Recipe for Sweet Transitions and Medicare Topics

1. Recipe for Sweet Transitions and Medicare Topics

2. MHCA Medicare Team Members Beth Branz, North Memorial Homecare and Hospice Vickie Brand, HealthEast Home Care Denise Edgett, HealthPartners Integrated Home Care Dori Finch, Superior Home Health Care Mary Jane Fraser, Allina Home and Community Services Deb Klein, Guardian Angels Home Care Deanna Hammond, Firstat Nursing Services Mary Riha, Fairview Home Care and Hospice Jennifer Stark, St. Lukes Home Health Services Sue Shampine, Presbyterian Homes Geri Wagner, All Homecaring

3. Introduction Many of us have accepted referrals where little information has been provided by referral source A half baked transition is a recipe for a disaster Presentation will provide the tools to enable your safe patient transitions during handovers in care

4. What are “Care Transitions”? “The movement of patients from one health care practitioner or setting to another, as their condition and care needs change”Eric A. Coleman, MD, MPH Can occur: within a specific setting (such as moving from ICU to a general care unit) between settings (hospital to homecare, homecare to ambulatory care; sub-acute facility to ALF) across health states (curative care to end of life care; independent community dwelling to ALF)

5. “Sweet” Transitions Goals Improve Safety Reduce risk of re-hospitalization Improve patient satisfaction Responsible stewardship of health care resources

6. Ingredients for “Sweet” Transitions: Sharing of crucial information, including clinical status, plan of care, patient goals, and preferences of patients, caregivers and family Agreement by and education of patient and family Procuring needed supplies, equipment, transportation Consistent processes insure coordination and continuity of care as patients transfer between locations, providers or levels of care

7. Results of “Half Baked” Transitions = Poor Outcomes Patient, caregiver or healthcare team unprepared Delays in initiating or resuming care Medication errors or wrong treatment provided Harm to patient- severe adverse events and delayed recovery Increased healthcare utilization, including acute care readmission, duplication in tests, procedures, etc Complaint/dissatisfaction of patients and caregivers Legal or regulatory action, litigation and harm to the reputation of care providers

8. Characteristics of a “perfectly baked” transition All information exchanged crucial to the transition, including plan of care and patient safety is relayed Patient, caregivers and healthcare team in agreement and prepared Elegance- timely transitions occur without gaps, duplication or incidents

9. Transitions to be Discussed Transition to Homecare Transition to Hospital or Sub Acute Facility Transition to Ambulatory Care Providers

10. Recipes for Sweet Transitions Homecare Regulatory and Accreditation Requirements

11. Bill of Rights and MN regulations • Homecare Bill of Rights #17. Right to a coordinated transfer when there will be a change in the provider of services • MN 4668.0160 subpart 4 Transfer of Client If a client transfers to another home care provider, other health practitioner or provider, or is admitted to an inpatient facility, the licensee, upon request of the client, shall send a copy or summary of the client’s record to the new provider or facility or to the client.

12. Medicare Requirements • 484.18 Patients are accepted for treatment on the basis of a reasonable expectation that the patient’s medical, nursing, and social needs can be met adequately by the agency in the patient’s place of residence • “Timely initiation of care”- within 48 hr of referral, unless otherwise ordered

13. Homecare Regulatory and Accreditation Transition Requirements Joint Commission Standard PC.02.02.01 Coordination is recognized as a major challenge in the safe delivery of care. Due to the rise of chronic illness and acuity, patients are likely to have a array of providers in a variety of health care settings. The most frequently cited root cause of sentinel events evaluated by the joint commission on accreditation of heath care organizations is communication.

14. Joint Commission Standards (continued) PC.02.02.01EP 1: organization maintains continuity in the way it shares and receives patient information with other providers of care treatment or services EP2: the organizations process for handoff , communication provides for the opportunity for discussion between the giver and the receiver of patient information. EP 17: The organization coordinates care, treatment or services within a time frame that meets the patient’s needs

15. Joint Commission Standards (continued) Standard PC 02.02.02 EP1:The organization maintains continuity in the way it shares and receives patient information with other providers of care, treatment, or services. EP2: The organization’s process for hand-off communication provides for the opportunity for discussion between the giver and receiver of patient information.

