State Home Per Diem (SHPD) 10-10SH Automation VISN 12 Pilot National Association State Veteran Home (NASVH) Summer Conference March 2-5, 2015

Purpose of Pilot Provide the capacity for the SHPD Program to design, launch, support and evaluate automated 10-10 SH form with support of CBOPC and CBO Systems Management. Phase I of pilot underway at VISN 12 SVH (Marquette) and VAMC (Iron Mountain). Phase II of pilot will serve remaining facilities within VISN 12 and/or other VISNs based on the outcomes and recommendations from Phase I pilot. Required to use current 10-10SH form (May 2009) until OMB approves new form with improved clarification and functionalities. We believe the new 10-10SH form holds real promise for the future. We are using the pilot to tweak the form and the workflow as issues and opportunities have arisen.

Goals of Phase I Convert current 10-10SH PDF form into a web-based, fillable form that can be electronically submitted to VHA State Home Per Diem Care Program – accomplished! Include validation on form that precludes the 10-10SH from being submitted electronically unless all required fields/information have information in them – accomplished! Require an electronic signature or equivalent prior to submission – accomplished! Provide a date/time stamp and notification to the SVH upon receipt at the VA facility to assist with the 10 day rule determination. Include business rules in the VA portion of the form to help standardize determinations – accomplished! Allow the VA representative to return incomplete applications to the SVH along with a notification to them and record the receipt of a “completed” application – accomplished!

Some Lessons from Phase I The form is necessarily strict, but it doesn’t mean unworkable Signed forms cannot be altered because that negates the signature The individual who signed the form is the only one who can remove a signature The form has a function (Comment) that can be used to make small pen and ink changes while maintaining the integrity of the form. Working cross-agency and cross-government can be time consuming The form relies on secure/encrypted email for submission The VA requires certain types of proof/credentials to create an email account with encryption The State has to be willing to set up the account in their domain for it to work It doesn’t always work right the first time, or the second, or the third When it does work, it’s an amazing feeling to be able to send something to directly to the VA Attachments can be a lifesaver Because it’s sent by email, supporting attachments can be sent with the forms The Comment function is one we are still exploring. We envision using it for those times when the physicians, physical therapists, nurses, and social workers who we rely on for their expert appraisals of the Veteran’s condition encounter a gremlin on the keyboard or in the form. We’ve all met these gremlins. They change dates, transpose numbers, misspell names, and otherwise cause havoc with parts of our forms that are important, but could be easily fixed without changing the diagnoses or other parts that require the health professional’s time. Using Comment allows the SVH administrative staff to mark a mistake (not change it) and include the corrected information. It identifies who made the comment and when it was made as well. It is under consideration as a workaround to the current requirement that the form be unsigned, corrected, and resigned. The avenues we have for sharing information are fairly limited. Both groups have existing secured environments with lots of rules about who can and cannot have access. We have found that Microsoft Outlook will allow both sides to send and receive encrypted email, which protects the Veteran’s PII and PHI. Getting to that state; however, can be time consuming. We are looking for other avenues that might be used to send Veteran’s information back and forth between our groups.

Goals of Pilot Phase II Begin Phase II after completing the lessons learned from Pilot Phase I and incorporating any changes to the form/workflow Complete the adoption of the form within the VISN 12 region for all remaining SVHs and VAMCs Begin the rollout of the form and workflow in the VISN 19 region Implement the measures portion of the program to collect metrics on form usage Provide useful reporting and feedback to SVHs, VAMCs, VISNs and leadership Collect feedback and suggestions for workflow and form improvement Determine a governance structure and schedule for selecting, developing, and implementing improvements

Current Manual Business Process for 10-10SH (AS-IS PROCESS) Lots of paperwork, redundancy and increased burden hours Varied interpretations of admission/eligibility requirements Increased risks to providing timely and accurate payments and eligibility data/reporting . In the absence of an automated system, significant reliance on manual data entry and manual verification of processing the 10-10SH negatively affects the accuracy of ensuring the form is completed as required and determining Veteran eligibility to receive per diem payments. This has required additional program management and resources dedicated to implement internal controls to ensure documents are completed correctly and accurately. This is why we have been testing and retesting the electronic form during the pilot so that we can deliver you a quality product to help reduce the time spent performing manual administrative tasks—so that you can spend time on other things in your daily work. Continuation of current process will not resolve the problems noted above.

