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 firnt nce 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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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
Executive
Myer
Ruseski, Steel, Meadows
Finance
Bond
Blau, Logic, Giles, Martin
Members
Professional Advisory
Vosper
Metz, Doe, Care, O'Brien, Ellis
Publicity and Public Relations
Fisher
Donnelly, Black
Shields
Graham, George
Building and Grounds
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.
lan dscaping. 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 inMiddleboro, 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 inMedicare andMedicaid.
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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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 Du ty 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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The Middleboro Casebook
National Utilization Statistics- Home Health
Patients currently being served by home health agency
Patients under 65 years of age
Rate per 10,000
population
16.4
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...
91.0
1,439.3
Percent
Remained in community
71.5
Transferred to another setting
20.5
Is deceased
2.3
Unknown
5.7
NOTE: Discharge means when a case is closed by the home health agency.
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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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.
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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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. W hen
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.
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
59
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.
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 bee n 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
health
and has asked for a management assessment of che staffs productivity. At
home
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
Visits per 8-hour shift
RN
4.90
LPN
5.90
HC aide
5.17
Physical therapist
5.39
Occupational therapist
5.25·
Social worker
3.20
NOTE: Does not include travel time. -
61
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.
The Middleboro Casebook
64
TABLE 2.1
Agency Staffing in
FTE and FT Salary:
December 31 ,
2012-2014
2012
2013
2014
Salary
FTE
Salary
FTE
Salary
FTE
Homemaker/
housekeeper aide
22,900
10.0
21,500
8.o
20,433
6.o
Other
71,700
0.1
71,000
0.1
70,500
0.1
Secretary
24,200
1.0
20,440
1.0
19,000
0.5
Position
Community Health Division
Manager
63,500
1.0
63,500
1.0
63,500
1.0
RN
53,330
3.0
52,000
3.0
43,500
4.0
Secretary
21,670
1.0
21,000
1.0
19,500
1.0
98.2
Total FTE
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
Division
Home Care
1 Service
Boalsburg
'
'
-·· ...
Harris
City
Carterville
·".
·JI'
. '
Jasper
"
Middleboro
. _;: .!)r __.,;'
,
.. ..
Mifflenville
,.1
Minortown
Stateville
.,
l
.........
Total
ii:·,f,
�!
,
RN visits
1,702
2,00 4
3,404
3,220
16,071
3,794
3,020
820
34,035
LPN visits
HHAvisits
330
356
676
666
3,264
725
445
200
6,662
r,
422
82
823
863
4,904
967
106
263
8,430
PTvisits
OTvisits
150
26
301
605
Ill
11)
1,547
335
18
92
3,074
56
59
107
101
490
100
71
30
1,014
STvisits
Social workervisits
Private Duty
10
13
18
20
91
21
11
5
189
26
24
47
51
230
53
38
18
487
73
54
154
194
798
150
61
so
1,534
0
794
290
1,241
1,448
7,109
1,571
293
419
13,165
r,
0
C
:J
RN in-home hours
LPN in-home hours
..
,...
'"
"'
N
:t:
i
Ill
O"
0
PCA in-home hours
957
1,487
1,835
1,741
9,479
2,155
1,315
376
19,345
HHA in-home hours
Other in-home hours
Community Health
844
1,513
1,517
1,291
7,658
2,040
1,729
4 26
17,018
10
43
21
6
64
0
39
8
191
Ante/postpartum visits
18
38
56
34
190
101
16
23
476
11)
Child health visits
7
23
11
44
198
131
12
30
456
:t:
11)
72
0
653
114
12
45
923
0
246
0
0
il.i
[:
Senior Health Clinic Attendees by HCHHA Office Location
Seen at Middleboro office
15
12
Seen at Jasper office
...
0
0
'<
i
..
:t:
0
3
"'
::r
{This table can also be found online at ache.org/books/Middleboro.)
I
0
l
8
I
254
)>
(IQ
11)
:J
r,
'<
:J
r,
C7\
V,
66
2.3
Services to
Patients:
2010-2014
The Middleboro Casebook
TABLE
Division/ Program
2014
2013
2012
2011
2010
Unduplicated client census
1,596
1,582
1,578
1,498
1,499
RN home visits
34,035
35,463
35,867
36,30 4
37,192
LPN home visits
6,662
5,678
5,980
4,823
4,725
HHA visits
8,430
8,230
8,356
8,856
8,923
PT visits
3,0 74
2,647
2,630
2,240
2,430
OT visits
1,014
993
897
899
90 3
ST visits
189
165
174
178
156
SW visits
487
472
434
445
342
Total visits 53,891
53,648
54,338
53,745
54,671
Home Care
Private Duty
Unduplicated client census
260
225
145
RN in-home hours
1,534
1,267
1 ,050
LPN in-home hours 13,165
12,564
9,160
Personal care attendant 19,345
in-home hours
16,745
1 4,290
HHA in-home hours 17,018
11,788
8,304
212
180
210
Total hours 51,274
42,544
33,014
Other in-home hours
·-
Community Health
Ante/postpartum visits
476
512
500
499
412
Child health visits
456
502
656
450
496
Prenatal class enrollees
139
140
123
1 30
112
Children seen, Middleboro
901
740
634
812
845
Children seen, Jasper
301
222
305
3 17
328
(continued)
Case 2: Hillsboro County Home Health Agency, Inc.
