Author: Maxwell Healthcare Associates
Posted: February 27, 2024
The post-acute care industry continues to face turmoil under employment shortages, regulatory scrutiny, and the overall need to do more with less. Throughout this struggle, agencies find increased productivity and success through intake centralization empowered by tech-enabled tools. To discuss this current landscape, we sat down with MHA’s Senior Consultant, Kristopher Smith, alongside Claire McIver, Enterprise Client Engagement Manager with our partner, Forcura. The pair discuss the importance of technology, opportunities stemming from intake centralization, and overall best practices for agency success in 2024.
Intro:
Welcome to the MHA Corner podcast, where we discuss news and developments in the post-acute space. Today, we sit down with MHA senior consultant Christopher Smith alongside Claire McIver, client engagement manager with our strategic partner Forcura. The pair discuss the current state of post-acute care, technology's pivotal role in success, and the importance of intake centralization, while adapting to do more with less. Thanks for joining us today. Please take some time to introduce yourselves.
Kris:
My name is Kris Smith. I'm a senior consultant with Maxwell Healthcare Associates. My specialty is generally home health. I've got twelve plus years’ experience in the home health industry, I've done everything in the home health world from start-of-care admissions, to case management, to intake, to auditing eligibility, to clinical supervision, I was even a regional director. If there's something inside of that world, I have probably done it in some capacity. I've got experience as a quality auditor, a chart reviewer, I’m OASIS trained, ICD 10 trained.
Home health has been something that I've greatly enjoyed in my nursing career and it is an awesome opportunity to help home health agencies continue to work on things like efficiencies and intake and workflow designs and all of those other fun processes.
Claire:
My name is Claire McIver and I am an enterprise client engagement manager at Forcura. I've been at Forcura about six years now and I spent the first four years really implementing clients and consulting with clients on their workflows, really streamlining and optimizing processes. Now I manage three of our top five clients.
Kris:
Well, currently the home health industry and hospice industries, we're in kind of some transition points post pandemic. COVID-19 did a number of things, not being able to have staff in the hospitals, not being able to even have staff necessarily available due to being out on quarantine or sicknesses.
We found a need for availability to be more remote, for agencies to be able to handle and monitor those reerral sources, to be able to connect with the hospitals. Through that we see the rise of the portals that are coming through and there's all different types of portal platforms that require different sign-ins and logins and we go on and down the line with things post 2020.
You even get into cost cutting points with Medicare HMOs and agencies are having to do as much work, if not more work, without the same level of reimbursements that it's really coming down to, how do we manage and get our referrals from the hospitals and facilities without having someone on site?
How are we managing internally what that looks like? Is the quality of work still the same across the board? We've got a lot of different agencies that have agencies in remote parts of the country. How are we handling that with staffing and all those things? So, to be able to have one design that we can manage with certain metrics and KPIs and performance indicators really gives agencies a good handle to make sure that they are still growing. But being able to manage those resources appropriately and still have client relationships.
Claire:
Yeah. And just to kind of add on to that, another thing that we've seen a ton of is agency merges and acquisitions, really, in the past few years. And I would say as it continues, many are moving towards a common technology system, and they really need one single process for better transparency into their enterprise.
Claire:
So, I'll start with the first question, and you're right, it's very crucial for agencies to adapt. And centralization is one way that agencies can modify their intake processes.
Really keeping in mind that intake determines time-to-care, which is a critical metric for referring partners, payers, and patients.
To kind of jump to your second question there, while it's inevitable that every agency will encounter challenges, it's so important to really embrace those obstacles as opportunity for growth.
It really is key. And one of the biggest challenges that they will face is going to be employee buy-in. So, explaining the bigger picture, to really affirm that this is the right decision, another big challenge that they will face will be the processes that differ from location to location. Especially on larger agencies, where you have 100 plus locations, that process is different at each one. And really, from a Forcura point of view, agencies have the opportunity to leverage technology and partners. So, one of our big pushes last year was the idea of a referral hub that uses our referral IQ technology to consolidate all referrals into a single dashboard, and that will instantly queue up referrals to be worked first.
