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Achieving Optimal Clinical Management and Financial Balance. Pat Laff, CPA, Managing Principal Lynda Laff, RN, BSN, COS-C, Principal. OASIS-C… Fast Track to P$P. Federal Register/Vol. 74, No. 44, Monday, March 9, 2009
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Achieving Optimal Clinical Management and Financial Balance Pat Laff, CPA, Managing Principal Lynda Laff, RN, BSN, COS-C, Principal
OASIS-C…Fast Track to P$P • 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. • New Process Measures - • 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. • 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
Clinical Episode Management Goal • “Provide the right amount of care efficiently and effectively to achieve anticipated or desired patient & financial outcomes”
Human Resources… • Make sure you have the right people in the right positions • All registered nurses are NOT case management material • A warm body doesn’t cut it! • All PTs are NOT team players…. • An experienced nurse is not always a qualified coder or quality review nurse… • An excellent field clinician is not always an excellent manager • A scheduler is NOT a manager of patient care
Components of Clinical Episode Management • Clinical Management Information • Key Indicators • Routine Reports • Education • Clinical assessment • OASIS Accuracy • Supervision & Oversight - Vigilance • Documentation Timeliness • Care Plan Development • Continuity • Case management • Clinical model • Accountability/ Responsibility • Reward / incentive • Corrective Action
Key Management Indicators • 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 • Outcomes Improvement • Patient Declines • Productivity by discipline - Actual
Education • 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! • 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
Oasis ACCURACY IS THE KEY 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
CMS - Value Based Purchasing Currently hospital payment is contingent upon; Aggregation of performance with process measures, patient care measures and patient satisfaction measures (HCAHPS) Home Health Care P4P OASIS-C provides Home Health Care P4P information Outcome Measures Process Measures Implementation of – HH-CAHPS
Cardiac Status (M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the previous OASIS assessment? ⃞ 0 - No [ Go to M2004 at TRN; Go to M1600 at DC ] ⃞ 1 - Yes ⃞ 2 - Not assessed [Go to M2004 at TRN; Go to M1600 at DC ] ⃞ NA - Patient does not have diagnosis ofheart failure [Go to M2004 at TRN;Go to M1600 at DC Time Points: Transfer/D/C Laff Associates 2009
Heart Failure Follow Up (M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond? (Mark all that apply.) ⃞ 0 - No action taken ⃞ 1 - Patient’s physician (or other primary care practitioner) contacted the same day ⃞ 2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room) ⃞ 3 - Implemented physician-ordered patient-specific established parameters for treatment ⃞ 4 - Patient education or other clinical interventions ⃞ 5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.) Time Points: Transfer/D/C Laff Associates 2009
(M2250) Plan of Care Synopsis: Does the physician-ordered plan of care include the following: Time Points: SOC/ROC Laff Associates 2009
(M2400) Intervention Synopsis: Since the previous OASIS assessment,were the following interventions BOTH included in the physician-orderedplan of care AND implemented? Time Points: Discharge/Transfer (M2400) Intervention Synopsis: (Check only one box in each row.) Since the previous OASIS assessment, were the following interventions BOTH included in the physician ordered plan of care AND implemented? Laff Associates 2009
Supervise and Manage • Education without validation and reinforcement is Money down the drain! • 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
Supervise & Manage • Average case weight – by month and by clinician on EOE • Clinician productivity – actual 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 or percent of OASIS errors • Number of OASIS corrections actually made (are you accepting excuses?) • LOS higher than national benchmark • Number of patient improvements & declines
Continuity • Continuity = patient management • Admission Nurse Model • Hand-offs = errors • The more staff involved – the less the accountability • Clinical model must insure actual case management • Primary nursing • Adequate ratio of nurses/therapists to patients • Productivity expectations must be reasonable
Accountability • Primary clinician • 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
Case Conference • Review of patients on census – not a 2 hour meeting! • Expect clinician to be prepared • Manager must question; • 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 • Extraordinarily low case weight
Clinical Efficiency And Effectiveness • Learn to be efficient AND effective • Higher base rate of $2,312.94 • Provide care the patient really needs! • Focus on newest technologies • Improve clinical knowledge, skills and practice
Operational Efficiency Think “Process” • Accurate Care Planning • Right number of home visits – no more – no less • Efficient workflow processes • 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 • Use of Tele-monitoring • 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
Start The Episode On Top • 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…
Elizabeth Allen Elizabeth Allen is an 85 year old woman who was admitted to home care following hospitalization for an ORIF due to a hip fracture as a result of a fall at home. She has insulin dependent Diabetes Mellitus, she had an acute exacerbation of COPD while in the hospital and the MD stated she also had Mild Senile Dementia. She was referred to home care for surgical wound care for an infected surgical wound, 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. She will be seen by nursing for daily dressing changes to her surgical wound, 3xwx4 by therapy for transfer training, gait training, strengthening and ambulation.
