Transcript Achieving Optimal Clinical Episode Management

Financial Manager’s Conference
July 2009
 “Provide
the right amount of care
efficiently and effectively to achieve
anticipated or desired patient &
financial outcomes”
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Clinical Management Information
◦ Key Indicators
◦ Routine Reports
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Education
◦ Clinical assessment
◦ OASIS Accuracy
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Supervision & Oversight - Vigilance
◦ Documentation Timeliness
◦ Care Plan Development
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Continuity
◦ Case management
◦ Clinical model
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Accountability/ Responsibility
◦ Reward / incentive
◦ Corrective Action
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Case Weight
Timeliness of RAP Submission
OASIS Errors by Clinician
OASIS Corrections Completed
Cases Managed per Clinician
% of Therapy Visits per Threshold
Average visits per episode
Outcome Improvement
Patient Declines
Productivity by discipline - Actual
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OASIS education must be thorough, credible and
ongoing
 The cost to educate properly will be a fraction of the
dollars you will lose… if you don’t!
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OASIS accuracy or inaccuracy goes right to the
bottom line.
Put your money where it will have the most effect..
 SOC assessment determines revenue and outcomes
 Value Based Purchasing – SOC = risk adjustment
 Declines will be even more expensive in P4P
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Federal Register/Vol. 74, No. 44, Monday, March 9, 2009
◦ CMS ultimately plans to create a standard patient assessment that can
be used across all post-acute care settings.
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New Process Measures -
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OASIS – C was not intended to impact payment policy and OASIS items
used in the payment algorithm were assessed to make sure they were
not changed in a way that would affect the payment algorithm. Once
OASIS data are collected it will be possible to assess whether they
could be useful for refinements to the case mix adjustor.
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All information in OASIS –C will be considered for use in the updated
risk-adjusted models that will be applied to OASIS – C based outcome
measures in Home Health Compare, OBQI and OBQM measures.
OASIS –C: Public comments & Responses
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OASIS accuracy is a key driver of clinical and
financial performance
OASIS – C is the New Key Driver for payment
under Value Based Purchasing
 Clinician assessment accuracy is critical to patient outcome
improvement AND agency financial success
 Clinician assessment determines case weight and revenue
 Clinician assessment determines non-routine supply revenue
 Clinician assessment and completion of OASIS - C process
items will affect aggregated score for VBP
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Currently hospital payment is contingent upon;
◦ Aggregation of performance with process measures,
patient care measures and patient satisfaction
measures (HCAHPS)
◦ Build on the foundation of the current Reporting of Hospital
Quality Data for Annual Payment Update (RHQDAPU) Program
◦ OASIS-C provides Home Health Care P4P
information
 Process Measures
 Patient Outcome of Care Measures
 Patient Satisfaction Measures
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New Process Questions;
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Influenza Vaccine
Pneumococcal Vaccine
Pain Assessment and mitigation
Pressure Ulcer Risk Assessment
Heart Failure Assessment and Follow Up
Depression Screening
Fall Risk Assessment
Hospitalization Risk Assessment
Patient / Caregiver High Risk Drug Education & Intervention
2008 © California Association for
Health Services at Home (CAHSAH)
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Plan of Care Synopsis - Interventions
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Vital sign parameters
Diabetic Foot Care
Falls prevention
Depression intervention
Pain mitigation
Pressure ulcer prevention
Pressure ulcer treatment
2008 © California Association for
Health Services at Home (CAHSAH)
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Flow sheet or software “flagging” will be necessary
for Process Items
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Documentation of Influenza Vaccine
Documentation of Pneumococcal Vaccine
Pain assessment score
Pain intervention and mitigation
Diagnoses of Heart Failure. Pressure Ulcers or Diabetes
 Assessments
 Interventions
◦ Depression screening score
 Depression medication and/or care planning
◦ Fall risk assessment
 Interventions
2008 © California Association for
Health Services at Home (CAHSAH)
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Education without validation and reinforcement is
Money down the drain!
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How do you know?
What checks are in place?
How long does it take?
Who is validating?
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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Average case weight – by month and by clinician
Clinician productivity – visits not equivalents!!!