Kris:
So, there's always kind of this old age battle that happens in agencies between your intake departments and your clinical departments. Clinical departments, and I can say this as a former clinical director, we want things neat and tidied on a silver platter, a clear expectation of what are the diagnosis, what's going on with the patient, as much information as we possibly can give the start-of-care clinician as possible, we want that, and we try to leverage that.
The goal is, always know what our regulatory standards are in order to complete a referral. Because all of those things that we want to put a bow on, as Claire said earlier, it can change our timing. We want to operate by getting things through the intake process as fast as possible, but we want to make sure know we're not just sending out garbage, because you put garbage in, and that's what you're going to get out.
And so much of your home health episodes and your hospice episodes are based on that intake process. Regulatory items, financial items, even being able to build a plan of care for your patients, that you want to have as much information there. But what I find is that when we bring the compliance department in and they can kind of help work and leverage that messaging to say, okay, compliance wise and regulatory wise, here is what we need to move this referral through.
Would we like more? Yes. Are we going to ask for more? Yes, but being able to put those processes in place to say, but we're not holding it up as part of our intake process, that we're going to have other ways to follow up on those items. I've worked with agencies where the face to face becomes a big deal, where they will not move that referral from workflow and their intake flow until they have assigned quantifying face to face that meets that expectations.
And we want to be very careful of that because CMS gives you 30 days to secure it. So, we want to be able to take the leverage that CMS is giving us. We want to take those industry regulatory items that compliance is well versed in and be able to have that as an understood basis for everybody else.
Ultimately, like I said, that's not the minimum of what we're pushing through and wanting to put through, but we want to have everybody on the same page that, yeah, you might not have a full diagnosis list, but you've got a couple of diagnosis and that is a reason for a plan of care in an MD order, and that's enough to go see the patient.
Claire:
Yeah. And one other thing just to add to that, really, with ensuring compliance and with regulations, while centralizing, should include just a few things here. So regularly reviewing and updating those regulatory standards for alignment with the process, so really dusting off those regulatory standards and just making sure that the processes are designed to be compliant and really based on that, just making sure each staff member knows their role on the team, which could be different once the team is centralized.
Kris:
100%. And we see this across the board with a lot of things. Claire, to your point on the previous question, there's a lot of ways that people were doing things five years ago that don't necessarily work for now. Regulatory standards change year in and year out with new rulings and things like that.
So, compliance is a huge factor that needs to make sure that it's being updated, that it's not just something that's looked at every three years, and those education components built into the intake team itself, that they understand compliance wise, what is their expectations, and how does that look? What does documentation look like?
Claire:
So let me give you the Forcura perspective here. Successful centralization cannot be achieved without a technical infrastructure that really empowers and allows consistency across all locations.
And we automate the process so that intake can move faster and really, then staff can concentrate on more of those patient care tasks, which is the most important thing. Right. And I'm going to fight the urge here to go too granular into Forcura, but I just want to name three things that we can really assist with, and one is going to be consolidating your referral activities into a single dashboard.
So, we basically have a dashboard that anyone from your local branch manager to an enterprise executive can monitor, really, all of those intake activities, and they can also monitor branch and staff performance. So, it really gives you a way to manage it at a high level in one place.
Another way we can assist with is identifying and prioritizing referrals. So, we can help do this by patient location, referring source or payer, and this can really be from any inbound source that you receive referrals from. And then the last thing is we really integrate with the top EHRs, so that information flows directly into patient charts with just a click.
Kris:
We're talking about Forcura and with the ability to be able to connect with EMRs, and reiterating that idea that speed is faster than intake can process and the more efficient things can process, being able to get referrals, get them started without having to download as a PDF off your computer, then go back and load to it.
Even saving 60 seconds of time, 60 seconds extrapolated out by multiple charts, is just helping agencies become more efficient.
Kris:
Well, one of the things, you know, every agency has those stories of a patient that didn't get seen. I can tell you specifically of a patient now that was discharged from a hospital and was readmitted before we ever got back into the home. And twelve days had gone by while we were waiting on requirements and things like that to get the referral through.