Key Features of Current Automated 10-10SH Form Acts as a guide, asking all of the required information and filling out the actual 10-10SH from those answers. Includes data field validation, precluding the 10-10SH form from being submitted electronically unless all required fields/information has been filled out. Provides for and requires an electronic signature or equivalent prior to submission. Provides a date/time stamp upon receipt at the VA facility to assist with the 10-day rule determination. Landing page provides a link to the 10-10EZ to remind the SVH to determine if the 10-10SH should be paired with a 10-10EZ for initial admission to an SVH and for per diem payments for domiciliaries. VA portion of the application also includes business rules to assist the VA representatives in making uniform determinations, will allow the VA representative to return incomplete applications to the SVH along with a notification to them, and record the receipt of a “completed” application. Although we have significantly turned the corner with our IPERIA error rate in FY2014, we want to provide an online automated tool and process when implemented nationwide that will help assure compliance and fiscal integrity in the submission and management in the State Home eligibility determination process, as well as improve program standardization, efficiency and timeliness of per diem payments being made by the VA to SVHs.

Where We Are Today Guided version of the 10-10SH completed and vetted within VA Launched Phase I, provided training and helped to establish internal process to SVH (Marquette) and VAMC (Iron Mountain) from 08/25/2014 to present. SVH personnel obtained PKI and have secure email VA site setting up email account for receipt of SVH submissions Training package for both groups provided Practice data selected and formatted Live forms being submitted and processed Incorporating lessons learned and feedback from the SVH and VAMC into the form We have made incredible progress during the last several months since we launched the pilot of the automated 10-10SH application between VISN 12 (Iron Mountain VAMC and Jacobetti /Marquette SVH). We know this requires precision and careful attention to detail in a process that can take many hours of employees’ time and we have been there. Finally, the automation of the 10-10SH form will provide the capacity for all involved parties to work together to pilot the automated online 10-10SH application process and if implemented nationwide may help improve program efficiency by streamlining operations, reduce the number of “touches” in the admission process, improve SHPD ability to comply with regulations and significantly reduce payment errors/improper payments. In the end, we hope that we have improved the language in the revised data fields, including the administrative and clinical authorization section, reduce burden hours and need for retroactive payments and the likelihood of errors leading to improper payments. It is our expectations to decrease retroactive payments by having intelligence built into the product to prevent incorrect eligibility decisions.

Development Phase II Work with SVHs, State governments, and the VA to determine credentialing requirements Create a version of the 10-10SH that can be accessed in the VA environment by credentialed SVH staff Develop a form that marries the 10-10EZ into the 10-10SH and provides predetermination information on a Veterans eligibility status to the SVH Centralize VA storage of 10-10SH Veteran data Provide VAMCs with access to the centralized storage and alert them when a new 10-10SH is received and ready for processing Enable automated receipt and decision reporting to the SVH

Back up Slides

10-10SH Pilot Screen Snapshot

The 10-10SH Admissions Application Process The SVH Application Packet (cont’d) This link opens the 10-10SH

The 10-10SH Admissions Application Process The SVH Application Packet (cont’d) Will generate this:

10-10SH Pilot Screen Snapshot The automated 10-10SH is made up of a series of panels devoted to specific areas of the 10-10SH form. Filling out the panels populates the actual form. It also makes it possible to populate multiple fields from one entry. The panels are divided between the two sections of the form. There is one set for the SVH, one for purchased care, and another for the clinical reviewer. The fields on the panels are also tied to the business rules for SVH.

The 10-10SH Admissions Application Process The SVH Application Packet (cont’d) For Veterans seeking nursing home, domiciliary, or adult day health care, VA Form 10-10SH must contain sufficient medical information to justify the level of care that is being recommended. The 10-10SH must be filled out entirely. The new 10-10SH electronic form has the required fields marked and will not allow an incomplete form to be submitted. For all Veterans seeking domiciliary care, the VAMC of Jurisdiction must obtain, maintain, and utilize income data to assure eligibility for VA Per Diem.

The 10-10SH Admissions Application Process The SVH Application Packet (cont’d) Recent audits revealed significant errors in the completion of State Veterans Home admission applications, which if continued, may result in improper payments. Using the new, electronic 10-10SH will ensure: All signature blocks have been filled All date blocks have been filled The recommended/approved level of care has been selected All information entered is legible The applicants full legal name is provided

The 10-10SH Admissions Application Process The SVH Application Packet (cont’d) Will generate this:

The 10-10SH Admissions Application Process The SVH Application Packet (cont’d) Each panel covers a section of the 10-10SH. Filling out the panels ensures required fields are filled. Required fields are marked with an

The 10-10SH Admissions Application Process The SVH Application Packet (cont’d) There are panels for each SVH clinical provider.

The 10-10SH Admissions Application Process The SVH Application Packet (cont’d) Text can be copied and pasted into free text fields, reducing time needed to fill out the form. Electronic signatures help ensure section integrity.

The 10-10SH Admissions Application Process The SVH Application Packet (cont’d) The form keeps track of items that need to be filled out and directs the user back to the appropriate panel. Signatures cannot be applied until all the fields are completed.

