Engaging Employees through Functional Leadership Strategies

1. Engaging Employees through FunctionalLeadership Strategies Pennsylvania Homecare Association Annual Meeting – May 2012 Cindy Campbell RN BSN Associate Director Operational Consulting Fazzi Associates, Inc.

2. It’s a Changing World! In a world of change.....there is no standing still

3. The Future of Home Care Begins with the History of Home Care 1980-1986: Growth of Home Care 1987-1991: Decline, Denials & Staggers Law Suit 1991-1997: Growth and FFS 1997-2000: Decline and IPS 2000-2007: Growth and PPS What’s Next? Want to Guess?

4. Medicare-Certified Home Health Agencies Source: CMS/CSP, Table VI.3, Other Medicare Providers and Suppliers Selected Years, December 2011 and MedPAC, Report to the Congress: Medicare Payment Policy, March 2012

5. Home Health Future Industry Challenge – Do More With Less • 2011: Standard 60-day episode rate was reduced by 2.5%. • 2012 and 2013: Market basket update was reduced by 1%. • 2014 to 2016: A phased rebasing was implemented to lower payments to a level to reflect changes in average visits per episode and other factors that may have changed since rate was originally set. • 2015 and following years: Market basket was reduced by multifactor productivity for each year.

6. Growth of Hospices Source: MedPAC, Report to the Congress: Medicare Payment Policy, March 2010 and NAHC, 2011

7. In 2010, more than 1.1 million Medicare beneficiaries received hospice services from more than 3,500 providers, and Medicare expenditures totaled almost $13 billion. (MedPAC) In 2010, an estimated 1.58 million patients received services from hospice. (NHPCO) For 2010, 44% of all deaths in the U.S. were under the care of a hospice program. (MedPAC) Hospice

8. Future Hospice Payment Reform Recommendations MedPac 1/2012 – “U-shaped” reimbursement: • Increase payments per day at the beginning of the episode & reduce payments per day as the length of the episode increases • Provide an additional end-of-episode payment to reflect hospices’ higher level of effort at the end of life.

9. MedPAC’s View of Home Health Source: Changes in supply and utilization of home health care, 1997-2010, Table 8-1, MedPAC Report to the Congress: Medicare Payment Policy, March 2012

11. “Medicare spending on home health increased 84% from $8.5 billion in 2000 to $15.7 billion in 2007. The rise of home health spending leads to concerns about the potential for improper payments due to fraud and abuse.”-Department of Health and Human Services, Office of Inspector General Study on Documentation of Coverage Requirements for Medicare Home Health Claims

12. 1997: Office of Inspector General (OIG) found 40% of total services in home health agency claims did not meet Medicare reimbursement requirements. (Four state review, CA, IL, NY, and TX) In 1999 review, found unallowable or highly questionable claims with charges totaling about $675.4 million. 2009: Suspicious billing patterns (particularly in Florida’s Miami-Dade county). More than 65% of the county’s claims were outliers, much higher than the national average. 2011: U.S. Senate Committee on Finance initiates inquiry into home health therapy practices at Amedisys, LHC Group, Gentiva, and Almost Family after a Wall Street Journal analysis of therapy utilization patterns. 1 Heightened Monitoring 1 Source: Committee on Finance United States Senate, Staff Report on Home Health and the Medicare Therapy Threshold, September 2011

13. Obama Administration: elimination of fraud, waste and abuse a top priority. Health Care Fraud Prevention & Enforcement Action Team (HEAT). Affordable Care Act enhances screening and enrollment requirements, increased data sharing across government, expanded overpayment recovery, and greater oversight of private insurance abuses. In 2011, Medicare Fraud Strike Force Teams charge 323 defendants who allegedly billed Medicare more than $1 billion. Health care fraud prevention and enforcement efforts result in record-breaking recoveries totaling nearly $4.1 billion (largest sum ever recovered in a single year, 2011) Heightened Monitoring (continued…) Source: HHS, News Release, February 14, 2012

14. HH Office of Inspector GeneralMedicaid Integrity Program Report – FY 2011Medicaid Projects in FY 2012 Work Plan

15. ECONOMIC RECESSION • Epic bust of credit bubble • Unsustainable debt and deficit burdens • Entitlement programs in hot debate • Medical bills contribute to > 50% of bankruptcies (many among people who are insured) • Medical spending exceeds 16% of GDP • Per capita spend is >50% higher than any other developed country • Healthcare Reform also debated with variable levels of adoption

16. LOW QUALITY DESPITE THE SPEND “Ranking 37th — Measuring the Performance of the U.S. Health Care System” NEJM | January 6, 2010 | Topics: Health Care Delivery Christopher J.L. Murray, M.D., D.Phil. and Julio Frenk, M.D., Ph.D., M.P.H.