I know of another case where a person was ordered for wound care and they were held up for over seven days getting authorization, so that by the time the nurse got out to the wound to see the patient, the patient had gone septic. So these are all things that we want to keep in the mind of that while home health and hospices, no one's generally volunteering their time to do all of this work, but there are businesses that we are still in the business of taking care of people, and we want to make sure that regardless of how we centralize and optimize things and look at things, you're looking at clinical departments, and the goal of clinical departments is patient care.
So, when we think about, on one hand, we're talking about productivity and increasing efficiencies and being able to do more with less. The outcome is that we're seeing the patients sooner, that we're not having someone's grandmother sitting there in a chair waiting for home health because she was promised from home health that someone was going to be there or PT was going to be there, and then waiting for seven days for someone to give her a call.
We also know that agencies are competing for referrals. The agency that gets the referral that can call that patient sooner is probably going to be the one that gets accepted in, and we want to be able to hold the fact that we've called the patient that we're providing that care.
From a personal note, I can tell you my dad had hip surgery a couple of years ago, and he got lost in the system of an intake process, and he went ten days before he even had a physical therapist look at him. And by that point, he had to go to an outpatient physical therapist to get it done.
So, he sat at home with a repaired hip without getting any PT, and tried to do things on his own and strengthen himself without really knowing what he was supposed to do. So, we think about intake as just intake, and we're pulling referrals and we're trying to data entry and collect our things from compliance, but it needs to always come back to how are we best serving our patients, and how can we put measures in place that the patients are getting care when they need it by the people who need to deliver it.
So that's always on the top of my mind. Regardless of whatever department I find myself working in, I'm always an RN at heart. I'm always a clinician at heart. And you get into this business to take care of people.
Claire:
Yeah. And Kris, just to comment on that, what you mentioned, like, patient satisfaction really begins before discharge.
There are so many times where you need to quickly get that information to your back office so that they can take a look at the referral documents so we're not waiting as a patient sent home. We want to go ahead and have a plan for them. So really a strategy that an agency can take is equipping your business development reps with the technology that allows them to send patient referral documents to the back office immediately.
Because that way, the back office can go ahead and quickly accept the patient based on payer, patient location, and current staff capacity, of course. But it makes the process much more streamlined and so much easier on the patient.
Kris:
100%. Being able to have that face-to-face time, having that documentation up front, getting the staff trained intake is that rare department that is both client facing and referral facing.
You're working with your business development team to get referrals in-house and build that network up. But you're also having to have that client facing part where the clients know who their agency is and that agency is delivering on what they promised that patient to do. If agency “A” is calling the patient and saying, we're going to have a nurse out there within 48 hours, patient satisfaction needs to be secured that that 48 hours window is taking place, because at 49 hours, that patient's going to be upset.
Claire:
So, I would say in order to have effective change management, you should partner with a reliable vendor.
A big thing is planning with a team who will champion that change. So making sure that you create that core team who understands what the change is going to be and how best to support it. And really a big thing is acknowledging the challenges that staff are going to face, but also keep the focus on the long term benefits.
I think we all know change is scary. Technology change can be even scarier. So, making sure that staff understand why you're making the change and understanding that there will be stress around it and acknowledging that is a huge piece of it. I think another thing is making sure that you have enough training materials, that's crucial, if you're changing any sort of process with technology, there needs to be efficient training for the team to feel like they are supported and can actually make this change once you're ready.
And then I would say the last thing, and it could be arguably one of the most important ones, is going to be the continued support. I can't tell you how many times we've seen where you implement something and then if you don't continue to support it, to check in to get feedback, to see how things are going, to understand there's going to be changes that come out in technology that could continue to assist that process.
So, making sure that your staff understands any of those best practices that can come into play. It could be new staff, it could just be refreshers, it could be once they've gone live now you have some maybe more advanced training, but just continuing to give the staff support and make sure that they understand the technology.
Kris:
And that's so critical, we see it time and time again on our end, Claire, that we go in and agencies will attempt a centralization or optimize. And they started the process, but they were trying to do something that was maybe an older process that didn't get updated. They weren't necessarily informing the people that were sitting at the table of what the new process looked like, or they gave them a very abbreviated 15-20 minutes saying, okay, you're going to do this now, this now, this now and then assuming that they know what they're doing and that that's going to be able to translate and whether that's a process or it's a technology, too many times agencies walk away from technology platforms just because they simply didn't understand really how to use it.