16. Joint Commission Standards (continued) Standard PC. 04.02.01: When a patient is discharged or transferred, the organization gives information about the care, treatment, or services provided to the patient to other service providers who will provide the patient with care, treatment, or services

17. Joint Commission Standards (continued) Standard PC. 04.02.01: EP 1: At the time of the patient’s discharge or transfer, the organization informs other service providers who will provide care…. To the patient about the following: The reason for the patient discharge or transfer A summary of care….., provided to the patient The patient’s progress toward goals A list of community resources or referrals made or provided to the patient

18. Joint Commission Standards (continued) Standard IM.01.01.01 • EP 1, 2 • The organization identifies the internal and external information needed to provide safe, quality care • The organization identifies how data and information enter, flow within , and leave the organization

19. Joint Commission Standards (continued) • Additional standards LD 03.02.01 EP 2,3,4 LD 03.04.01 EP 1,3,5 RC 01.01.01 EP 8, 13

20. Joint Commission Standards (continued) • Additional standards PC.04.01.01 EP 15 PC.04.01.03 EP 2 PC. 04.01.05 EP 1 LD. 03.02.01 EP 2,3,4 LD. 03.04.01 EP 1,3,5 RC. 01.01.01 EP 8,13 NPSG. 03.06.01 EP 3,4

21. Transition to Homecare Homecare is often asked to operate with limited patient information and physician involvement The transition from hospital/facility to home and the period immediately following is crucial to insure patient safety and care efficacy. Patients most vulnerable- error rates documented in up to 50% of transitions (Boling, 2009)

22. Dartmouth Study 1 in 6 Medicare patients re-hospitalized within 30 days Dartmouth study included 10.7 million Medicare patient Hospital Discharges from 2003-2009 Widespread and systematic failures cited in coordinating care for patient’s after they leave the hospital These findings underscore the need for hospital, the patient, the outpatient and in patient providers to work together in a coordinated fashion to make sure the patient receives the quality of care that minimize the risk for preventable hospital readmission Medicare penalize hospitals for high re-admission rates of targeted diagnosis beginning in 2012

23. Look familiar? “OK for homecare” “Continue previous meds” “Home nurse for wound care” “Home safety eval”

24. Home Health Referral – Crucial Information Date and time of referral/transfer Physician ordered start of care, if applicable Patient Demographics: Name DOB Gender Address Phone Caregiver/Emergency Contact Interpreter needs Power of Attorney

25. Home Health Referral – Crucial Information Providers: - Referral source and contact information - Attending physician and contact information - Specialists and contact information - Other community providers, such as county case managers, insurance case coordinator, if applicable

26. Home Health Referral – Crucial Information Insurance Information Name of insurance company Policy number Contact information if known HHA is responsible to verify details of home care coverage

27. Home Health Referral – Crucial Information Medical Information: Recent Clinic Visit Note/History & Physical/ Facility Discharge Summary Medication list Advance Directive/POLST( Physician order for life sustaining treatment) Treatment/ discipline Orders: examples labs, precautions, wound care specificity… Status of prescriptions, supplies/equipment needs

28. Home Health Referral – Crucial Information Medical Information: Follow up appointments Date/Documentation of the Medicare Face to Face Encounter, if applicable Other pertinent information as appropriate such as safety concerns, vulnerable adult issues, leaving against medical advice

29. Home Health Referral – Crucial Information Talking Points “The information you provide insures a safe transition for the patient” “The information we request is consistent with that of other community providers” HIPAA: sharing information for treatment is permitted

30. The “Unbaked” ReferralReferrals Not Admitted Referring facility discharge plan is home care services When this does not happen as planned then loop back to referral source HHA should have policy to define practice (see example policy)

31. Transition to Hospital or Sub Acute Facility Date and reason Meds and Allergies Primary Diagnosis Physician Precautions Advance directives/POLST

32. Transition to Hospital or Sub Acute Facility SBAR ( Situation, Background, Assessment, Recommendation) Situation: immediate needs of the patient Background: History 3. Assessment: Sensory (mental status, behavior, communication) Mobility ADL Pain, Respiratory, elimination GI & GU Skin, Nutrition Alteration in Coping/Spiritual Alteration in Family Processes/ Social Support 4. Recommendations: what needs to be followed up on?

