Transcript Slide 1

2011 HHFMA Financial
Management Conference
Optimize Clinical & Financial
Outcomes by Enhancing
Episode Management
Presented by:
Lynda Laff
Pat Laff
Laff Associates 2011
Managing Smarter
Efficient Home Care Means…
Less care?
Fewer staff?
Cut middle management?
Eliminate PI programs?
Hiring freeze?
Eliminate all educational travel?
No IT system upgrades???
No “tools”?
Laff Associates 2011
REALLY?
How Did We Get Here?
Escalating health care costs – all sectors of the
delivery system
CMS identified home care “behavioral
changes” to influence payment
Practice variation among providers
Continued potentially avoidable events
Slow outcomes improvement
Continued re-hospitalization
Laff Associates 2011
Continued Increase In
Home Health Care Utilization
1997
2000*
2009
1997–
2000
2000–
2009
Agencies
10,917
7,528
10,961
-31%
46%
Total spending (in billions)
$17.7
$8.5
$18.9
-52%
123%
Users (in millions)
3.6
2.5
3.3
-31%
32%
Number of visits per user
72.6
36.8
39.4
-49%
7%
% of FFS beneficiaries who
used home health services
10.5%
7.4%
9.4%
-30%
27%
Number of visits (in millions)
258.2
90.6
129.6
-65%
43%
Skilled Nursing
41%
49%
55%
Home Health Aide
48%
31%
16%
Therapy
10%
19%
28%
Medical Social Services
1%
1%
1%
Visit type (percent of total)
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Costs Increase But…
Outcomes Do Not Improve
Costs continue to escalate with little improvement in
outcomes
Major variations in the cost of care delivery vs.
patient outcomes
No substantial improvement in re-hospitalization
rates
High numbers of potentially avoidable events
Inadequate communication and coordination of
patient care
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Statistics Don’t Lie
Medicare hospital patients in 2006 – 2007, readmitted
for the same conditions that prompted their initial
hospitalization” (AHRQ 2010)
25%
Medicare hospital patients were readmitted in 30 days in 2009
20%
Medicare patients re-hospitalized within 90 days
34%
Medicare patients experiencing multiple hospital admissions
42%
(AHRQ, 2010).
Medicare patients experiencing multiple emergency
department (ED) visits. (AHRQ, 2010).
30-day Medicare readmission rates varied
(2009)
http://medpac.gov/documents/Jan11_RegionalVariation_report.pdf
38%
12.9%
Oregon
22.7%
D.C.
Statistics Don’t Lie
Medicaid patients experienced multiple hospital admissions
23%
Medicaid patients went to the ED more than once” (AHRQ,
50%
2010).
Hospitalized patients over 65 discharged to a long term care
or other institution
21%
Medicare SNF residents readmitted to the hospital
25%
Individuals with chronic conditions—may see multiple
physicians in one year
16 MDs
Medicare hospital patients in 2003 that saw 10 or more
physicians during their stay.
41.9 – 70%
Medicare patients readmitted within 30 days that do not
receive any post-discharge care before readmission
64%
Medicare patients readmitted within 30 days did not have a
physician follow-up visit
50%
Patients who have problems with medications
within the 1st week of discharge
70%
Cost Savings
Cost of hospital readmissions
$15 Billion Annually
Potentially avoidable hospital
readmissions
13.3%
Savings if potentially avoidable
hospital readmissions were
prevented
$12 Billion Annually
MedPac Findings
Capacity and supply of providers: Agency
participation is at record levels
In 2010, HHAs numbered more than 11,400 with a net
increase of 527 agencies.
“Number of agencies has exceeded the high watermark of
the 1990s, when the number of agencies exceeded 10,900.
The high rate of growth is particularly concerning because
new agencies appear to be concentrated in areas with
fraud concerns, including California, Texas, and Florida”.
Laff Associates 2011
MedPac Findings
Volume of services continues to rise
Beneficiaries without a prior hospitalization
account for a rising share of episodes
Changes in therapy distribution
“Providers target therapy visit thresholds used to adjust
home health payments”.
“Volume changes since implementation of PPS provide
evidence of providers targeting the ranges that appear
most profitable”.
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MedPac
Findings & Conclusions
Outcomes improve on functional measures but the rate of
adverse events is unchanged ?????
Payments increase by more than costs in 2009
Medicare continues to overpay for home health services
High margins for home health in 2011 reflect that payments
substantially exceed costs and that reductions and
administrative adjustments by CMS have not significantly
reduced payments.
