An Agency's Journey to Quality Cycle Management in the Eraof PDGM

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An Agency’s Journey to QUALITY CYCLE MANAGEMENT

in the Era of PDGM

Laura Page-Greifinger BSN, MPAPresident, Chairman, Founder

• 30+ years of experience in senior-level healthcare management

• Fostered the development of multiple new programs and the provision of a variety of services and programs to clients resulting in positive outcomes

• Programs were the first of their kind in a region, necessitating education at all levels of professionals and community organizations, as well the education of referral inlets for those in need of the program for care

• Focus is post-acute organizational structure:– the education and support of staff needed to succeed in

this structure– key indicator development– quality outcomes for patients within the structure– project management, financial analysis, and profitability.

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Goals

Learn what Quality Cycle Management (QCM) means for the post-acute industry

Follow the agency journey to QCM in the era of PDGM by identifying best practices and expected outcomes for each task and the metrics by which to measure results

Implement compliant workflows Outline agency operations that reflect best practices of the day-

to-day workflow Identify tools, reports, and practices necessary to monitor

and maintain compliance within the organization and/or respond to change

It’s the journey, not the destination

QCM Basics• Culture change

• Hold all staff accountable

• Connect all parts of the workflow processes

• Achieve the goal of patient-centered care

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Bringing QCM to the Post-Acute Industry: OIG 7 Elements of Compliance

Implementing written policies, procedures, and standards of conductImplementing

Designating a compliance officer and a compliance committeeDesignating

Conducting effective training and educationConducting

Developing effective lines of communicationDeveloping

Enforcing standards through well publicized guidelines to include disciplinary outcomesEnforcing

Conducting internal monitoring and auditingConducting

Responding promptly to detected offenses and developing corrective actions.Responding

Four Pillars

I. Integrity of the agency

II. Passion for performance

III. Innovation

IV. Focus on people

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Striking Balance: FINANCIAL & CLINICAL

Clinical• Quality measures• OASIS• Patient outcomes• Response times (referral to

SOC)• Internal audit findings (from

tools)• State audit findings• Visit accuracy• EMR data• Re-hospitalization rates• Readmission rates

Financial• Claims accuracy reports• Internal billing statistics• Financial performance

measures• Episodic financial reports• Supply management/episode

management• Company performance

QCM Unites Clinical and Business

Time (Prompt) - Earlier is better – whether for care delivery or for revenue realization

Quality (Appropriate) – Do the right thing whether planning and delivering care, or documenting and billing

Cost (Effective) – Are you making a difference – whether achieving care goals or inroads on collections

Time (Prompt)

Quality (Appropriate)

Cost (Effective)

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QCM Should Become the Goal for Every Agency

Focus on a patient-centered, data-driven,

outcome-oriented workflow process.

Promote high quality patient care at all times

- IN REAL TIME -

for all patients and agency compliance.

QCM Monitoring

Who is monitoring these steps? How often?

INTAKEDEFENSIBLE DOCUMENTATION

ASSESSMENTS AUDITING

QCM MONITORING

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INTAKE

QCM Referral/Intake

Steps Along the Way:

How does your agency’s intake work at present?

• Ratio of staff to tasks

• Written protocols

• Written work flows

• Written policies

• Decision trees

• Written audit tools/when audits are done, show need for PI project(s)

• Predictive analytics specific to intake: referrals/day; referral sources/day; cases to be opened next day; # referrals rejected/day; reason referral rejected/day; F2F received and acceptable/unacceptable – why?

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Obtain All Critical Information

Intake(Referral and Pre-admit)

•F2F Validation•Referring Dx Verification•MD is in PECOS•Patient primary insurance is correct/verified

•Insurance authorization for visits is acquired

•Demographics are correct•Support systems are established for patient

Perform a gap analysis.

Begin coding to PDGM now.

• Understand what will be RTP

• Fix the codes now

Train

• Intake | Billers

Define query criteria

BEST PRACTICESBEFORE PDGMEducate.• Intake staff must know

what to look for and how to collect all necessary information

• Clinicians must understand the importance of accurate coding and primary dx

Evaluate• Are your referral sources

compliant with your workflow demands?

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Development of Best Practice Processes

Agile Model

Home Health Review Tool Step 1 (Face-to-Face Encounter Requirement)

Yes

1) Is a face-to-face encounter note* present? NO YES

1.1) Was the face-to-face encounter note signed and dated by an allowed provider type**?

Yes

1.2) Was the face-to-face encounter performed by an allowed physician or NPP**?

YES NO

1.3) Does the face-to-face encounter progress note indicate the reason for the encounter was related to the need for home health services?

1.4) Is the face-to-face encounter note dated between 90 before or 30 days after the start of home health services? NO YES

YES

YES NO

NO

F2F Encounter Requirement ARE MET. Proceed to Step 2 (Plan of Care requirements)

No

Yes

Yes

Yes

Yes

Note Deny/ Non-Affirm

reason (continue to step

2)

No

No

No

No

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Decision Tool

Patient had R THR

Collect metrics. Develop audit tool and review all intakes for

a month. Audit intake department monthly and those metrics with lower compliance scores would

choose & start PI Projects

Step 1:Was H&P information included

Step 3:Was all information contained in

referral and was it correct

Step 2:Was F2F completed appropriately? All

parts submitted

Step 5: This patient is a THR and will be eligible for our JRP. Appropriate protocols to be followed.