◦ Expected versus actual
◦ Number of patients managed by case manager over time
◦ Total number of admissions (weekly, monthly)
Documentation timeliness
Documentation accuracy
Average visits per patient within national benchmark or
better
Outcomes better than state & national benchmark
Number of OASIS errors
Number of OASIS corrections actually made
LOS higher than national benchmark
Number of patient improvements & declines
Continuity of care isn’t just a “nice” clinical
term!
 Hand-offs = errors
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◦ The more staff involved – the less the accountability
Clinical model must insure actual case
management
 Primary nursing
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◦ Expect critical thinking and accountability
◦ Reward good performance
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Primary clinician
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Must be accountable for patient and financial outcomes
Accurate assessment
Appropriate care plan
Constant knowledge of;
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Goals of care
Projected visits vs. actual
Team performance
Patient response to care
Need for change in plan
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Review of patients on census – not a 2 hour
meeting!
Expect clinician to be prepared
Manager must question;
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Clinician “does not know patient”
“Cookie cutter” scheduling
Visits never increase or decrease – always a 60 day episode
Patient declines occur frequently
Abundance of “missed visits”
LOS longer than national benchmark
Case weight extraordinarily low
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Learn to be efficient AND effective
◦ Lower base rate of $2,270.32
◦ Dollars are spread over more visits and time
 Provide care the patient really needs!
 Focus on newest technologies
 Improve clinical knowledge, skills and practice
Think “Process”
 Accurate Care Planning
◦ Right number of home visits – no more – no less
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Efficient workflow processes
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Use of Tele-monitoring
◦ Focus on doing it right the first time – not constant correction
for poor performance
◦ Don’t duplicate work processes
◦ Right staff performing clerical tasks – time is money
◦ To identify incremental changes in the patient’s condition
 Intervene in a timely manner
 Prevent unnecessary hospitalizations
◦ To provide the right amount of CARE most efficiently and
effectively
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OASIS errors set the scene for negative revenue and
patient outcomes
Revenue and patient outcomes can not improve if
the initial episode is submitted incorrectly
Manage the patient care episode by teaching case
managers how to manage
Hold them accountable…
Here Is How An Incorrect OASIS Might Impact
Episode Revenue and Outcomes…
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Elizabeth Allen is an 85 year old woman who was admitted to home
care following a hip replacement due to a fall and resultant fracture.
She has insulin dependent Diabetes Mellitus, COPD and Mild Dementia.
She was referred to home care for surgical wound care, physical
therapy, supervision and management of her COPD and stabilization
and monitoring of her Diabetes and monitoring of her response to a
change in her insulin dose. Mrs. Allen lives alone but has a daughter
who lives 2 miles away and checks on her each day. She has been
independent in her home with daily checking and meal assistance from
her daughter and granddaughter until she fell and fractured her hip.
The initial assessment indicated that her surgical wound was dehisced,
not healing with minimal to moderate drainage. The nurse who
admitted Mrs. Allen (on a Friday) planned for 13 nursing visits, 4 daily
then QOD decreasing, 12 therapy visits and 11 home health aide visits.
SN 2w1, 5w1, 3w1, 2w1, 1w1 PT 3w4 HHA 2w1, 3w2, 2w1, 1w1
Diagnosis
Points
M0230 a V54.81 Aftercare hip replacement
0
M0240b
781.2 Gait Abnormality
0
M0240c
250.13 Diabetes Mellitus
2
M0240cd
496.00 COPD
0
M0240e
290.8 Dementia
0
Case Mix Variables
M0 250 IV Therapy
OASIS Score
Points
4
0
(None of the Above)
M0 390 Vision
0
0
M0 420 Pain
2
1
M0 450 Pressure Ulcers
0
0
M0 460 Most Problematic Pressure Ulcer
0
0
M0 476 Stasis Ulcer
0
0
M0 488 Surgical Wound
3
4
1
0
M0 540 Bowel Incontinence
0
0
M0 550 Ostomy
0
0
M0 560 Cognitive Functioning*
2
N/A
1
N/A
0
N/A
0
0
M0 490 Dyspnea
When walking 20 feet or climbing stairs
Requires assistance and some direction in specific situations
M0 610 Behaviors*
Significant memory loss so that supervision is required
M0 780 Oral Medications*
Able to independently take correct medications at correct times
M0 800 Injectable Drug Use*
Able to independently take the correct medications at correct times
Total Clinical Points
7
M0 650 / 660 Upper OR Lower Body Dressing
1
2
2
M0 670 Bathing
2
3
M0 680 Toileting
2
2
M0 690 Transferring
2
0
M0 700 Ambulation
2
1
Total Functional Points
8
Table 10 NRS Points = 14
C2 F3 S5
(Table 9) NRS Severity Level = 2
(Table 9) NRS Revenue = $51.00
(Table 5) Case Weight 1.7737
(Table 5) Revenue = $4,026.87
HHRG + NRS Revenue =
$4,026.87 + $51.00
Total Revenue = $4,077.87
1.