Conclusion: overutilization and inadequate care
Encourage appropriate use of the home health benefit
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MedPac
Recommendations
1. Increase medical review in counties with aberrant home
health utilization; suspend payment and limit provider
enrollment.
2. Begin a two-year rebasing of home health rates in 2013 and
eliminate the market basket update for 2012.
3. Revise the home health case-mix system to rely on patient
characteristics to set payment for therapy and non-therapy
services; no longer use the number of therapy visits as a
payment factor.
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MedPac
Recommendations
4. Establish a per episode co-pay for home health episodes that
are not preceded by hospitalization or post-acute care use.
5. Modify the home health payment system to protect
beneficiaries from stinting or lower quality of care in
response to rebasing..
Laff Associates 2011
Method To the Madness…
Where is CMS going and will YOU be there when they
get there?
Cost Reimbursement 1999
PPS 2000
Home Health Compare - 2003
PPS Refinement 2008
RAC and ZPIC audits – 2009
OASIS – C – process measures - 2010
Billing code changes - G Code additions – 2011
Face to Face visits at SOC and therapy thresholds
Diagnosis coding – ICD-10 - 2013
PPS Refinement 2013? 2014?
Value Based Purchasing – 2013?
Laff Associates 2011
Can You Afford
The Affordable Care Act?
ACA Establishes:
Hospital Readmissions Reduction Program
Hospital Value-Based Purchasing program and plans
for a home health and skilled nursing Value-Based
Purchasing program
Medicare Shared Savings Program (Accountable Care
Organizations)
Heart Failure
Heart failure is the most common diagnosis
associated with 30-day readmission among Medicare
beneficiaries (Hernandez et al., 2010).
30-day readmission rates for heart failure patients
have increased while LOS decreased
In-hospital mortality rates have decreased
Less marked reductions in 30-day mortality rates
Hospital
Value Based Purchasing
ACA – will reduce hospital payment in 2013 for
Medicare admissions by 1% if hospital readmissions
are above national average for AMI, Heart Failure
and Pneumonia beginning with discharges on or
after Oct. 1, 2012.
Penalties to hospitals will increase to 3% in 2015
What happens in the acute care setting will happen
in home care!
Affordable Care Act (ACA)
Facilitate care transitions across the continuum to;
Optimize choice and control of services
Ensure that decisions are based on patient needs
Provide coordinated, high quality care with seamless
transitions between settings
Reward excellence - pay for quality measures- P4P (VBP)
Recognize role of family care giving
Utilize health information technology
Improve Patient Safety
Promote Evidence Based Best Practices
Focus on Error Prevention -PAE
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Manage Smarter
Clinical Management Information
Key Indicators
Routine Reports
Education
Clinical assessment
OASIS Accuracy
Supervision & Oversight
Documentation Timeliness
Care Plan Development
Continuity
Case management
Clinical model
Accountability/ Responsibility
Reward / incentive
Corrective Action
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Manage Smarter
To be profitable, management must:
—Know what it costs to provide services — by discipline
—Monitor and manage ALL aspects of agency operations
from intake to billing
—Create appropriate efficiencies
—Prevent redundancy and unnecessary hand-offs
—Promote standardization for entire agency
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Smart Moves
Patient Centered Care
Patient Outcomes at or above state and national averages
Best Practice implementation
“Right-size”
May or may not add or eliminate positions
Focus on function and responsibility
Invest in people
Right person for the position
Invest in education
Eliminate “warm body syndrome”
Stop “fixing”
Implement and integrate Telehealth
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Accountability
Primary case management –
Clinician – with F2F contact
May be RN or PT
Must be accountable for patient and financial outcomes
Accurate assessment
Appropriate care plan
Constant knowledge of;
Goals of care
Projected visits vs. actual
Team performance – Therapists must be included in the team
Patient response to care
Need for change in plan
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Management Statistics
Case Weight
Case weight variance – SOC to EOE
EOE case weight
Re-certifications and LOS
Visit Utilization Averages
Ratio nursing/therapy
Actual Revenue versus Anticipated Revenues
Timeliness of RAP Submission
% of Therapy Visits per Threshold
Average visits per episode
Productivity by discipline - Actual # of Patients
Cases Managed per Clinician –
WHO IS REALLY MANAGING THE PATIENT?
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Management Statistics
OASIS Errors by Clinician
OASIS Corrections Completed
Outcomes Improvement
Patient Declines – actual or documentation?
Potentially Avoidable Events
Have you audited each of them?
What did you do to prevent them in the future?