OASIS EDITS - P4P The Quality Review staff identified the following issues; • M1342 was a score 3 (Non Healing Surgical Wound) and there was no diagnosis listed in M1020 or M1022 to support the (complicated) non-healing surgical wound • ICD-9 496.00 is a general DX with no associated points for revenue. Her hospitalization information indicted an acute exacerbation of chronic bronchitis (COPD). • ICD-9 290.00 DX is a non-specific general code with no associated case mix points and her MD stated she had stated that she had senile dementia. • An inconsistency was identified with a score of 2 at M1700 and a score of 1 at M1740 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.
OASIS EDITS - P4P • The Quality Review staff discussed the patient with the clinician and the intake nurse; together they determined that wound care for the infected wound was the primary reason the patient was referred; physical therapy was the additional reason for the referral. • M1020 should be a non-healing surgical wound DX. They also discussed the diagnoses of COPD and Dementia with the intake staff and reviewed the referral documentation that indicated an acute exacerbation of CHF. They also noted that the MD has specifically indicated the patient had senile dementia, a DX with associated case mix points. They discussed the DX with the clinician and suggested a change in the DX codes. • They reviewed the scoring inconsistencies with the clinician and the clinician corrected the OASIS to reflect a score of 1 at M02020 (management of oral meds) and M2030 (management of injectable meds). • 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. • With OASIS accuracy - look what happened to the episode revenue….
OASIS Edits/Corrections = Revenue • Let’s Recap the Change After Editing: • Change in the HHRG due to ↑in clinical points • C2 F3 S5 to a C3 F3 S5 • $4,102.46 to = $4,490.11= + $387.65 • Change in NRS Revenue • Severity Level 2 to Severity Level 4 • $51.96 to $211.69 = + $159.73 • Total additional revenue $547.38
Clinical Episode Management Goal • “Provide the right amount of care efficiently and effectively to achieve anticipated or desired patient & financial outcomes”
Clinicians and Finance…A Language Apart • Patient Outcomes vs. Bottom Line • Home Health Compare Scores vs. Unit Costs • Case Weights vs. Realized Revenue • Diagnosis (Disease) Management vs. Episode Costs
Clinicians and Finance…A Language Apart Clinicians learned financial language quicker than Finance has been learning clinical language and operations because Clinicians already understand that: • Accurate assessments generate the most appropriate Case Weights that translate into revenue • Good outcomes with fewer visits reduces costs • Productivity, increased case capacity and efficiency result in lower unit costs • Better Home Health Compare scores will mean increased revenue under Value Based Purchasing
Clinicians and Finance…A Language Apart As a CFO you need to understand the Bottom Line Impact of… • Disease Management…the most appropriate disease specific levels of care • Patient Case Management…the most appropriate frequencies and duration of visits by discipline • Primary Nursing Model…OASIS C implications and the consistency and continuity of care • Positive Outcomes and Home Health Compare Scores..VBP • Staff Satisfaction…Positive Outcomes and recognition are a “feel good”! Knowledge is Everything!
Clinicians and Finance…A Language Apart How much time has your finance staff spent • In the field with Clinicians making visits? • Have the CFO make an admission visit with a clinician! • At patient staff meetings to learn and truly understand the ongoing care planning process? • Really trying to understand OASIS C? IT IS advanced rocket science! • Understanding documentation requirements and the time required? • Point of Care technology? • Travel patterns
Clinicians and Finance…A Common Language Clinicians and Finance have to listen to each other and understand what is being said! • A sincere willingness to learn • A willingness patiently teach without being condescending • Improvement in the levels of understanding is critical
Clinicians and Finance…A Common Language The Clinicians generate the revenue and determine the related unit expense components. They should understand: • What contributes to Direct Costs of their discipline and those they case manage, and • What comprises Indirect Costs, over which they have little control
Clinicians and Finance…A Common Language The Finance staff need to learn and understand: • Differences in visits (and OASIS C) and how they effect per visit costs • Admission • Follow-up • Recertification • Discharge • How different diagnoses effect the length of a visit and the documentation requirements • How visit frequency factors and diagnostically specific standards of practice effect productivity, efficiency and costs per visit and episode of care
Necessary Financial Drilldowns • Revenue Recognition as Costs are incurred • Identify Accurate Direct Costs by Discipline, Supply and Tele-health day • The Measure of Average Visits by Discipline and Supply Use by Diagnosis and Cost
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