Transcript The Value of Home and Community Based Service Organizations in

January 19, 2017
HHQI UP Network Webinar
Value of Home &
Community-Based Services
Transforming the Healthcare System
& Improving Patient Outcomes
This material was prepared by Quality Insights, the Medicare Quality Innovation Network-Quality Improvement Organization
supporting the Home Health Quality Improvement National Campaign, under contract with the Centers for Medicare & Medicaid Services
(CMS), an agency of the U.S. Department of Health and Human Services. The views presented do not necessarily reflect CMS policy.
Publication number 11SOW-WV-HH-MMD-011917
UP Networking Event
 Value of Home & Community-Based Services: Transforming the
Healthcare System & Improving Patient Outcomes
 Guest Speakers from Alleghenies United Cerebral Palsy Service
Coordination:
• Tammy Rhoades, BA, CEO
• Tina Trimbath, RN, OT, BS
 Free 1.25 nursing continuing education credits (ANCC)
Value of Home & Community-Based Service:
Transforming the Healthcare System & Improving
Participant Outcomes
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AUCP began as a grassroots effort by a group of concerned parents looking
to find support for family members age 18 and up with both physical and
intellectual disabilities
A 501c3 organization located in Johnstown, PA that has been in operation
since 1955.
Serves as a Service Coordination Entity (SCE) in Pennsylvania providing
in-home, case management to individuals with disabilities, the elderly, and
those recovering from an injury or illness who may be in need of assistance
to remain in or return to their homes.
Most people who need long-term services and support want to live in their
own homes and communities for as long as possible.
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Cost effectiveness: Research has shown the cost effectiveness of HCBS.
Studies consistently showed lower average costs per individual for HCBS
compared to institutional care, usually less than half the cost of residential
care (according to CMS)
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Familiarity: Participants can enjoy the comfort of their own home or small
residential facility in the community
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Services: Medical and personal services to help with daily living tasks
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Care: Some waivers permit family members to be paid caregivers
The Pennsylvania Department of Human Services (DHS) defines
Community HealthChoices (CHC) as the delivery of Medicaid funded
long-term services and supports (LTSS) through a capitated managed
care program.
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DHS Plans to Implement CHC in Three phases:
Phase I, Southwest – Scheduled to begin January 1, 2018
Phase II, Southeast – Scheduled to begin July 1, 2018
Phase III, the balance of the state – Scheduled to begin January 1, 2019
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CHC-Managed Care Organization’s (MCO) are not required to
include all current Medicaid providers in their networks.
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There may be limits placed on how many providers the
MCO’s decide to include in their network and contract with.
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Organizations who contract with CHC-MCO’s may be
required to have different electronic medical record and billing
systems in place in order to effectively work with the MCO’s.
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Contracted providers will need to negotiate payment for
services with the CHC-MCO’s
Agency staff understand the importance of making Person
Centered Planning the main focus of each participant’s care.
Service coordinators take the time to learn about the needs of the
individuals, their strengths, preferences and life goals to
determine the best way to assist them in reaching their goals.
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Qualified and experienced service coordinator staff already located
and working throughout western and central Pennsylvania.
Financial literacy – Assisting participants to understand how financial
choices and behaviors affect individual goals including the
consequences that may occur as a result of these choices.
AUCP staff has built effective partnerships and relationships within
the communities they serve as well as having developed a
community resource guide for areas served.
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Emergency on call process to address issues 24 hours per day.
Report and track all incidents as well as providing preventative
measures in an effort to reduce the number of incidents.
Track number of hospital and ER admissions as well as any
repeat consumer admissions to determine the health outcomes in
order to improve and reduce future admissions.
Track any behavioral health diagnosis, medications and
treatments in order to assist consumers with continuum of care.
Track any consumer with wounds in an effort to ensure that the
consumer is receiving proper care in order to improve overall
health.
Track incidents of self-neglect and/or abuse to ensure the health
and wellbeing of the consumers.
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All service coordinators contact the consumers monthly by phone
and visit the consumers quarterly in their homes and in the
community.
