ventive services. Senior health clinics are offered free to all seniors over age 65; younger

seniors can pay a modest fee. Clinics are held monthly in Jasper and Middleboro and approximately once every two months in ocher cowns in che county. Support for chis pro­ gran1 is provided by a grant from the state.

HEAD LICE PROGRAM

Services are provided based on referrals from school nur.ses. Services include education, prevention, and creacmenc. Services are available at both offices by appoimmenc. The pro­ gram is totally financed ·by an annual grant from the Retail Pharmacy Association of Hillsboro County.

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58 The Middleboro Casebook

OTHER PROGRAMS

This division also manages the agency's speakers bureau and provides formal classes in first aid and CPR.

When interviewed, Marcin stated chat she was concerned chat more needs were being left unfulfilled because of the lack of funds. She indicated chat state and town fund­ ing appeared adequate but that she might have a problem in the future "making ends meet." She did say, however, that the United Appeal has expressed concern that the agency had been "so active and successful in its own fund raising, that future allocation decisions [funding to the agency from the United Appeal) would be weighed carefully against the more substantial needs of ocher worthy organizations."

Issues related to the agency's need for continued outside or community fw1ding were highlighted in a recent letter co the editor of the local paper, in which a family mem­ ber of an agency client expressed her anger at having to pay for services delivere4 "by an agency that is supposed to be there for the community, which turns a large profit every year, and which we support through the United Appeal."

Martin expressed concern that the agency was attempting to meet the "needs" of the middle class and becoming less oriented co the "real health needs in the area." She did indicate that a need for adult day care and respite care existed in the community. When asked about the operation of her division, she indicated that she has a positive relationship with her staff, people she has worked with for many years, but chat she was concerned that the board and management "seemed to favor the other divisions." She also stated that her division's relationship with the Hillsboro County Health Department was mixed. "We probably need to meet more often, and they typically want us to take on contracts for less than our costs. We have issues with them."

FINANCIAL Issues

Medicare and Medicaid cover the services provided by the Home Care Division. Both pay the agency on a prospective basis, with no retrospective settlement. For Medicare, the prospective payment is based on the scoring attributed co the acuity level of the patient at a race determined by federal guidelines. In 2011 the national standardized payment rate from Medicare was $2,192.71 per 60-day service period. This rate was 18 percent higher than the rate received by the HCHHA. The most recent national data for home health services indicates that the average payment (all sources) per visit was $145.99. On average a home care agency receives approximately $5,216 per patient served. For Medicaid, the prospective payment is based on a statewide rate per service. When services are rendered to individuals not covered by Medicare or Medicaid, bills are issued either directly to the patient or to the patient's insurance carrier.

The Private Duty Division issues a bill for all services rendered. Every service has a specific hourly charge. Expenses associated with travel to and from the client's home are

Case 2: Hillsboro County Home Health Agency, Inc. 59

built into these rates. Medicare does not cover any service provided by this division. Med­ icaid covers select services that must be preapproved and has a fee schedule for specific ser­ vices. Mose of the revenue earned in this division is from self-pay and commercial insurance.

The Community Health Division finances its services through grants from the state or local agencies. Some towns also provide support as a line item in their budgets. Modest user fees are solicited when appropriate.

Each division is managed as a distinct financial entity and is allocated a portion of che overall agency's general and administrative costs. Managers prepare budgets approxi­ mately six months prior co implementation. The board's finance committee reviews Wash­ ington's recommended budget; the entire board approves it. The finance committee also oversees budget implementation and examines all significant budget variances.

OTHER INFORMATION

The overall reputation of HCHHA is positive. The agency is known for its prudent admin­ istration of funds, high quality of care, and can-do attitude. It is considered by area health professionals to be a highly professional place to work.

The Middleboro office is located in the HartSdaJe House, a spacious home on the border of Middleboro's central business district. This house is noted for its antiques. Ample parking is available as this historic home is located on approximately 11 acres. Hansdale House is a community landmark and is featured in area travel brochures. The HartSdale family donated this location to the agency in 1979 with a restricred endowment co ensure its physical upkeep and maintenance in perpetuity. The current market value of the property is approximately $1,200,000. The agency is slowly retiring a mulciyear loan to modernize the building and install fire warning and sprinkler systems. A motion at a recent board meeting co consider selling this house and use the proceeds for the endowment was defeated. The Jasper office is located in rented space in a professional office building in downtown Jasper.

