Financial Manager’s Conference July 2009

 “Provide the right amount of care efficiently and effectively to achieve anticipated or desired patient & financial outcomes”

 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

 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 Actual  Productivity by discipline - Actual

 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

 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

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) ◦ 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

 New Process Questions; ◦ 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)

 Plan of Care Synopsis - Interventions ◦ 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)

 Flow sheet or software “flagging” will be necessary for Process Items ◦ 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)

 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?  Were the suggested corrections actually made?  What “tools” do you use?  Are there repeated errors? If so – WHY?  Repeated errors cost money

 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 ◦ The more staff involved – the less the accountability  Clinical model must insure actual case management  Primary nursing ◦ Expect critical thinking and accountability ◦ Reward good performance

 Primary clinician ◦ 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  Patient response to care  Need for change in plan

 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 ◦ Case weight extraordinarily low

 Learn to be efficient AND effective ◦ Lower base rate of $2, ◦ 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  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

 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 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

DiagnosisPoints M0230 a V54.81 Aftercare hip replacement 0 M0240b Gait Abnormality 0 M0240c Diabetes Mellitus 2 M0240cd COPD 0 M0240e Dementia 0

Case Mix Variables OASIS Score Points M0 250 IV Therapy 4 (None of the Above) 0 M0 390 Vision 00 M0 420 Pain 21 M0 450 Pressure Ulcers 00 M0 460 Most Problematic Pressure Ulcer 00 M0 476 Stasis Ulcer 00 M0 488 Surgical Wound 34

M0 490 Dyspnea When walking 20 feet or climbing stairs 10 M0 540 Bowel Incontinence 00 M0 550 Ostomy 00 M0 560 Cognitive Functioning* Requires assistance and some direction in specific situations 2N/A M0 610 Behaviors* Significant memory loss so that supervision is required 1N/A M0 780 Oral Medications* Able to independently take correct medications at correct times 0N/A M0 800 Injectable Drug Use* Able to independently take the correct medications at correct times 00 Total Clinical Points 7

M0 650 / 660 Upper OR Lower Body Dressing 122 M0 670 Bathing 23 M0 680 Toileting 22 M0 690 Transferring 20 M0 700 Ambulation 21 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 (Table 5) Revenue = $4, HHRG + NRS Revenue = $4, $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 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 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 Points (Table 2a) M0230a (Skin 1) Non-Healing Surgical Wound 10 M0240b V54.81 Aftercare for hip replacement 0 M0246b Gait Abnormality 0 M0240c Diabetes Mellitus 2 M0240d COPD (Chronic Bronchitis) 1+1 Amb. Score 2 2 M0240e Dementia (Psych 2) 1

M0 250 IV Therapy 4 (None of the Above) 0 M0 390 Vision 00 M0 420 Pain 21 M or ↑ Pressure Ulcers Stage 3 or 4 00 M0 460 Problematic Pressure Ulcers 00 M0 476 Stasis Ulcer 00 M0 488 Surgical Wound 34 M0 490 Dyspnea 10

(Table 10) NRS Points = 37 (Table 3) HHRG Score = C3F3S5 (Table 9) NRS Severity Level = 4 (Table 5) NRS Revenue = $ $ $ (Table 5) Case Weight = Revenue = $4, $ (HHRG Revenue + NRS $ = Episode Revenue) $4, = Total Revenue = $4, $537.26

Let’s Recap the Change After Editing: ◦ Change in the HHRG  C2 F3 S5 to a C3 F3 S5  $4, to $4, = +$ ◦ Change in NRS Revenue  Severity Level 2 to Severity Level 4  $51.00 to $ = ◦ Total additional revenue $537.26

 “Provide the right amount of care efficiently and effectively to achieve anticipated or desired patient & financial outcomes”