2.3
SeNices to
Patients:
2010-2014
(continued)
TABLE
DivisionI Program
2014
2013
2012
2011
2010
People screened
7,456
6,867
7,234
7,124
6,838
MD referrals
398
423
307
456
512
Clients seen, Middleboro
923
902
920
934
978
Clients seen, Jasper
254
243
289
389
412
High Blood Pressure Program
Senior Health Clinics
(This table can also be found online at ache.org/books/Middleboro.)
TABLE 2.4
Home Care Division per visit exclusive of discounts and contractual allowances'
95.78
RN
55.50
LPN
50.00
HHA
Physical therapist
80.40
Occupational therapist
74.23
Speech therapist
70.60
Social worker
70.89
Private Duty Division per hour exclusive of discounts 2
75.00
RN
51.00
LPN
HHA
33.00
Personal care attendant
35.00
.Physical therapist
71.00
Occupational therapist
71.00
Speech therapist
71.00
Social worker
71.00
Other
Immunizations, each
Physical examinations
10.00
50.00
NOTES: 1. Excludes the cost of travel. Client is billed $0.55 per mile to and from Middleboro office. Medical
supplies are billed at cost plus 10%. Medicare Home Care prospective rate is determined by fiscal intermediary
based on patient information and diagn�is.
2. Includes the cost of travel to and from Middleboro office. Medical supplies and equipment are billed at cost
plus 10%. Medicaid has specific fee schedule. Some managed care and commercial insurance plans must not
exceed reimbursement rates.
Fee Structure as
of December 31,
2014 ($)
68
The Middleboro Casebook
2.5
Referral Sources
for New Cases by
Division for
TABLE
2012-2014
2014
2013
2012
Self-referral
4.0
2.0
2.0
Family or friend
2.0
3.0
2.0
Physician
34.0
32.0
39.0
Hospital-Webster
13.0
15.0
14.0
Hospital-Middleboro
42.0
40.0
39.0
Hospital-Other
1.0
2.0
o.o
Nursing home
2.0
4.0
2.0
Other
2.0
2.0
2.0
Self-referral
42.0
40.0
42.0
Family or friend
21.0
21.0
20.0
Physician
12.0
15.0
12.0
Hospital-Webster
4.0
3.0
2.0
Hospital-Middleboro
9.0
9.0
12.0
Hospital-Other
0.0
2.0
2.0
Nursing home
7.0
6.o
8.o
Other
5.0
4.0
2.0
100.0
100.0
100.0
Home Care Division
Private Duty Division
NOTE: Numbers are percentages of all new cases.
Case 2: Hillsboro County Home Health Agency, Inc.
69
2.6
Statement of
Revenue and
Expenses for
Calendar
Year Ending
TABLE
2014
2013
2012
6,736,375
6,3 22,329
5,936,445
(85,240)
(88,340 )
(72,450)
Less contractual allowances (2,049,283)
(1,737,912)
(1,365,999)
4,601,852
4,496,077
4,497,996
3,165,221
2,843,959
1,893,345
Less allowances for bad debt
(65,340 )
(45,230)
(24,550)
Less contractual allowances
(18,469)
(12,669)
(8,738)
Net revenue
3,081,412
2,786,060
1,860,057
Support from state and towns
208,750
240,000
240,000
United Appeal
20,000
20,000
60,000
Other
1,935
1,257
1,458
Net revenue
230,685
261,257
301,458
7,913,949
7,543,394
6,659,511
Salaries and wages
4,186,227
4,086,160
3,604,595
Fringe benefits
1,255,868
1,022,548
1,021,445
Travel
725,388
701,383
604,387
Supplies
453,778
398,202
258,304
Equipment
152,430
122,494
82,394
Total divisional
6,773,691
6,330,787
5,571,125
Salaries and wages
360,233
340,229
335,110
Fringe benefits
102,339
98,334
96,990
Supplies
157,910
158,705
140,680
Equipment
45,929
42,393
34,220
Home Care Division
Less allowances for bad debt
Net revenue
Private Duty Division
Community Health Division
Total net operational revenue
Expenses
Divisional
\
Administrative
(continued)
December 31 ($)
70
The Middleboro Casebook
TABLE 2.6
Statement of
Revenue and
Expenses for
Calendar
Year Ending
December 31 .