Twelve years ago the agency received a restricted $960,000 bequest from a former patient "co ensure that quality home care services can be provided co alJ residents of the area regardless of their ability to pay." The annual fundraising Holiday Ball at the Middle­ boro Country Club remains a highlight on the local social calendar; additional fund rais­ ing evencs each year include an antique auction, a spring fashion show, a walkathon, and a holiday ornament sale. All philanthropic events are arranged by a local volunteer, Nora Fisher (whose husband serves on HCHHA's board), and her many friends.

On the negative side, a letter recendy appeared in the local newspaper asking why a Medicare-certified hospice was not available within the county. The letter suggested that Medicare patients were being denied a valuable benefit because the local health agen­ cies could not "get their acts together." Four years ago rhis agency decided not to merge with che local hospice, in order to provide these services. When recently asked by a news

60 The Middleboro Casebook

reporter for a response, both Myer and Washington indicated that che board would recon­ sider the idea of a Medicare-certified hospice during the next few months.

Last year, news articles in the Middleboro Sentinel and on TV Channel 32 on care for the terminally ill highlighted a study released by the state medical sociery. The medical sociery's study indicated "approximately 61 percent of all hospice patients have primary diagnoses of neoplasms, with cancer of the lungs, colon, and prostate accounting for 50 percent of all neoplasms." The report continued, "The second-largest group was conges­ tive heart failure, accounting for 45 percent of the admitting diagnosis for this group." On the interview conducted on TV Channel 32, city council members Jennifer Kip and Alan Simpson referred to the lack of a Medicare-certified hospice as "still another indicator as to why new blood is needed in Middleboro--the residents of Middleboro should nor be denied this service merely because its home health agency is too busy serving clients from other towns." As a result of chis report and che board's concern, the HCHHA fngaged consultants to estimate the need for a Medicare-certified hospice in Hillsboro County. The following was extracted from the consultant's reports:

Medicare-Certified Hospice Planning Parameters

National studies indicate that approximately 55 percent of all individuals who die from

cancer enroll in hospice services prior to their death. Noncancer enrollees include

individuals who died from heart disease (12 percent); dementia, including Alzheimer's

disease (11 percent); lung disease (8 percent); stroke (4 percent); kidney disease (3

percent); liver disease (2 percent); HIV/AIDS (o.6 percent); and all other causes (11

percent).

On average enrollees in a Medicare-certified hospice are enrolled for approximately

68.5 days prior to death. Note that 31 percent of enrollees died or were discharged from

hospice in seven days or less. Studies also indicate that most hospice care is regular

care provided in a patient's home based on periodic visits and home visits as needed.

Nationally, Medicare-certified patient care days are classified as routine care (96 per­

cent), continuous (24-hour) home care (1 percent), inpatient respite care (1 percent),

and hospital general inpatient care (2 percent). These same studies indicate that

approximately 85 percent of all patients of a Medicare-certified hospice are covered

by Medicare, 4 percent are covered by private insurance, and 6 percent are covered

by Medicaid. Currently the maximum rate paid by Medicare is $150 per day of routine

care, $850 per day for continuous home care, $160 per day for inpatient respite care

and $650 per day for general inpatient care. Also, the total annual cost per case cannot

exceed $23,000 per hospice enrollee.

Recently, Myer received a letter from a former patient. The letter indicated that the patient had been a long-term contributor co the agency and was very displeased to learn

Case 2: Hillsboro County Home Health Agency, Inc. 61

that she would have co pay so much to secure the services of a nurse after her Medicare

eligibility ran out. Myer promised to bring chis concern to the board. Both hospitals continue to contract with a private duty nurse, Amy Edwards, RN,

and her associates for in-home IV therapy. Edwards also accepts referrals from out-of-area

hospirals. It should be nored that on three occasions she has rejected an offer of employ­ ment from the HCHHA. She prefers to work independently and bill her services privately or through the hospital. Washington recently learned from a former colleague that Edwards

has been in contact with a regional chain of for-profit home health agencies and requested

information abouc establishing a franchise in Middleboro. Edwards has also been contacted

by the administrator of Rock Creek, a private, long-term care facility in Mifflenville, and

asked co provide them a feasibility study for establishing a private home care agency to serve the greater Middleboro area. Edwards's husband, Keith, is mayor of Middleboro.