33. Transition to Ambulatory Care Providers Progress of home care plan of care: still active or discharged from home care Up to date medication list Clinical status and progression while receiving home care Questions or concerns Contact information: home care staff, county workers, worker comp rep…

34. Summary Regulatory and Accrediting requirement for coordination of care at time of transition Dartmouth Study findings underscore the need for hospital, the patient, the outpatient and in patient providers to work together in a coordinated fashion to make sure the patient receives the quality of care that minimize the risk for preventable hospital readmission Dartmouth study included 10.7 million Medicare patient Hospital Discharges from 2003-2009

35. Medicare Topics HHCAHPS Observation Status HH Compare ICD 10 PECOS OIG Work Plan New Survey Therapy NOMNCF2F MEDPAC RAC

36. HHCHAPS • Home Health Consumer Assessment of Healthcare Providers and Systems • Medicare Certified Agencies with unduplicated census of fewer than 60 clients over 12 months can file for an exemption for 2013. • Publically reported April 2012 • Official website where you can view preview reports https:/homehealthcahps.org/ • HH Compare 3 composite measures • Care of patient (Q9, Q16, Q19 and Q24) • Communication between providers and patients (Q2, Q15, Q17, Q18, Q22 and Q23) • Specific care issues ( Q3, Q4, Q5, Q10, Q12, Q13 and Q14) • HH Compare: 2 global ratings • Overall rating of care given by HHA care providers (Q20)i.e. ranked as 9-10 • Patient willingness to recommend the HHA

37. Home Health Compare Outcome measures • Changes to publically reported outcome measures • No longer reporting improvement in incontinence • No longer reporting increase number of pressure ulcers

38. PECOS • Provider Enrollment Chain and Ownership System • Physician ordering home health must be enrolled in the PECOS file or future services may not be paid • Phase 1- the enrollment process, currently the claim will still be processed and paid • Phase 2- Implementation has been delayed. Future services will not be paid if the physician is not enrolled in PECOS • Recent MLN matters dated 1/20/12 (SE1201) regarding home health services • Home Health Agency (HHA) services may be ordered or referred by a Doctor of Medicine (MD), Doctor of Osteopathy (DO) or Doctor of Podiatric Medicine (DPM). Claims for HHA services ordered by any other practitioners will be denied

39. Revalidation • Affordable Care Act section 6401(a) require that all enrolled providers and suppliers to revalidate their enrollment • This revalidation is for all providers that were enrolled prior to March 25, 2011 • Notices are being sent to agencies already enrolled and the agency will have 60 days to respond • The agency will receive 2 reminder letters • Authorized official must sign off on the form this should match the original official who signed initially. If this official is no longer available the agency is to submit a change form • Penalty: • first layer is suspension of payment • once CMS received the letter it will take 3 business days upon receipt of the letter to release suspension • Website • https://www.cms.gov/MedicareProviderSupEnroll/11 Revalidations.asp

40. New Survey Guidelines • Focus on interview process esp. regarding patient care process • Standard Survey • CMS identified 9 of the 15 CoPs and highest priority standards called Level 1 standards are addressed in standard survey • Partial Extended Survey • Extended Survey • May be conducted at any time at the discretion of CMS • Must be conducted when any condition-level deficiency is found

41. RAC • Recovery Audit Contractor for MN is CGI, identify and correct under and over payments for Medicare FFS claims. • Is one of 5 claim review programs that review claims both before and after payment • RAC are beginning to release Home Health Issues, which are posted on the CGI web site • Home Health Agencies are beginning to receive RAC requests • Can not request the same patient’s information twice or review a claim previously reviewed by another entity. “ Look back” of claims is up to 3 years from the date claim was paid. • RAC request letters can be from CGI or from a sub-contractor • Have agency processes in place to quickly identify notifications or information received from RAC’s .Time limits on appeals, interest accruals on recoupment's • Have designated staff at each agency to be alerted immediately regarding RAC requests