(continued)
2014
2013
Insurance
56,729
54,202
45,043
Interest
54,894
53,890
53,004
Maintenance- Middleboro
138,595
79,303
78,380
Rent-Jasper office
40,500
40,500
40,500
Computer services
84,253
80,150
73,229
Travel
18,356
18,430
13,450
Heat/light- Middleboro
11,488
10,004
7,545
Legal/audit
55,088
44,411
28,340
Printing and postage
15,540
13,450
12,000
Telecommunications
21,364
19,560
18,334
Staff development
10,060
7,010
7,500
Board expenses
10,150
10,445
6,342
Publications and memberships
10,700
10,500
8,550
Depreciation expense
38,240
39,440
44,350
Total administrative
1,232,368
1,120,956
1,043,567
8,006,059
7,451,743
6,614,692
Gain (or loss) from operations
92,110
91,651
44,819
Other Income
202,445
245,300
295,606
110,335
336,951
340,425
Total expenses
Gain (or loss)
(This table can also be found online at ache.org/books/Middleboro.)
2012
The Middleboro Casebook
72
TABLE
2.8
Revenue and
Accounts
Receivable (AR)
Analysis as of
December 31, 2014
Percent of AR by Average Days as Receivables, Three-Year Average
Average Days in °AR
by Payer
Percent of
Net
Revenue (%)
2014 Total
30 or
Fewer
Days
31-60
61-120
Days
days
More
Than 120
Days
Medicare
25
28
38
9
72.5
Medicaid
10
45
40
5
13.5
Commercial
insurance
60
25
10
5
10.7
Managed care
45
45
9
1
1.4
Self-pay
78
15
5
2
1.9
Medicare
0
0
0
0
0
Medicaid
5
45
45
5
12
Commercial
insurance
35
55
5
5
21
Managed care
25
30
40
5
4
Self-pay
30
60
5
5
63
Home Care Division
Private Duty Division
Community Health Division
The agency bills each grant source, including divisions of government, 1/12 of the
total grant amount on the first of a month. On average, 30% is received within 30 days
of billing, and 70% is received within 31-60 days of billing. The only exception is the
United Appeal grant that is received in total on July 1.
The Middleboro Casebook
74
2.10
HCHHA Quality
TABLE
HCHHA
State
Average
National
Average
How often patients got better at walking or moving
around
58%
54%
58%
How often patients got better at getting in and out
of bed
54°/o
48%
54%
How often patients got better at bathing
62%
68%
66%
How often the home health team checked patient
for pain
96%
96%
How often the home health team treated
patient's pain
940/0
98%
98%
How often patient has less pain when moving
around
62%
62%
67%
How often the home health team treated heart failure (weakening of the heart) patient's symptoms.
92%
99%
98%
How often patient's breathing improved
540/0
60%
63%
How often patient's wounds improved or healed
after an operation
91%
86%
890/0
How often the home health team checked patient
for the risk of developing pressure sores
100%
96%
98%
How often the home health team included treatments to prevent pressure sores in the plan of care
100%
88%
96%
How often home health team took doctor-ordered
action to prevent sores
92%
93%
95%
How often the home health team began its
patient's care in a timely manner
92%
92%
91%
How often the home health team taught patients
(or their family caregivers) about their drugs
87%
86%
91%
Scorecard: Most
Recent
Data
Managing daily activities
Managing pain and treating symptoms
'
98%
Treating wounds and preventing pressure sores
(bed sores)
Preventing harm
(continued)
76
TABLE
The Middleboro Casebook
2.11
National
Mean
Length of
Service
(Days)
National
Median
Length of
Service
(Days)
ICD Code
Percent
of All
Patients
(National
Data)
Diseases of
the circulatory
system
390-459
12.6
412
93
15.3
Endocrine, nutritional, and metabolic diseases
and immunity
disorders
240-279
11.7
410
89
11.2
Diseases of the
musculoskeletal system and
tissue
710-739
12.6
365
79
14.4
Diseases of
the respiratory
system
460-519
8.6
308
73
7.3
Diseases of the
skin and SC
tissue
680-709
6.2
189
73
6.2
Diseases of the
nervous system
320-389
4.8
612
327
4.9
Neoplasms
140-239
3.5
1 38
48
4.3
Diseases of the
genitourinary
system
580-629
2.6
232
79
3.0
Diseases of
the digestive
system
520-579
2.3
261
44
2.1
Medicare Home
Health Utilization
by Most Common
Diagnoses: 2014
Data
Cumulative total
64.9
Percent
ofHCHHA
Patients
68.7
Purchase answer to see full
attachment