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Smart Moves
OASIS Accuracy
Who is reviewing the OASIS?
Is that a primary function?
Is that individual qualified?
Manual review or Data Scrubber?
Duplicative functions
Corrections versus consequence….
Management oversight
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Smart Moves
Adequate education
Validate and reinforce
How do you know?
What checks are in place?
How long does it take?
Who is validating what?
Were the suggested corrections actually made?
What “tools” do you use?
Are there repeated errors? If so – WHY?
Repeated errors cost money
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Do You Ever
Have Enough Staff?
How do you know????
It depends……..
Clinical Model
Agency Size and Scope
Geography
Volume
Paper or Point of Care
Clerical versus Clinical Function
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When is Enough Enough?
The Clinical Director comes to you and says “I don’t
have enough nurses to see all these new patients.
What’s the first thing you do?
a. Call a temp agency
b. Put an add in the paper
c. Review statistics
Laff Associates 2011
Staffing-Statistics to Review
Number of ACTIVE patients on your census list
“Clean” census list
All discharges removed at least weekly
Identify why “old” patients remain
Expectations for staff productivity
Visits per day, per week
Actual performance of staff – how many actual unweighted visits per day did they perform last week?
Identify “weakest links” and investigate why….
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Standardize Productivity
Do you expect the same level performance from
each clinician?
If not – why not?
Are your expectations per clinician met?
Are they reasonable? Maybe too reasonable???
Do you use remote monitoring?
Do you monitor and enforce the expectations?
Are you using the “warm body approach?”
Is there a consequence for non-performance?
Laff Associates 2011
Set Realistic Expectations
Number of visits per day is dependent upon clinical
model
Do your field nurses case manage a census of patients”
If so – is the number consistent among your staff?
Do you have admission nurses?
Do you use a point of care documentation system?
How many miles does a clinician average per day/week?
How are they compensated?
How often are the patients’ care case conferenced?
Laff Associates 2011
You May Be At Risk If….
A review of operations and records indicates
presence of one or all of the following;
Many OASIS item inconsistencies
Large variance in SOC/EOE
DX Coding errors
Low EOE case weight
High LUPA rate
Higher than average therapy utilization
LOS average over 60 days / multiple re-certifications
Rotating primary DX
Skilled service provided to large % of patients is
“Observation & Assessment”
Laff Associates 2011
Smartest Moves…It Depends…
Primary Care Case Management
Clinician manages – 20 – 25 patients…it depends….
Effective use of Telehealth increase capacity
Responsible for entire episode of care
Responsible for outcomes
Don’t come into the office to get NRS
Adequate supervision
Supervision – primary responsibility
Ability to enforce process and policy for productivity, OASIS
corrections, appropriate care delivery
Laff Associates 2011
Smartest Moves
Productivity expectations
SN -Minimum average of 5 actual visits per day – 6 – 6.25
weighted visits
PT – Minimum average of 5.5 actual visits per day – 6.5
weighted visits
Supervisor/Manager – 1 per 5-7 FTEs (depends on function)
OASIS Reviewer – w/data manager - 75 - 85 patients
Adequate OASIS review process
Data management tool to decrease review time and
increase accuracy
Laff Associates 2011
Achieving Positive Financial Outcomes
Good clinical outcomes lead directly to good financial
outcomes!
Required ingredients
Strong clinical management and staff oversight
Field clinician responsibility and accountability
Consistent and continuing oversight of episode frequencies
and durations to achieve realistic outcome goals
Plan of Care consistently reviewed every 14 days!
Adjusted to medical necessity and realistic outcome goals!
Consistent use of the “data scrubber” in OASIS review
The annual cost will be covered within a week!
Efficient use of the field clinician resources – no office time!
Consider a “Weekender Program”
Laff Associates 2011
Achieving Positive Financial Outcomes
Gross profit issues
The majority of the direct cost/visit is compensation and
related taxes (staff and direct supervision)
The cost/visit of premium-based fringes is directly
proportional to visits made
The cost of mileage/auto reimbursement is directly related to
geographically sequential patient scheduling, the size of the
territory and a global vision of the entire week
An agency specific formulary and trunk supply protocol,
electronic ordering with independent oversight and patient
specific direct delivery reduces costs and increases
productivity
Laff Associates 2011
Weekender Program
Begins Friday at noon..ends Monday at noon
Friday admissions – patients with weekend follow-up visits
Monday morning conference call with weekday RNs
Converts Agency from 5 days/ week plus weekends
to 7 days/week
Frequencies spread over 7 days, not just 5 days
Do all weekend visits
Takes weekend on-call
Eliminates weekday staff weekend rotation and
compensatory time
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Weekender Program
Shares case management responsibilities with
weekday RN – patients with weekend frequencies
Weekend differentials apply
Considered full-time for Fringe Benefits
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Achieving Positive Financial Outcomes
Who owns the patient?
