Home Care Alliance of Massachusetts Financial Management Conference December 9, 2010

1. Home Care Alliance of Massachusetts Financial Management Conference December 9, 2010 Meeting the Financial Challenges Of Implementing OASIS-C Pat Laff, CPA Managing Principal

2. OASIS-CIs Costing You More • Reduced Revenue and Increased Cost Factors are driven by: • Inadequate initial and continuing education • Supervisory personnel • Quality personnel • Field clinician personnel • Clinical Management Model • Case Conferencing Model

3. OASIS-CThe Key Issues OASIS-C is a moving target…… • Education of Clinical Staff • Supervisory • Quality • Field clinicians • Clinical Management Model • Case Conferencing Model • Incentive Compensation

4. Cost DriversEducation The Costs of Education…doing it right up front is far less costly! • “Train the Trainer” • Unless the “trainers” are RN, COS-C’s • Did the “trainers” remember all that was taught? • Did the “trainers’ teach all the they remembered? • Have there been timely and periodic follow-up sessions, including updates from latest Q&As?

5. Cost DriversEducation • Expert Teaching onsite (by RN, COS-C) • Private sessions provided to the entire staff • Staggered shifts including RNs and all therapists • Consistently delivered education content with Q&As • Timely follow-up as new CMS interpretations are revealed during monthly Q&As • Expertise developed internally at the Quality level • Educational tools provided to educate new staff • Continuing resource

6. Cost DriversOASIS-C Inaccuracy • Incorrect DX codes • May not be using a certified coder • Must have home care RN oversight to correctly use coding conventions and ensure presence of support for code • Other case mix items • Use a data scrubber to assist with OASIS inconsistencies • Cost is recouped by finding 1 or 2 inaccuracies

7. Cost DriversOASIS-C Inaccuracy • Reasons for OASIS inaccuracy include • Inadequate education • Clinical Management Model • OASIS workflow process • Therapist involvement and timing • Quality Review • Repeatedly “fixing” errors is more costly than doing it correctly • Case Conference Model

8. Cost DriversOASIS-C Inaccuracy 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 • Don’t forget…Value Based Purchasing is coming soon to your agency! Here Is How An Incorrect OASIS Might Impact Episode Revenue and Outcomes…

9. 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.

10. Elizabeth Allen Clinician Diagnosis Coding

11. Elizabeth Allen OASIS

12. Elizabeth Allen OASIS

13. Elizabeth Allen Functional Scores

14. Elizabeth Allen Revenue

15. Elizabeth Allen OASIS EDITS - VBP 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.

16. Elizabeth AllenCoding Corrections

17. Elizabeth AllenCoding Corrections

18. Elizabeth AllenCoding Corrections

19. Elizabeth AllenNo Change

20. Elizabeth AllenCoding Corrections

21. Elizabeth AllenOASIS 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

22. Questions Often Asked • Recommended Clinical Model: • Primary Clinician – Care Management • Recommended Clinicians to Supervisor • Up to 10 FTEs • Recommended Case Conference Model • Every 14 Days (voice to voice) from SOC date • Productivity and Case Capacity • RNs: minimum 25 – 27 visits (hands on) / week 25 – 30 Patients (without Telemedicine) • PTs & OTs: minimum 27 – 30 visits (hands on) / week

23. Educate Managers • Home Care Management (including Supervisors) must have a solid understanding of: • OASIS-C Process Measures • Case Weights • Timeliness of RAP Submission • OASIS Errors by Clinician • OASIS Corrections Completed • Cases Managed per Clinician • Average # of Therapy Visits per Episode • Average Visits per Episode • Productivity by Discipline – Actual • Outcomes Improvement • Patient Declines

24. Weekly Management Report

25. Financial Impact of OASIS-C • Differences in the types of visits (and OASIS C) effect per visit costs • Admission – takes longer due to added process measures • Follow-up – may take longer due to new incentives to assess for pain and other ongoing issues • Resumption – takes longer due to need for more thorough assessments and medication reconciliation and contact with MD • Recertification • Discharge – may take longer due to need to “look back” into the episode to answer some OASIS questions.

26. Provide the Right Tools“Point of Care” Having a Wireless feature and “Air cards” for Clinician laptops actually reduces cost per visit and facilitates: • Remote syncing to system • Access by all disciplines to most recent documentation • Email and team communications • Transmission of patient Admission information • Facilitates Clinical Case Conferencing • Clinician and supervisor (team leader) referring to same patient records • Provides complete up to date patient records for oncall • Ordering non-routine medical supplies directly from vendor At a cost of approximately $2.00 per day per clinician per day versus lost visits due to office time and travel!

27. OASIS-C and the Direct Cost per Visit All OASIS visits require additional effort! • Relative OASIS visit weights have increased • Productivity of salaried and hourly staff has declined • Overtime compensation for non-exempt clinicians has increased to accomplish the same number of average visits per day • Staffing issues • Covering visits • Admitting patients Compensation based upon effort versus time changes this dynamic, improves productivity, improves outcomes and controls the direct cost per visit!

28. Control theDirect Cost per Visit Incentive Based(Exempt) – Field Clinicians • Visit Rates • Structured by Type and Weight of Visit, including Telephone Follow-up Visits and Meetings • Case Management Fee for Cases Managed (RN, PT & ST) in a Calendar Month • Paid Days Off Based Upon Average Daily Earnings • Quarterly (12 week) Incentives • Visit Productivity • Patient Cases Managed • Outcomes Achieved • OASIS C measurements (real-time) & Home Health Compare scores • HHCHAPS results

29. Control TheDirect Cost per Visit Incentives – Clinical Supervisors (Team Leaders, etc.) • Bonus Incentives – Staff achievement for Visit Productivity, Cases Managed and Outcomes • Additional Incentives for staff achievements: • Admissions within 24 hours • Timeliness of submitted documentation • Reduction of corrections required for OASIS • HHCHAPS results

30. Questions Often Asked • Visit weighting – Based the Requirements and Complexities of completing OASIS C • Admission (evaluation) visit 1.90 • Resumption visit 1.30 • Recertification Visit 1.20 • Discharge Visit 1.25 • Follow-up Visit 1.00 • Virtual Telephone Visit (Telehealth) 0.25

31. Questions Often Asked( Visit Weight – Time Equivalents Based upon OASIS C)

32. Contact Information Pat Laff, CPA Managing Principal Laff Associates Consultants in Home Care & Hospice Phone: (843) 671-4170 Email: plaff@laffassociates.com Website: www.laffassociates.com