Board member David Ruseski recently returned from a statewide conference on home health and has asked for a management assessment of che staffs productivity. At this meeting he learned that national standards exist that could be applied to the agency's acute care program and home health program. For example, Ruseski indicated chat a recent

national study presented ac this meeting used 1.35 hours of nurse time as the average time for an initial home visit and 1.1 hours as che standard time for a continuing care visit done

by either an RN or LPN. Nore that Washington has recently reported co the board that approximately 20 percent of all home visits done by the Home Care Division are initial visits and char (on average) travel time to and from a home from the Middleboro office is

20 minutes, with a standard deviation of 18 minutes. Currently, all staff assigned to che Home Care Division work out of the Middleboro office.

Last month Washington sent to che executive commiccee, including Mr. Ruseski, the following national productivity standards she plans to use co assess staff productivity.

\

Home Health Visit Staff Productivity Profiles (National Standards, 2013)

Staff

RN

LPN

HC aide

Physical therapist

Occupational therapist

Social worker

NOTE: Does not include travel time. -

Visits per 8-hour shift

4.90

5.90

5.17

5.39

5.25·

3.20

62 The Middleboro Casebook

William Bond, chairman of the board's finance committee, has expressed con­ siderable interest in evaluating the likely impact of continuing changes in the Medicare

reimbursement system. At a recent board meeting he expressed concern as to whether the

agency could continue ro scay unaffiliated with at least one of the area hospitals. When the staff nurses were interviewed most indicated that "doing the required

paperwork from home after work was a burden and responsibility that should be recog­ nized and compensated." Some remember the "good old days" when they began and ended their workday at the office. "Today, we rardy go to the office in rhe morning, we go directly ro the client's home and sometimes-but not always-stop at the office in the middle or end of rhe day. We do the progress notes and ocher required paperwork from our laptops."

Additional information regarding HCHHA staffing, uciJization, fee structure, refer­

ral sources, financial status, patient demographics, and quality measures may be found in the following tables.

64 The Middleboro Casebook

TABLE 2.1

Agency Staffing in

FTE and FT Salary:

2014

December 31 ,

2012-2014

Position Salary

Homemaker/ 22,900

housekeeper aide

Other 71,700

Secretary 24,200

Community Health Division

Manager 63,500

RN 53,330

Secretary 21,670

Total FTE

FTE

10.0

0.1

1.0

1.0

3.0

1.0

98.2

2013 2012

Salary FTE Salary FTE

21,500 8.o 20,433 6.o

71,000 0.1 70,500 0.1

20,440 1.0 19,000 0.5

63,500 1.0 63,500 1.0

52,000 3.0 43,500 4.0

21,000 1.0 19,500 1.0

94.2 84.7

NOTE: Full-time equivalent (FTE) positions are paid for 2,080 hours per year. All full-time employees receive two weeks paid vacation and 13 paid holidays and work 1,896 hours per year. All salaries are expressed as the average salary for that position. Benefit costs are in addition to salary costs.

�- - -- -�-

- - -� - .

. � . -.. - -

TABLE 2.2

Service Area

Utilization by Town

for Calendar Year

Ending December

31,2014

Boalsburg Carterville 1 ServiceDivision

Home Care ' ' ·". ·JI' -·· ...

RN visits 1,702 2,004 LPN visits 330 356

HHAvisits 422 82 PT visits 150 26 OT visits 56 59 ST visits 10 13

Social worker visits 26 24 Private Duty

RN in-home hours 73 54 LPN in-home hours 794 290 PCA in-home hours 957 1,487 HHA in-home hours 844 1,513

Other in-home hours 10 43 Community Health

Ante/postpartum visits 18 38 Child health visits 7 23

Senior Health Clinic Attendees by HCHHA Office Location

Seen at Middleboro office 15 12 Seen at Jasper office 0 0

Harris City

. '

"

3,404

676

823

301

107

18

47

154

1,241

1,835

1,517

21

56

11

72

0

{This table can also be found online at ache.org/books/Middleboro.)