Develop with the consumer a person centered plan (ISP) which
includes identifying emergency backup plan utilizing unpaid
caregivers.
Track any medical services that the consumer has going into the
home and get permission to speak with those agencies.
Communicate monthly with medical agencies in an effort to provide
continuity of care.
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Work with Durable Medical Companies to obtain medical
equipment for participants.
Identify consumers with at risk behaviors such as smoking with
oxygen to ensure that the participants are educated on the dangers
and this is done in conjunction with the Durable Medical Provider.
AUCP gets a copy of the documentation signed by the participant
that they have been educated.
RN on staff to assist with any critical incidents in a effort to ensure
participant health and safety.
Quality management checks are done quarterly and monthly to
ensure all is updated and accurate.
Create caseloads in a manner that ensures better management.
Created policies and procedures to identify risks.
 Created a risk assessment form completed quarterly to identify and
address risks both physical and environmental.
 Educate participants on the identified risks and provide mitigation
strategies as well as providing consumer choice.
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Monthly case conferences by a supervisor with the service coordinator
to identify issues and to assist in remediation.
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Dedicated staff to the Nursing Home Transition program to reduce
institutionalization.
AUCP has developed a comprehensive professional development
training protocol to meet state waiver program requirements as
well as AUCP’s agency requirements.
A significant portion of the professional development training provided
to AUCP employees is delivered by the Staff Development Trainer in
collaboration with Supervisors.
In most cases, AUCP utilizes the “train the trainer” model of delivering
professional development training. This method not only reduces
operational costs of employee time lost at work, but encourages
lifelong learning and continuing education credits among employees.
It also strengthens employee-to-employee working relationships by
having a peer employee serve as the facilitator of learning new or
changing service methodologies, government requirements, or other
industry-related trends.
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HCBS waivers and programs
Eligibility requirements and assessment forms
HCBS enrollment and eligibility process
HCBS participant-centered service plan development process
Cultural sensitivity/Cultural diversity
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Crisis management/Compliant management
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Customer service and communication skills
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HIPPA Privacy and Security training, confidentiality regulations, and
Medical Assistance confidentiality requirements
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HCBS delivery system – Nursing Home Transition (NHT) and Money
Follows the Person (MFP) initiatives
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Department of Human Services (DHS) Person Center Planning
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Differing geographically-based needs for rural vs. urban settings and the
challenges and opportunities faced by participants in each area
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Unique aspects of OLTL’s (Office of Long Term Living) participant groups and
the service needs associated with various types of disabilities and which waivers
or programs provide services targeted to each specific type of disability or age
group
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Understanding the services available through each of the covered HCBS waivers
and programs; such as available models of service
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Collaboration of internal/external stakeholder groups involved in the enrollment
process and service delivery including, but not necessarily limited to : Area
Agencies on Aging (AAA’s), Service Coordinators (SC’s), County Assistance
Offices (CAO’s), NHT Coordinators, and regional LINK entities
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Understanding the role of the mandated reporter, as required by the
Commonwealth’s Older Adult Protective Services Act ad Adult Protective
Services Act
Bachelor’s Degree in social Work or Equivalent
 Prefer that staff have resided within the local community for
2+ years
 Knowledge of culture and values in the local community
 Familiarity with the resources available within the community
 Field Based experience
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Confidential and Sensitive Information
AUCP protects the confidentiality of patient, client, provider and
Departmental records in compliance with Federal and State laws,
regulations and policies. AUCP agrees that any breach of this
provision may result in termination of the contract (s).
All personnel comply with the Health Insurance Portability and
Accountability Act (HIPPA) and sign a copy of the HIPPA policy.
A copy is provided to the employee and one copy is filed with the
employee’s personnel file.
Additionally, each new employee hired by AUCP is required to
submit to a thorough and comprehensive background check.
AUCP covers the cost of the background check for each
employee.