Educate staff to H&P need and documentation needed within H&P. Utilize tool if no H&P with referral

F2F was returned to source of document with education to person to amend documentation

Referral lacking emergency contacts. Call back to elicit correct information

Insurance verification failed. Referral source or liaison called back to get correct insurance

No

No

No

Yes

Yes

Yes

Yes

Step 4:Was all information regarding insurance

information collected and correct and verified.

No

ASSESSMENTS

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QCM in Assessments

Evaluate.

Educate.

Elevate.

Case Study

1. ABC Agency began the journey program in March, 2018.

2. After the evaluation stage, half of the clinicians qualified for adjusted reviews, saving the agency $3750 in the FIRST MONTH.

3. If every clinician qualified for adjusted reviews:

4. ABC Agency could save as much as $7500 a month or $90,000 a year.

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BEST PRACTICES

Staff to document at the visit and have a complete visit with plan of care

SOC/RCT/ROCs and Discharges completed before leaving the home

Staff education:

Reimbursement **PDGM

Cost of the POC

Clinician writes per patient for both direct and indirect costs, and compare reimbursement to the cost of that plan of care

DEFENSIBLE DOCUMENTATION

IT’S A STORY

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Documentation must tell a consistent story.

Effective Communication & Coordination of Care

1. Integrated & patient-centered 2. Patient training3. Improved patient experience 4. Reduced duplication5. Integrated resources

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BEST PRACTICE

• Education

– All staff must be educated on the differences in

documenting a skilled assessment and a general

monitoring assessment.

• Documentation must be defensible.

• Policy of no cut and paste with escalating sanctions

AUDITINGTHE JOURNEY OF CONTINUOUS IMPROVEMENT…

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BENCHMARKS

AUDITING

Benchmarks Measure What Is Important

TO THE INDUSTRY TO THE AGENCY

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KEY PERFORMANCE INDICATORS(KPIs)

AUDITING

Identify PDGM KPIs for Your Agency

Effectiveness Efficiency Equity

Patient Centeredness

Operational Compliance

Timeliness

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Monitoring Agency Performance

• Daily

• Weekly

• Monthly

• Quarterly

• Annually

METRICS

AUDITING

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QCM Data

Tools / Reports / Practices to Monitor and Maintain Compliance

In healthcare, data is tracked and maintained, through common working files (CWF) and/or via claims data.• Data mining has been utilized over the years, in efforts to gain insight to care

related trends.• Over time, quality performance measures, began to be measured via the

OASIS.• Electronic Medical Record (EMR) systems have means of reporting and

tracking data meaningful to operations.• Agencies must learn to utilize key elements, found within their data, and be

sure of the accuracy of the data to appropriately manage the patient cycle…

What do we look for with auditing:

1.Compliance

2.A chart should read like a good book.

• A beginning, a middle, and an end.

3.A picture should emerge

4.Prove the agency value

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BEST PRACTICE

• Know the data to use

• Define your goals

• Educate your staff on the reason for audits

The Blame Game?

WHAT AUDITING IS NOT:

• Not about blame, shame, or guilt

WHAT AUDITING SHOWS:

• The responsibility of every person who touches the patient chart to clearly document their task or have an audit trail of the task completed

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What are we trying to

accomplish?

Development of tool/

questionnaire

Sampling

Data collection

OutcomesDoing something to make things

better

Process redesign

Did we do it – make it better?

Put in practice to achieve change &

sustain improvement

What are we trying to

accomplish?

Development of tool/

questionnaire

Sampling

Data collection

OutcomesDoing something to make things

better

Process redesign

Did we do it – make it better?

Put in practice to achieve change &

sustain improvement

BEST PRACTICES

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Best Practices for All Agencies

1. Training and education

2. Customer approach –individual approach – what are the pain points?

3. Communication across all staff

Best Practices

• Documentation is done for all visits in the home

• Follow the guidance and not document excessive narratives

• Learn all the capabilities of the software your agency utilizesStaff training

• If your agency does not have an EMR, finding one is of the utmost importanceEMR

•Document at the point of care process – create the culture now

•Inter‐rater reliability with the source of the document decreases as the time between assessment and documentation increases.

Create a solid quality review process

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More Best Practices

Hold staff accountable to

productivity standards

Teams in geographic

regions

Weekend staffing model development.

*Important*

Effectively use therapy

assistants

Staff to document at the visit and have a

complete visit with plan of care

SOC/RCT/ROCs and Discharges

completed before leaving the home

Staff education:ReimbursementCost of the POC

Clinician writes per patient for both

direct and indirect costs, and compare reimbursement to

the cost of that plan of care

RESEARCH. IMPLEMENT. PRACTICE.• Update staff on skilled requirements and documentation of homebound status often; test

them in their knowledge; read their notes• Policy on not allowing cutting and pasting in EMR• Consider calling a patient instead of visiting; use virtual visits - utilize technology such as

telehealth – many pilots out there – start one in your agency• Develop daily/weekly/monthly dashboards to provide to executives and managers and

include productivity, TAT for orders, visits per episode, recert rate, claims held for problems and so forth and hold managerial staff and line staff responsible and accountable

• Do not use nurses or therapists in administrative positions unless required by regulation. Think of how administrative/clerical personnel can be used

• Outsource administrative tasks – focus on referrals, intake and patient care• Fully utilize your EMR and make technology your workforce partner• Create a solid QAPI process internally or externally through outsourcing

What’s an agency to do?

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It is a journey – not a destination.

SUMMARY

Questions?

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Y O U R PA RT NE R O N T H E J O U R N EY TO Q U A L I T Y

Further questions? Comments? Contact us:

info@QIRT.com

855.485.QIRT