OASIS edits identified that M0488 was a score 3 (Non
Healing Surgical Wound) and there was no diagnosis
listed in M0230 or M0240 to support the (complicated)
non-healing surgical wound.
2.
The Quality Review staff discussed the patient with the
clinician and the intake nurse; together they determined
that wound care for the dehisced wound was the primary
reason the patient was referred; physical therapy was
the additional reason for the referral. M0230 should be a
non-healing surgical wound DX.
3.
OASIS edits identified ICD-9 496.00 to be a general DX
with no associated points for revenue.
4. Quality Review staff contacted the clinician who called the
MD’s office to request a more specific COPD DX
5. OASIS edits questioned the ICD-9 290.8 DX
6. Quality Review staff (again) contacted the clinician who
also requested more information about the patient’s
dementia.
7.
OASIS edits also identified an inconsistency of a score of 2 at M0560
and a score of 1 at M0610 indicating the need for assistance and
some direction in specific situations and the inability to recall events
of past 24 hours requiring supervision for some activities while her
OASIS scores indicated she was able to take oral and injectable
medications independently.
8.
Quality review discussed these inconsistencies with the clinician and
the clinician corrected the OASIS to reflect a score of 1 at M0780
(management of oral meds) and M0800 (management of injectable
meds).
9.
Without these corrections, outcomes in medication management
would potentially have declined; with the correction, outcomes will
remain stable (no decline) and P4P will not be in jeopardy.
Diagnosis
M0230a 998.83
(Skin 1)
Non-Healing Surgical Wound
Points (Table 2a)
10
M0240b V54.81 Aftercare for hip replacement
0
M0246b 781.2
Gait Abnormality
0
M0240c 250.13 Diabetes Mellitus
2
M0240d 491.20 COPD (Chronic Bronchitis) 1+1 Amb. Score 2
2
M0240e 331.2
Dementia
(Psych 2)
1
4
M0 250 IV Therapy
0
(None of the Above)
M0 390 Vision
0
0
M0 420 Pain
2
1
M0 450 2 or ↑ Pressure Ulcers Stage 3 or 4
0
0
M0 460 Problematic Pressure Ulcers
0
0
M0 476 Stasis Ulcer
0
0
M0 488 Surgical Wound
3
4
M0 490 Dyspnea
1
0
(Table 10) NRS Points = 37
(Table 3) HHRG Score = C3F3S5
(Table 9) NRS Severity Level = 4
(Table 5) NRS Revenue = $207.76+
+ $156.76
(Table 5) Case Weight = 1.9413
(HHRG Revenue + NRS $ = Episode Revenue)
$4,407.37 + 207.76 =
Revenue = $4,407.37
+ $380.50
Total Revenue = $4,615.13
+ $537.26
Let’s Recap the Change After Editing:
◦ Change in the HHRG
 C2 F3 S5 to a C3 F3 S5
 $4,026.87 to $4,407.37 = +$380.50
◦ Change in NRS Revenue
 Severity Level 2 to Severity Level 4
 $51.00 to $207.76 = +156.76
◦ Total additional revenue $537.26
 “Provide
the right amount of care
efficiently and effectively to achieve
anticipated or desired patient &
financial outcomes”