Documents to be completed upon hire include
1. Pennsylvania Child Abuse History Clearances (CY113)
(recertified annually)
2. Pennsylvania Criminal Record Checks (SP4-164) (recertified
annually)
3. Federal Bureau of Investigations (FBI) Criminal Background
Checks (renewed annually)
4. Federal Bureau of Investigations (FBI) Fingerprinting
5. Medicaid Fraud Check (completed monthly)
A Quality Management Plan (QMP) is utilized to manage the
quality of services provided by Alleghenies United Cerebral
Palsy. A focus on quality is important in order to meet or exceed
participant expectations and to assure the health & safety of
AUCP participants. AUCP utilizes the following methods to
meet quality standards:
The QMP plan assists Alleghenies United Cerebral Palsy staff in actively
achieving the agency’s mission to assist children, youth, and adults with
disabilities in meeting their basic needs, enhancing their quality of life and
promoting their independence, while also allowing them to be active
participants in decision-making and the direction of service.
 Monthly binder and service note review to ensure compliance with OLTL
regulation
 Monthly participant phone calls and quarterly home visits
 Ensure participant satisfaction with annual surveys; follow up on results to
make suggested improvements
 Incident management in order to reduce the number of overall incidents
 Employee retention and satisfaction
 Quarterly Quality Improvement Committee meetings
All staff is trained annually on the QMP and as needed when the QMP is
revised/updated. The QMP is reviewed and updated on a quarterly basis in
order to promote agency performance.
AUCP recognizes the importance of data tracking in order to drive better
quality of care and improved outcomes. These efforts assist the agency by
providing important benchmarks for quality improvements.
AUCP has identified the following as significant for improving consumer
health & safety:
Incident/Risk management (hospitalizations, ER visits, falls, abuse and
neglect)
 Number and type of incidents
 Repeat incidents per consumer
 New condition or diagnosis
 Decline or change in consumer condition
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Changes to overall Person Center Plan (decrease or increase to
services)
Medication changes
Offer preventative measures or education materials
Follow up phone call to participant or visit as needed
Develop Individual Action Plan to assist participant in mitigating
identified risk
Obtain Consent to Release from participant
Reduction in hospital readmissions
Reduction in number of ER visits
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Over the last three years we have been tracking the number of reported
hospitalizations/ER visits with a goal to reduce these admissions through
education and an increase in home care as needed.
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The agency RN and staff have developed a resource library to educate the
participants on specific diagnosis's in an attempt to improve overall health
and reduce admissions.
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Information on area Urgent Care Centers and Out-Patient Clinics were
provided to participants who had ER visits along with education regarding
when it may be more appropriate to use the Emergency Room vs. an Out
Patient/Urgent Care Center.
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Identified at risk participant
Current treatment
Medications
Professional services
Interruption of waiver services & physical health services
Attempt collaboration with providers
Create Person Center Plan to support behavioral needs
Develop Individual Action Plan to assist participant in mitigating
identified risk
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Identified at risk individuals through Person Centered Planning (ISP)
Work in collaboration with other medical professional to ensure plan of
care
Work with participant to ensure follow through of the treatment plan
Obtain Consent to Release from the participants
Gather monthly treatment reports
RN reviews monthly
Work with consumers in effort to ensure treatment plan is followed
If consumer refuses to follow treatment Plan implement Individual Action
Plan and report to appropriate parties
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Annual survey
Follow up with participants on any identified issues
Monthly phone contact with participant
Complaint process
Tracking of all complaints and resolution
AUCP is experienced with, and currently accesses, all of the following
DHS systems:
1. The Home and Community-Based Services Information System
(HCSIS), the information system used to maintain consumer records
centrally.
2. The Social Administration Management System (SAMS), the
information system used to maintain consumer records centrally for the
Aging Waiver
3. The Provider Reimbursement and Operations Management
Information System (PROMISe), the Department’s claims processing
and management information system.
4. The Commonwealth of Pennsylvania Access to Social Services
(COMPASS), an online application for Pennsylvanians to apply for
many health and human service programs.
5. The Client Information System (CIS) which uses on-line and batch
programs to collect, process, and store client data used to determine
eligibility for TANF, Food Stamps, Medicaid, the SSI-State
Supplement, and State General Assistance.
6. AUCP agrees to adhere to the Information Technology Policies
(ITP’s) issued by the Office of Administration, Office for Information
Technology (OA-OIT); and the DHS Business and Technical Standards
created and published by DHS/CMS.