Using a combination of Admission and Visit RNs /LPNs
challenges both good clinical and financial outcomes
Lacks care consistency and continuity
Limited, if any, patient care oversight
Cause of patient dissatisfaction
Primary Care Case Management achieves all of the
desired patient care outcome goals and is the best
approach towards best financial outcomes
Completely integrates with incentive compensation for both
the field clinician and their immediate supervisor!
Laff Associates 2011
Achieving Positive Financial Outcomes
Align Clinical and Case Conference Models
with Compensation!
Incentive Compensation…
Determines ownership of the patient, resource utilization
and care oversight and outcomes achieved
Matches clinician responsibilities and achievements
Not based upon the length of time or just a fixed salary to
accomplish their patient needs
Reinforces consistency and continuity of patient care
Reduces the direct cost of care for those disciplines
Laff Associates 2011
Achieving Positive Financial Outcomes
Key Ingredients!
Effective Clinical Management (Supervisory) staff
Primary Case Management
Case Conference Model
Every Patient…Every 14 days!
Reviews prior 14 days utilization and outcome achievement
Plans next 14 days utilization and outcome goals
Tools for efficiency
Laptops with power cords to car power source and air-cards
Smart cell phones
Patient specific electronic ordering and delivery of NRS
Laff Associates 2011
Achieving Positive Financial Outcomes
Primary Care Case Managers are responsible for the:
Case Management of their patients
Primary visits, including admission, resumptions and
recerts, most follow-ups and the discharge.
Achieve the desired patient outcomes and HH-CAHPs
results
Self scheduling!
Places responsibility where it belongs
Provides for more autonomy and control of clinician’s
day…
Eliminates the cost of schedulers
Laff Associates 2011
Incentive Based Compensation
Compensates the staff for what they do, not for how
long it takes them to complete what they do!
Rewards efficiency, productivity, capacity and clinical
(HH-CAHP) outcomes achievement
Improves team chemistry…Encourages underperforming staff to improve or seek a successful career
elsewhere
Assures that clinicians meet and exceed individual
productivity and case capacity goals
Applies to Weekender staff
IT WORKS!
Laff Associates 2011
Incentive Based Compensation
Can apply to all disciplines, depending upon
patient census and discipline demand
Exempt status does not apply to LPNs, PTAs,
COTAs and HHAs (FLSA)
Most effective for RNs, PTs and OTs
– Supervisory responsibility
– Visits are Unique
– No portion of compensation is based on time
(Hourly)
Laff Associates 2011
Visit Weights
Visit weighting – Based the Requirements and
Complexities of completing OASIS C
–
–
–
–
–
–
Admission (evaluation) visit
Resumption visit
Recertification Visit
Discharge Visit
Follow-up Visit
Virtual Telephone Visit (Telehealth)
Laff Associates 2011
1.90
1.30
1.20
1.25
1.00
0.25
Questions Often Asked
( Visit Weight – Time Equivalents Based upon OASIS C)
Visits /Day
Follow-up
Admission
Resumption
Recert.
Discharge
Visit Value
1.00
1.90
1.30
1.20
1.25
5.00
96 minutes
1hr 36min
182.4 minutes
3 hrs 2min
124.8 minutes
2 hrs 5min
5.25
91.4 minutes
1hr 31 min
173.7 minutes
2hrs 54min
118.9 minutes
1hr 59min
109.7 minutes
1hr 50min
114.3 minutes
1hr 54min
5.50
87.3 minutes
1hr 27min
165.8 minutes
2hrs 46min
113.5 minutes
1hr 53min
104.7 minutes
1hr 45min
109.9 minutes
1hr 49min
5.75
83.5 minutes
1hr 23min
158.6 minutes
2hrs 39min
108.5 minutes
1hr 49min
100.2 minutes
1hr 40min
104.4 minutes
1hr 44min
6.00
80 minutes
1hr 20min
152 minutes
2hrs 32min
104 minutes
1hr 44min
96 minutes
1hr 36min
100 minutes
1hr 40min
115.2 minutes
1 hr 55min
120.0 minutes
2 hrs
All times include hands-on, documentation, travel, conference and case management time
Incentive Based Compensation
Bonus structure for Primary Care Case Managers
Calendar quarter or 12 week period (based upon payroll
periods)
Accumulated Visit Weights = $ per hands-on visit for every visit
Total Cases Managed = % of earnings for the measured period
Outcomes Achieved = % of earnings for the measured period
Bonus structure for their immediate “supervisors”
Same as above, plus
Other to address problem areas, such as
OASIS error rates
Timeliness of corrections, etc.