We want to be able to have that leverage to say, okay, this is a good tool for you to use to help you with this process, and it needs to be a tool, but you need to know how to drive it.
Claire:
Absolutely. And I will say another thing is we had someone, just a client that comes to mind that rolled out the Forcura technology probably a year, two years ago, and there have been changes in compliance, there have been changes in technology, there have been just changes in different states that they're having to consider.
And so, they continue to hold bi-monthly sessions where people can call in, ask those questions, they can do these little hot topics. So, things that they know have come up a lot, things that they know have changed to make sure their staff feels supported and knows any changes that they're making at the company.
Kris:
Well, one of the biggest things that you're going to look at is you want to think about conversion from an admission standpoint where you do a lot of work.
You want to see that get across the finish line. We're talking with doctors’ offices, referral sources. There's a lot of legwork and things, and we talked about that compliance standpoint and documentation standards that need to be accounted for in a referral. You're doing a lot of work for that referral. You want to see that referral cross the finish line.
So, being able to know manage your conversion rates and being able to not just say an overall conversion rate, you want to be able to specifically look at what are my Medicare conversion rates? What are my commercial payer conversion rates? You want that Medicare conversion rate to be high with it being the better payer. You want to make sure that those are getting across. The Medicare referrals are the easiest ones to cross the finish line anyways. Right? So, we want to be able to make sure that's being measured.
We want to be able to manage the profitability of what we're doing. And that comes back into that. Looking at your higher payers as an intake department, the intake staff should also be aware of what payers are ones that we shouldn't take. And that comes with working hand in hand with your RCM team.
Are there payers that if we are stuck on staffing, we can take referrals, but we're limited? We really want to make sure that the intake team and the marketers know that, okay, we're going to really key in on our higher payers here. Those are going to be the referrals that have the biggest bang for their dollar, so to speak.
And again, not trying to take out off the patient centered stuff, but if we're looking at the fact of making sure that we are getting things across the finish line efficiently and profitably, because again, nobody works for free, we really want to take that into account. And then the big one is every agency, every home health agency is being managed on their timely initiation of care.
How quickly are you getting to the bedside of that patient? How quickly are you getting that patient admitted? These are all big indicators that your intake process is working or it's not working. Conversion rate and the time-of-care are usually the two first items that I go and look at when I'm working with an intake department that's going to tell me that either we've got a delay or it's working pretty well.
But then you've got other things that you can factor in. How long is it taking you to complete tasks inside the system? Where are your bottlenecks coming up? And there's all different KPIs and censuses that you can look at. A healthy intake department and a well efficient intake department is going to see a growth in census.
So that's going to be your final KPI that you're going to see to be able to manage. What we've got working now is working.
Claire:
And just to add analytics and metrics bring so much value when you're viewing how successful you've been with centralization. Being able to have analytics and metrics is huge.
So, we really provide agencies with dashboards and reports so that you can help monitor performance. You can help detect any of those bottlenecks like you mentioned, Kris, and also it can help you identify certain branches that are your top performers. And you can use that to help across the company, to use that kind of as an example or to help learn from those.
Kris:
100%. If your looking at your KPIs and you're looking at time to complete tasks, that's going to help you drive a daily productivity expectation. And if you kind of put that clear in front of them and your intake team knows that I have to meet x amount of referrals today, then that's also going to make sure that you've got the people in the right seats that are doing the expectations of their job.
If you've got the expectation is I'm just throwing a number out there, 20 referrals a day, and you've got an intake coordinator who is only processing ten to twelve. She might be a great worker, she might be a hard worker, but she might not be designed for that seat.
There might be another opportunity for her in the company somewhere else. Something's not working right there, but you don't necessarily want to put on her. She might be getting a really bad lot of missing documentation. So, you really are able to identify individual areas of success in your department, but also individualized areas that need more attention in your department.