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What is the agencies mission statement?
Is the agency accredited or licensed?
Is the agency a qualified provider in the state? If not, due to what
infractions?
What safety measures and assurances does the agency have in place to
protect participants and their rights?
What are the required qualifications of the staff and what types of on-going
trainings are provided to maintain the highest possible quality standards?
Is the agency respected in the community it serves?
What connections does the agency have to supporting organizations in the
community?
Does the agency have a 24-hour emergency on-call policy?
How many participants does the agency serve?
 What is the Case Manager to Participant ratio?
 Is participant satisfaction monitored and if so what is the approval rate?
Our success as a service coordination agency stems from our expertise
in delivering high quality, compassionate, person-centered case
management services in a cost effective manner.
We strive to create a positive relationship with our participants. We
work with agency nurses and physicians, as well as behavioral health
professionals involved in our participant’s care to keep them healthy
and out of the hospital. We provide education on various disease states,
suggest preventative measures for improved outcomes and provide
services aimed at improving health, preventing injury and enhancing
the overall quality of life for those we serve.
www.scalucp.org
Tammy Rhodes - [email protected]
Tina Trimbath - [email protected]
Questions?
HHQI Resources
 Underserved Populations Best Practice Intervention
Package (BPIP)
 Fundamentals of Reducing Hospitalizations BPIP
Simple Tips for Creating Health Care Collaboration
(located in the UP BPIP on page 22)
Understand Partners
Deliver
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Determine who you wish to become your
partner including community programs
(think out of the box)
Find out if any partners are involved or
thinking about new initiatives such as Patient
Centered Medical Homes, Accountable Care
Organizations (ACOs), Care Transitions
(CCTP), etc.
Learn their values, mission & goals
Discover their current priorities
Inquire about their current needs and wants
Offer
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Determine what you can provide to improve
outcomes
Discuss common goals, missions, & projects
Offer solutions to their needs and wants
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Be open and share information to set the
tone
Make sure you deliver everything you
promised in a timely manner
Deliver more than you promised
Communication
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Use care to communicate clearly and
effectively
Brush up on communication strategies
Determine best approaches for
communications (e.g. e-mail)
Follow-up oral communications
in writing
Ask for clarification
if unsure
Summarize after action
conference calls
Next UP Networking Event
 Patient Safety: All in a Day’s Work!
First Steps to Meet the New Home Health CoPs
– April 20, 2017 2-4 pm (ET)
– Tina Hilmas, RN, BSN, Project Manager
– Subscribe to HHQI’s mailing lists to be among the
first to know as soon as more details are available
Continuing Education
 Corresponding course in HHQI University
 Free continuing education credits (1.25 hours)
– Nursing CEs (ANCC)
 Requirements
– Watch this webinar (1 hr)
– Register for the course
– Complete the evaluation (15 min)
– Download & print your certificate
 Contact [email protected]
with any questions
Continuing Education Steps
Follow these steps to get your CE certificate:
1. Register/log in to HHQI University. You will be automatically
redirected to the HHQI University website when you exit this webinar.
Continuing Education Steps
2. Click on the Value of Home && Community-Based Services course in
the Underserved Population course catalog.
3. Click on Enroll under the
icon.
4. Click on My Account
to launch the course.
5. Click on the
icon next to the course in the View column.
Continuing Education Steps
6. Click on the
icon in the Action column next to Lesson 1.
• Complete the Value of Home & Community-Based Services lesson with
evaluation
7. After completing the evaluation, you can print your certificate from
the My Account area in HHQI University.
• Click on My Account on the black menu bar.
• Your certificate will be in the My Certificates area on the left side of the screen.
Thank You!
[email protected]
www.HomeHealthQuality.org
This material was prepared by Quality Insights, the Medicare Quality Innovation Network-Quality Improvement Organization supporting the Home Health
Quality Improvement National Campaign, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of
Health and Human Services. The views presented do not necessarily reflect CMS policy. Publication number 11SOW-WV-HH-MMD-011917