17. Quality is a Problem Institute of Medicine: Over 98,000 patients die each year due to hospital errors.* Health Affairs: 1of 3 hospitalized patients are harmed while in the hospital.* OIG: In October 2008 alone, 134,000 experienced at least one adverse event.*** Health Affairs: In 1.5% of hospitalized Medicare patients, a harm event contributed directly to the patient’s death.** Health Affairs: 44% is clearly or likely preventable.** Sources: *To Err Is Human, Institute of Medicine, 1999 ** Hospital Errors Ten Times More Than Thought, Health Affairs, April 7, 2011 ***OIG, Adverse Events in Hospitals: National Incidence Among Medicare Patients, Nov. 2010

18. Incredibly High Hospitalization Rates Medicare patients over age 65 are admitted to the hospital over nine million times annually. 19.6% of Medicare patients discharged from a hospital are readmitted within 30 days. 28.2% of Medicare patients are re-hospitalized within 60 days.* Home care’s re-hospitalization rate nationally is at 27%. One out of four patients are re-hospitalized. Source: * New England Journal of Medicine, 2009, pages 1,418-1,428

19. High home care hospitalization rates means… $6,400,000,000 to take care of home care patients re-hospitalized. Costs are Out of Control

20. Home Care’s 27% hospitalization rate means… 891,000 home care patients are hospitalized every year.

21. High Hospitalization Rates Means….. Hundreds and thousands of patients and families suffer the consequences.

22. Options Being Considered and Their Goals Value Based Contracting: Work together and lower costs. Patient Centered Medical Home: Improve quality, lower costs, and be more patient focused. Care Transition Programs: Improve quality and improve patient experience. Chronic care or all patient focus. Bundled Payments: One payment to cover the services for the patient across health sectors. Accountable Care Organizations (ACOs): Work together, lower costs, and improve quality.

23. What are the Goals of all These Initiatives? Save money. Improve quality outcomes. Improve patient experience. Address patients with chronic disease. Reduce unplanned hospitalization. Increase the use of technology, EMR, and telehealth.

24. Projected Marketplace • Agencies are anticipated to consolidate; too many providers than desired at present. • Proposed/new payment constructs will compel agencies to compete on cost per visit, clinical outcomes achieved (acute care hospitalization rate) and patient satisfaction. • System-based alignment will be desired; optimally collaborating within a continuum of care-through end of life. • Care will move to the least expensive, least restrictive and most desirable ‘space’ – on and around the patient’s body/in the home and work setting when possible.

25. The Delta Study to Reduce Hospitalizations:A National Study to Reduce Avoidable Hospitalizations Through Home Care Dr. Bob Fazzi, Co-Director Eileen Freitag, Co-Director Fazzi Associates October 2011

26. Sponsor: Delta Health Technologies Co-sponsor: National Association for Home Care & Hospice Affiliated Sponsors Home Health Quality Improvement (HHQI) National Campaign NAHC Forum of State Associations Community Health Accreditation Program The Joint Commission American Physical Therapy Association Fazzi Associates, Inc. Facts on the Delta Study

27. Interesting Insights • Twenty-two distinct strategies were identified by the field. • Most agencies we studied used more than one strategy. National average: ten. • The top five strategies did not cost money. • Agencies who were successful were also very “intentional” in their efforts to reduce hospitalizations.

28. The Problem and the Opportunity % in Top 20% Lowest (Good) % in Top 20% Highest (Bad) Strategy 93.9% Fall Prevention 95.7% 91.4% Agency Awareness & Support 93.5% 87.6% Front Loading 90.3% Medication Management 76.8% 81.2% 24 Hour Availability/Response System 77.8% 79.3% Staff Education 75.7% 79.0% Care Management 77.8% 75.2% One Person in Charge 75.7% 70.4% Patient/Caregiver Education 70.4% 70.8% Risk Assessment 67.8% 71.3%

29. What Does This All Mean? All practices can work… and can fail. The difference in success and failure is not the practice, but the implementation of the practices. For most agencies, the answer will not cost money, can be immediately implemented and will be effective. It starts with the development of a new model, one based on accountability and leadership.

30. Accountability: An obligation or willingness to accept responsibility for one’s actions. Webster Dictionary. • Accountability: The obligation of an individual or organization to account for its activities, accept responsibility for them, and to disclose the results in a transparent manner. Business Dictionary • Accountability: Making a commitment and keeping that commitment in a timely and quality manner. Fazzi SafeSide Program Accountability Is Key

31. You Need a Leader… Not a Manager.Leadership and Accountability Make a Difference Management works in the system; Leadership works on the system Stephen R. Covey

32. Why Supervisory Management Training Is So Critical to Retaining Staff in Home Care Focus: One million workers and eighty thousand managers in four hundred agencies. Length of Study: Twenty-five years. One Goal: What leads to retention of staff? Finding: While there are many reasons why an employee initially takes a job in an organization, how long that employee stays with the company and how productive he or she is while there is determined primarily “by his relationship with his immediate supervisor.” Source: Break All the Rules: What the World’s Greatest Managers Do Differently. Marcus Buckingham & Curtis Cuffman

33. Reflecting on a Bad Experience • Think of a specific situation - past or present - when the way that your supervisor behaved discouraged your growth: • What was the situation? • How did you feel about it then? • How do you feel about it now?