Jasper Middleboro

. _;: .!)r __ .,; ' .. , ..

3,220 16,071

666 3,264

863 4,904

605 1,547

101 490

20 91

51 230 ..

194 798

1,448 7,109

1,741 9,479

1,291 7,658

6 64 ... il.i

34 190

44 198

0 653

246 0

Mifflenville Minortown

,.1 l ., . ........ ,

3,794 3,020

725 445

967 106

335 18

100 71

21 11

53 38 , ...

150 61

1,571 293

2,155 1,315

2,040 1,729

0 39

101 16

131 12

114 12

0 I 0 l

Stateville

�!

820

200

263

92

30

5

18

'"

so

419

376

426

8

[:

23

30

45

8 I

Total

ii:·,f,

34,035

6,662

8,430

3,074

1,014

189

487

1,534

13,165

19,345

17,018

191

..

476

456

923

254

i

i

r,

"' Ill

11)

N

:t:

Ill

O"

0

0

r,

0

C

:J

'<

:t:

0

3 11)

:t:

11)

"'

::r

)>

(IQ 11)

:J r,

'<

:J

r,

C7\

V,

66 The Middleboro Casebook

TABLE 2.3

Services to

Patients:

2010-2014

Division/ Program

Home Care

Unduplicated client census

RN home visits

LPN home visits

HHA visits

PT visits

OT visits

ST visits

SW visits

Total visits

Private Duty

Unduplicated client census

RN in-home hours

LPN in-home hours

Personal care attendant

in-home hours

H HA in-home hours

Other in-home hours

Total hours

Community Health

Ante/postpartum visits

Child health visits

Prenatal class enrollees

Children seen, Middleboro

Children seen, Jasper

2014 2013

1,596 1,582

34,035 35,463

6,662 5,678

8,430 8,230

3,074 2,647

1,014 993

189 165

487 472

53,891 53,648

260 225

1,534 1,267

13,165 12,564

19,345 16,745

17,018 11,788

212 180

51,274 42,544

476 512

456 502

139 140

901 740

301 222

2012 2011 2010

1,578 1,498 1,499

35,867 36,304 37,192

5,980 4,823 4,725

8,356 8,856 8,923

2,630 2,240 2,430

897 899 903

174 178 156

434 445 342

54,338 53,745 54,671

145

1,050

9,160

14,290

8,304

210 ·-

33,014

500 499 412

656 450 496

123 130 112

634 812 845

305 317 328

(continued)

Case 2: Hillsboro County Home Health Agency, Inc.

Division I Program

High Blood Pressure Program

People screened

MD referrals

Senior Health Clinics

Clients seen, Middleboro

Clients seen, Jasper

2014

7,456

398

923

254

2013 2012

6,867 7,234

423 307

902 920

243 289

(This table can also be found online at ache.org/books/Middleboro.)

2011

7,124

456

934

389

Home Care Division per visit exclusive of discounts and contractual allowances'

RN 95.78

LPN

HHA

Physical therapist

Occupational therapist

Speech therapist

Social worker

55.50

50.00

80.40

74.23

70.60

70.89

Private Duty Division per hour exclusive of discounts2

Other

RN 75.00

LPN 51.00

HHA 33.00

Personal care attendant 35.00

.Physical therapist 71.00

Occupational therapist 71.00

Speech therapist 71.00

Social worker 71.00

Immunizations, each 10.00

Physical examinations 50.00

2010

6,838

512

978

412

NOTES: 1. Excludes the cost of travel. Client is billed $0.55 per mile to and from Middleboro office. Medical supplies are billed at cost plus 10%. Medicare Home Care prospective rate is determined by fiscal intermediary based on patient information and diagn�is. 2. Includes the cost of travel to and from Middleboro office. Medical supplies and equipment are billed at cost plus 10%. Medicaid has specific fee schedule. Some managed care and commercial insurance plans must not exceed reimbursement rates.