The 10-10SH Admissions Application Process The SVH Application Packet (cont’d) Electronic signatures can be created in Adobe Reader or Acrobat and used in the form. The attached document is a tutorial for setting up an electronic signature in Adobe Reader or Acrobat.

The 10-10SH Admissions Application Process The VA Administrative Application Packet (cont’d) When the form arrives from the SVH, the Administrative reviewer will need to enter the date received and identify the levels of care the SVH is licensed to provide.

The 10-10SH Admissions Application Process The VA Administrative Application Packet (cont’d) As the administrative reviewer begins to answer questions about the Veteran, other options will be displayed Selecting Yes for the first question brings up questions about discharge type and income. Domiciliary is asked, just in case the clinical review recommends that level of care.

The 10-10SH Admissions Application Process The VA Administrative Application Packet (cont’d) Selecting Yes for the discharge type brings up the questions about the 10-10EZ/R and Financials

The 10-10SH Admissions Application Process The VA Administrative Application Packet (cont’d) Answering the questions about the 10-10EZ/R populates the General Eligibility question

The 10-10SH Admissions Application Process The VA Administrative Application Packet (cont’d) Selecting Yes for Does Income Exceed Threshold question prepopulates the Eligible for Per Diem Payment for Domiciliary Care question.

The 10-10SH Admissions Application Process The VA Administrative Application Packet (cont’d) Selecting No for Does Income Exceed Threshold question also prepopulates the Eligible for Per Diem Payment for Domiciliary Care question. Both of these actions have an impact on the Clinical review.

The 10-10SH Admissions Application Process The VA Administrative Application Packet (cont’d) Selecting No for the first question automatically populates two of the questions, leaving just the Aid and Attendance question for the Administrative reviewer to fill out. Checking Yes or No will impact the Clinical review page.

The 10-10SH Admissions Application Process The VA Administrative Application Packet (cont’d) The second panel of the VA Administrative Review covers eligibility for Adult Day Health Care. Selecting anything but None of the Above will make the Veteran eligible for per diem for ADHC Selecting None of the Above will prepopulate the No answer for Eligible for Per Diem for ADHC

The 10-10SH Admissions Application Process The VA Administrative Application Packet (cont’d) The second panel of the VA Administrative Review covers eligibility for Nursing Home Care. Selecting anything but None of the Above will make the Veteran eligible for per diem for Nursing Home Care Selecting None of the Above will prepopulate the No answer for Eligible for Per Diem for Nursing Home Care

The 10-10SH Admissions Application Process The VA Administrative Application Packet (cont’d) Because we selected Yes, and the Veteran’s income exceeds Aid and Attendance, other questions become visible. Answering Yes to the first question would be sufficient, but we answered No, so we are given a final question to answer.

The 10-10SH Admissions Application Process The VA Clinical Application Packet (cont’d) The Clinical Reviewer’s page inherits from the main form and from the Administrative Reviewer’s input. In this case, the Level of Care Recommended has been prepopulated stating ADHC is not recommended based on the ADHC page. This recommendation cannot be overridden

The 10-10SH Admissions Application Process The VA Clinical Application Packet (cont’d) In this instance, the Veteran was service connected so the form prepopulated the level of care recommended as ADHC.

The 10-10SH Admissions Application Process The VA Clinical Application Packet (cont’d) For Nursing Home, the form inherits the Administrative Reviewer’s answers. Our Veteran was totally disabled, so that box is marked, along with the Level of Care Recommended. The Clinical Reviewer still needs to answer if the Veteran is SC and meets Nursing Home Level of Care.

The 10-10SH Admissions Application Process The VA Clinical Application Packet (cont’d) This Veteran was 70% or higher SC so there are fewer fields to answer. The Clinical Reviewer still needs to answer if the Veteran meets Nursing home level of care requirements. The higher per diem has been prepopulated in this instance.

The 10-10SH Admissions Application Process The VA Clinical Application Packet (cont’d) The form also covers Domiciliary Care with the same rules of inheritance.

The 10-10SH Admissions Application Process The VA Clinical Application Packet (cont’d) As far as specific requirements/items that must be present on the VA Form 10-10SH that the certifying medical official must/should use in making level of care recommendations, we do not, at this time have any guidance. If you need assistance, there are guidelines for nursing home care on the Medicare website. If the form lacks sufficient information to make a level of care determination, VA will ask the State Home to provide additional information (e.g. a recent discharge summary and/or a history and physical narrative).   *VA has the final authority on the determination of the level of care.  One of the most important steps in the process is the timely communication of approval or denial decisions to the SVH. Both reviews should be conducted promptly, within 10 business days after the application is received by the VAMC. A delayed review can have an effect on the accurate and timely submission of monthly SVH Per Diem claims.