34. Why Supervisors and Managers Fail at Supervision They fail to make expectations and how success will be measured clear to staff. They don’t provide staff with the training and support they need to do the job. They assume all staff are the same and supervise them all the same way. They don’t hold their staff accountable. They don’t provide consequences for staff who are not accountable or staff who do not perform adequately.

35. Reflecting on a Good Experience • Think of a specific situation - past or present - when the way that your supervisor behaved encouraged your growth. • What was the situation? • How did you feel about it then? • How do you feel about it now?

36. Seven Goals of Supervision To clarify job expectations, i.e. how success will be measured – Measures of Success. To assess the competency levels of your staff and train them to meet job expectations. To delegate responsibilities to your staff based on their proven competency levels and hold them accountable. To support your staff on the job. To build the confidence of your staff. To increase staff satisfaction and retention. To help your staff grow personally and professionally.

37. Questions 1. Who is your most “challenging employee?” 2. Why are they so challenging? 3. How have you tried to deal with them?

38. Outcome Management SystemHow Does the Agency Make Their Goals? CEO must be held accountable for achieving the agency’s measurable goals. Department leaders must be held accountable for achieving the department’s operational goals that support the organization’s goals. Supervisors, managers and staff must have performance or measurable work outcomes that help ensure their department meets their operational goals.

39. Do You Know What Your Target Should Be?

40. For a Management System to Work, You Need Three Types of Goals • Agency goals: Clear organizational and outcome goals for your agency. You monitor and manage your agency by managing your outcomes. • Department Goals: Each department must have clear measurable goals that support agency goals, Department goals support agency goals. • Employee Goals: Employee goals support the department goals. • If employees are successful, your department will be successful. • If your departments are successful, your agency will be successful.

41. Outcome Management SystemHow Does the Agency Make Their Goals? Every staff person at every level must know what measurable outcomes “Measures of Success” they must achieve to be a success. Staff must have the skills and competencies to meet their Measures of Success. Managers must hold staff accountable. Leaders must hold managers accountable.

42. Four Phases of the Outcome Management System Determine the “Measures of Success” for each staff person. Ensure each staff person understands their Measures of Success. Train and ensure they have competences to succeed. Delegate and hold accountable. Note: Using a collaborative process helps to ensure buy-in and success of this effort.

43. General Rules About the Measures of Success Closer to service delivery, the more specific the Measures of Success. The further from service deliver, the more general the Measures of Success. Failure to achieve the Measures of Success represent failure of BOTH the employee and his/her supervisor.

44. Measures of Success Example: Professional Field Clinicians Home Care and Hospice Complete documentation and transfer data in a timely and quality manner. Meet or exceed productivity standards at “x” visits. Strong people skills, i.e. proactive customer service with all three customer groups – patient/family, referral sources and colleagues. Proven clinical quality as measured by???? Personally accountable and follow-through with commitments – up, down, all around. Sharing knowledge, professional experience, skills, mentoring with colleagues.

45. Setting the StageStart With the Measures of Success Job Expectation Rule: Make sure staff know what they are expected to do. Measures of Success. Skill Development Rule: Make sure staff person is trained and has the skills to succeed. Accountability Rule: Hold staff person accountable for meeting the job expectations you know they can do.

46. The Ten Rules of Supervisory Excellence Job Expectation Rule. Measures of Success. Skill Development Rule. Based on Rule 1. Accountability Rule. Based on Rules 1 & 2. Individual and Team Morale Rule. Feedback Rule. No Embarrassment Rule. No Surprise Rule. Chain of Command Rule. Don’t Go It Alone/Protect Yourself Rule. Personal Modeling Rule.

47. If Staff Are Not Supported and Not Held Accountable, What Does It Mean? Staff learn that standards don’t matter. “Our managers don’t mean what they say.” Staff have no idea what success is. “If the productivity goals are not real, then what do I need to do to be a success?” Morale and motivation is affected. Good performers quickly realize that those who don’t perform are not held accountable and good performance really doesn’t matter. Department goals are not met. Agency goals are not met.

48. The Three Major Premises of Functional Management There is not one, but a number of supervisory approaches good managers can use when supervising and motivating employees. All employees are not the same. Different employees function at different levels of skill and motivation. Optimal supervision can be most effectively achieved by adjusting the supervisory approach to the functional level of each employee.

49. The Two Major Components of Employee Functioning • An employee’s level of functioning is determined by how well they are functioning on the job. • There are two key factors to measure: • Ability: Does the employee have the skills and knowledge to consistently do the job in a timely and quality manner? • Motivation: Does the employee have the confidence and willingness to consistently do the job in a quality and timely manner?

50. Clarifying Motivation Confidence: Is the employee self assured and believe that he/she can do the job in the manner that is expected? Willingness: Is the employee willing to do the job in the manner that is expected. High Motivation: High Confidence and High Ability. Low Motivation:Either Low Confidence or Low Willingness.