Claire:
It really is vital to have that collaboration between the technology providers like Forcura and consulting firms like MHA. I would say that our partnership is able to combine the Forcura side, so that specialized technology knowledge, and then you also have MHA's industry specific expertise. You've heard Kris, this whole time, those industry specific expertise he's been speaking about. And really putting these two things together will result in a comprehensive strategy that really is tailored to what that specific agency needs. Because, as we all know, there are no two agencies that are the same. So those things are very important to have the technology and industry specific knowledge. And I would say together, we really do put together and ensure a seamless implementation will help with effective change management and just having that continuous improvement.
Kris:
And I look at those ideas with your partners in those categories as if I'm building a house,
I've got to rely on multiple different tools, and I got to know how to use my tools and leverage them appropriately. I'm not going to take a hammer to try to undo a screw from a wall. I need to make sure I have the right tool but understand that I know how to use that.
So, all the technology vendors out there, being able to align them with that process should be a supplement to the process and being able to work accordingly with it. It should never necessarily supplant the process.
Kris:
Well, we see a lot of different things. AI is becoming more heavily involved in different arenas and different platforms and tools. Being able to make sure that that's being looked at is a possible tool. We know that there's possibilities of automation of workflow and being able to do things a little quicker with just the automation parts of it.
And we know that we've got a lot of different things that, as I said earlier, were great processes back in 2018 and 2019, but being able to really remap and look at those, and not necessarily needed. Now, the landscape has changed, now staffing has changed. Now there's different restrictions on different agencies.
So, being able to take anything and everything that's at your disposal, to be able to pull that in, to say, okay, how can we best remodel this department? How can we best make sure that it's optimized? I think knowing that the health industry is one of those industries that no matter what you do every year, you're going to seem to be constantly up against the gun of having to lose reimbursement.
Every year there's threats of cost cutting and changes and things like that, but every year, the cost of living goes up for your staff. So incrementally, we're in a business where people are going to have to be getting paid more money every year, but the agency is in the position of getting paid less.
So, we want to be able to look at efficiencies and productivity, and we want to be able to look at how we can best optimize. So as long as the agencies are up against that gun of continuing, having to relook on how they're doing things, I think strategic alignment is going to be a thing that agencies are going to be keeping a very close eye on because, Claire brought it up earlier lots of mergers and acquisitions, lots of big agencies taking over smaller agencies, we want to make sure that those processes are going to be standardized.
So, I think the trend is continuing to go in that way where we're going to see an influx of increased use of technology platforms, increased use of AI automation, and really looking at some of those KPIs to see, okay, what are the metrics that we need to abide by so that we can keep this department operational?
Claire:
And just on the note, like you mentioned, just increased use of technology. I met with our team that oversees our circle product, which is our electronic signature platform. And it really has been so exciting to see what we're working on and how connectivity with physicians and patients really is so important.
We're going to pour a lot of time into it this year and further it along to expand with sending and receiving patient documents. Because as you mentioned, using technology to speed up any part of the process, eliminate any sort of clicks, is going to be huge.
Kris:
So, I'm always a big proponent that you got to make sure you have the right people in the seats. So, I think as you're evaluating your intake department and you're evaluating your process, you don't necessarily create your process around the people.
You have your people adapt to the process. And if you've got people that are not able to work under that process or deliver under that process, they might be better suited for another role or a position. We often see some things with some agencies where your people who are manning the portal is so and so is from the agency's niece. So, somehow, they're related to someone in the company and they're sitting in that role. That doesn't necessarily mean that they're best suited to be the one in that role. And being able to make sure that you understand that intake is not a nine to five job. Home health is not a nine to five job.
There are doctor's offices that are staying late. There are doctor's offices open on the weekends. There's referrals that come in after hours from the attendings that round after a full day of surgery. There's different components on it that we have to be adaptable to, to have those in place as we're looking at centralizing, as we're looking at optimizing and strategically aligning.
So, all those factors must be in place again. We want to be able to make sure that KPIs are being looked at. You can centralize and say, okay, we've centralized, but we're not going back and looking at our KPIs to ensure that we had success in centralization.
And centralization is not an overnight thing. We don't get to flip the switch and say, okay, that's done. As Claire brought it up earlier, it's constant education, it's constant review, it's constant support in getting it across the finish line. A lot of times when you implement a change in your first week, you're going to get a whole bunch of people that come to you and tell you that the change didn't work.