Time to RAP and EOE billing
Laff Associates 2011
Case Study
Alterna-Care Home Health Agency
Located in Central Illinois
Main office located in
Springfield, IL with branches
in Jacksonville, and
Litchfield, IL
Serves over 2000 patients
annually in 31 contiguous
counties
Free-standing for profit
agency
Over 50 employees
Benefits of Incentive Compensation
Lost a nurse and didn’t have to be replaced
Improved communication with nurses and supervisor
Documentation is timely and better quality
Telehealth is being used more consistently and the
telephone follow up visits are visit weighted
Incentive compensation has improved ER and
Hospital outcomes
Incentive Compensation
Results
Nursing productivity increased
Timeliness of documentation improved. For the first time
anyone can remember, all nurses notes were completed
within 24 hours.
MD verbal orders and recertifications were completed on
time
Visit frequency orders were accurate
Case loads increased per nurse
Nurses made more visits per day and made more money
Monitors were in patient homes and no longer on the
shelves
Average Patient Caseload
2009 vs. 2010
2009 -7.5 nurses with an average monthly case load
of 36.3 (unduplicated patients)
2010 -6.5 nurses with an average monthly case load
of 44.9 (unduplicated patients)
(excludes PT only patients)
Visit Productivity
Average Visits Per Nurse
2009
Jan
Feb
Ma
Apr
Avg.
cases/RN
22
21
22
24
28
Monthly
Undup.
Census
223
233
229
240
10
11
10
Avg.
Cases/RN
24
31
Monthly
Undup.
Census
216
9
No. of
Nurses
May Jun
July
Aug
Sept Oct
Nov
Dec
23
20
21
20
24
23
24
253
229
205
208
195
216
210
213
10
9
10
10
10
10
9
9
9
30
27
30
35
32
27
31
29
29
37
252
242
222
247
279
264
237
241
257
260
257
8
8
8
8
8
8
9
8
9
9
7
2010
No. of
Nurses
HHCAHPS
HHCAPS
HIGHER %
ARE
BETTER
% RANKING
Care of Patients
99%
92% (Top 8%)
Communications Between Providers and Patients
95%
90% (Top 10%)
Specific Care Issues
91%
82% (Top 18%)
% of Patients who Rated Agency 9 or 10
95%
83% (Top 17%)
% of Patients who would Recommend Agency
83%
56% (Top 44%)
Average Nurse 11 Month Salary
2009 - Average 11 month comp. was $ 38,412
2010 - Average 11 month comp. was $ 46,362
Increase of $ 7,950 = 20.69%
2009 - Total Per Diem comp was $ 31,022
2010 - Total Per Diem comp was $ 10,119
Reduction of $ 20,903 = 67.38%
2009 - Direct Cost per Nursing Visit - $ 79.71
2010 - Direct Cost per Nursing Visit - $ 63.90
Reduction of $ 15.81 = 19.83%
Incentive Compensation
Results
Nurses did not complain
Comments:
“I’m really working hard”
“It’s difficult to get your paperwork done with this many
patients”
“But, I’m not complaining”
Supervisor states nurses are content
No problem getting nurses to see patients on weekends!!!
No push back when given a new admission in their
territory!
Incentive Compensation
The Results
The Direct and Total Cost per Visit were substantially
reduced!
Visits per episode were effectively reduced
Incentive compensation increased efficiency
throughout the entire organization
Quality of patient care was positively impacted
Accounting department is able to bill timely
Clinical staff are rewarded for their hard work
Communication with clinical managers improved
Telehealth being utilized to its fullest capabilities
Effective Episode Management
Reduces episode cost, increases efficiency and
communication, and improves clinical and
financial outcomes
Integrates:
Clinical Supervisory Management and Oversight
Primary Care Case Management
Goals and Performance
Can enhance compensation and reward
excellent performance
Laff Associates 2011
Contact Information
Lynda Laff, RN, COS-C Pat Laff, CPA
Laff Associates
Consultants in Home Care & Hospice
Phone: (843) 671-4170
Email: [email protected]
Email: [email protected]
Website: www.laffassociates.com
Laff Associates 2011