The 10-10SH Admissions Application Process The VA Clinical Application Packet (cont’d) If the application is denied, the VAMC of Jurisdiction POC should notify the SVH and advise them of the reason(s) why, and return the application.  A courtesy phone call to the SVH, letting them know the application is being returned may help reduce the delay. If, for example, the denial reason is the VA physician does not agree with the level of care recommendation, the VA physician should be providing specific reasons to the SVH for the denial so that they have the opportunity to appeal.  *If you find that you continue to experience frequent denials for the same reasons, you may want to consider an open dialog between the VA physician and the SVH physician to set standard expectations for medical documentation for each level of care.  Give them a call.

The 10-10SH Admissions Application Process The VA Application Packet (cont’d) After the reviews have been conducted: The SVH will be promptly notified of the admission application decision. VA Form Letter (FL) 10-356, Payment of Aid to State Homes by the VA, may be used to communicate approved applications. The VAMC will develop a standard letter template to communicate denials. The denial letter will include the specific reason(s) the application was not approved. The VAMC Per Diem POC will create, or update an existing Veteran’s profile in the VAMC’s Veterans Health Information Systems and Technology Architecture (VistA). Coordination is required with VAMC facility enrollment staff to assure that records and eligibility information is properly input. *This is important because not all Veterans who are admitted to State Homes are eligible for enrollment in VHA health care.

What You Can Do to Prepare to Use the Automated 10-10SH? Review/establish an internal workflow process in order to email encrypted electronic applications from SVH to VAMC. Review/obtain your State IT permission/requirements for installation of software on your computer network if deemed necessary. Identify your SVH Per Diem POC and backup. Have your SVH Per Diem POC and backup obtain VA PKI certificate and upload on their computer via ISO located VAMC of Jurisdiction. Have SVH Per Diem POC and backup complete required VA PKI Certificate training via TMS (VA Privacy & Information Security Awareness & Rules of Behavior); complete/sign VA PKI  Subscriber Agreement and Non-Disclosure Agreement. Make sure you have appropriate software for set up and authentication of electronic signature (Adobe Reader). Upload electronic signature software and setup on each SVH employee computer involved in completing electronic form (SVH Per Diem POC and backup, Referring Physician, Physical Therapist, Social Worker, Nurse, etc.)

Lessons Learned We had some minor hiccups since launching pilot with VISN 12, but we continue to fix them along the way. Centralized email site did not work. We helped the VAMC and SVH with their internal workflow process and helped the SVH meet/comply with the State of Michigan and VA PKI encryption/firewall requirements. SVH employees can now send/receive encrypted emails to the VAMC of Jurisdiction. We fixed issues with the electronic signature block and uploading attachments with submission of electronic form. We are currently reviewing/ validating form capability to send SVH receipt confirmation and exploring an alternative solution to VA encryption requirements in order to allow us to send/receive encrypted data to the SVHs. we hope the days of repetitive faxing, mailing the 10-10SH along with supported documentations and manually signing and date stamping will be a thing of the past. We all look forward to no longer disputing if the VAMC facility received the 10-10SH within 10 days.

What’s Next? Launch Phase II of pilot Develop Metrics and Analysis for the Pilot Continue Monthly Briefings with NASVH Leadership Await OMB approval to use form Once the process/procedure have matured for the VISN 12 pilot, measurement intervals we have mapped will be used to gather needed metrics. We need to expand the testing of the electronic 10-10SH application between SVH and VAMC facilities. We need volunteers – prefer facilities with high volume new admissions and have established best practices. As you can see, we still have a few kinks to resolve, but the overall feedback/results continue to be positive. In collaboration with CBOPC and CBO Systems Management (SM), the SHPD community looks forward to the future to implementing the automation of the 10-10SH nationwide.

VISN 12 PILOT CONTACTS Colette Alvarez, VA Program Manager, State Home Per Diem Program (SHPD) Colette.Alvarez@va.gov (775) 326-5721 Brad Radichel, VA Project Manager Richard.Radichel@va.gov (404) 828-5622 Brenda Wiggins, VA Project Manager/COR Brenda.Wiggins3@va (202) 382-2529

How to Have Your Questions and Concerns Answered For more information on the State Home Admissions Application Process, there is information that may be found on our State Home Program web page: State Homes hyperlink Resources include: State Veterans Home (SVH) Per Diem Payment Program Handbook, VHA Handbook 1601SH.01 Policies, Laws, and Regulations Forms Training Presentations Fact Sheets and FAQ’s (Eligibility Determination Fact Sheet, dated September 2012) Conference Call Minutes If you find that you have exhausted all of these resources, then please send your questions/concerns to: VHAStateHomePerDiemInquiries@va.gov

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