42. Observation Status vs. In-Patient Admissions • Hospitals are receiving RAC requests re: 3 day hospital stays • Increase number of patients held in Observation status instead of full In-Patient admissions • Work with ACH partners to determine if Observation status vs. In-Patient admission • Patients can be held in Observation status for a number of days and never officially admitted as an In-Patient status • OASIS implications since a Transfer OASIS is not required if not admitted to In-Patient facility

43. ICD 10 and Oasis C 2 • All HIPPA “ covered entities are required to adopt ICD-10 CM/PCS codes. Implementation is anticipated for October 2014. Does not affect CPT or HCPCS codes. • Watch the CMS ICD 10 website for more details. • ICD-10 codes will be much more descriptive than ICD-9. The transition to ICD-10 is a major undertaking and will go more smoothly for agencies that plan and prepare. • Take steps NOW • Talk to billing service, clearinghouse or soft wear vendors • Review processes that could be impacted and ensure necessary training is performed

44. ICD 10 and Oasis C 2 continued To process ICD-10 claims, the version 5010 Electronic Health Transaction Standards, mandated by HIPPA had to be implemented first. Compliance date for 5010 was 1-1-2012 enforcement date extended to June 2012. Oasis C -2 more details to be released In August 2012. Anticipate and plan for staff training and education

45. OIG Work Plan 2012 • States’ Survey and Certification Process: Timeliness, Outcomes, Follow-up and Medicare Oversight • Medicare Oversight of Home Health Agencies Patient Outcome and Assessment Data • Increase focus on oasis submitted within 30 days • Missing or Incorrect Patient Outcome and Assessment Data • Questionable billing characteristics of HHA services • HHA Claims’ Compliance with Coverage and Coding Requirements • Medicare Administrative Contractors’ oversight of HHA claims • Wage indexes used to calculate HH Payments • MA: looking at states who try to enforce HB criteria, dual eligible • OIG work plan 2012 website • http://oig.hhs.gov/reports-and-publications/archives/workplan/2012/Work-Plan-2012.pdf

46. MEDPAC Recent report to Congress Medical review activities in counties with aberrant home health utilization Two-year rebasing of the home health rates and eliminate the market basket rate for 2013. Recognized home care’s ability to improve functional status in non-hospitalized patients Revise the case mix system and eliminate the number of therapy visits as a payment Co-pay for community referrals, non post acute episodes. Also copay on second adjacent episode of home care services.

47. NOMNC • Notice of Medicare Non-Coverage • Release of new version Notice of Non Coverage March 2012.OMB-Approval # 0938-0953/ CMS Form-10123 • Combination form to cover both Medicare and Medicare/HMO plans • Agencies to utilize this form by May 2012

48. Face To Face Waiting for guidance regarding use with Medical Assistance patients Work with electronic medical records vendors as they are tweaking and making changes to systems to increase efficiency with face to face. January 2012 CMS Q&A clarification on how to handle late Face to Face Designate a champion at agency to assist with Face to Face

49. Therapy Functional Assessments Learning • Work with Electronic Record Vendors as they improve tracking mechanisms • Remember it is billable visits that are included in the count • Multiple therapy disciplines involved • utilize “close to but not beyond” threshold criteria • Single therapy discipline involved • assessment must be on the 13th and 19th visits. • The “ close to but not beyond” guidance does not apply to single therapy service involvement • Minimal every 30 day assessment • Crosses over certification time periods

50. CMS New Innovation Center • CMS Innovation Center still expects to play an important role in new care delivery models and forging new payment • Accountable Care Organizations (ACO) • Demonstration projects are beginning • Health Systems are participating in the pioneer demonstration projects • Develop relationships with partners in order to prepare for ACO involvement • Value Based Purchasing • No new updates • Demonstration projects have been completed