And they want to see things from the old process implemented back in. And too many times, agencies are quick to pull that trigger. Then we want to give it time to let them adapt to new processes, continue to encourage and continue to support, but let the process work itself, all of it.
You might have to make a change in it. It might not work based on specifically that agency as no two agencies are the same, but wanting to make sure that you're giving it that time, really, you want to be able to make sure that also from an intake standpoint, you can optimize your intake department and it can be a well running machine, but you've got to have a place for that jet to land.
And if you're not addressing your field staff, if you're not addressing the clinical side of things, you're turning a faucet on wide open for a very small container to take that and you're going to end up being backlogged anyways. And in that case, you're going to be having upset patients and referral sources.
So, increasing and optimizing your intake should come hand in hand with looking at, okay, what does our field productivity look like? What does our field capacity look like? How are we aligning that? Are we increasing? If we've got areas of tight disciplines and we don't have a lot of open capacity, are we really recruiting heavily for those areas?
What are we doing to make sure that that referral is truly getting to the patient's bedside and being seen? I did get to work with an agency, and it was a few months’ worth of process and retraining and conversations and even getting a revolving door of some people in some seats at times.
It was a process that took literally at least three months before they've got it started humming right. And they were able to see an increase in their census by almost 20%. But they recognized that everything went hand in hand. You can't just tinker with this nut and bolt here and not do anything with the other departments and think that's going to work.
So, recognizing that everything has a downstream effect, being able to anticipate that and clearing out downstream helps tremendously.
Claire:
What really resonated with me is all teams are impacted, right? Like, it's not just one position that's going to be the one that makes this change. And here we are, and now it happened.
It doesn't happen overnight, like you mentioned. And I will say we've seen a lot on our side as well, of someone who doesn't like the process or after a few days start those complaints, start that. It's just so quick to say, okay, this isn't for us, it won't work, cut it off.
Let's go back to our old processes and I think it's important just with any change. As we know, change is scary at first, when you're starting a new process, it could seem like it's taking you longer, right, because you're learning now. I need to click here, I need to do this, I need to do that.
And it does change your process. That doesn't mean that it's going to be slower in a month as you're getting used to everything, but first, it can slow someone down, and I think that can be scary to people. I've been working with a few clients on this, and I just had one where they successfully centralized within the past two to three months.
And then we're here to assist them in making those changes to their dashboard so that in Forcura, we can support them and make sure that they have what they need to continue to be successful.
And then I also had one where they tried centralization, and it truly didn't work for them. As you mentioned, no agency is the same. They're all different, and it's not an easy button. And really, every client has to evaluate that and see how it fits in their workflow. And we're really here to support wherever they land in that decision making process.
Kris:
And centralization, in a lot of cases, it comes across negative, and sometimes people just fear the word of it, because as a former clinical director, I wanted as much control over that thing as I could possibly get.
Because ultimately, if a surveyor came in through, it wasn't going to be intake that was at that desk, it was going to be me at that desk with the surveyor. And I had to take account for what the patients I was seeing. So, there's always going to be little bits of struggle and pushback, but if we can get everybody to think about the same page, that really, we're optimizing what's best for the patient, we need to get the patient seen quicker than what we are currently doing.
It kind of gets people, I think, to buy in a little bit more. But then on the intake side of things, you want to deliver, what you're saying you're going to deliver. There must be a trust that if I'm a clinical director and I'm relinquishing control, and I'm relinquishing having the ability to have things at my branch and work things at my branch the way that I want them worked, and I'm relinquishing that control.
What you are coming back on your end, I must trust that you're going to do a good job. And so, we never want to promise something and not be able to deliver it from intake. So that's, again, making sure we've got the right people, the right job, the right understandings, and that the process is compliant, driven, that there's still a level of compliance, we're not just pushing things through for the sake of pushing things through, that helps to kind of build that trust a little bit that I know I've got some things coming my way I can safely assign to my nurse and know that it's going to be a good admission.
Outro:
Thanks for listening to the MHA Corner Podcast. If you'd like to learn more about Maxwell Healthcare associates and our tech-enabled solutions or our strategic partners, like Forcura, contact us at [email protected] or visit us @ www.maxwellhca.com.