climb every mountain: improve every oasis outcome · purchasing (hhvbp) model. • this new model...

Climb Every Mountain:Improve Every OASIS Outcome

Presented byJennifer War�eld, BSN, HCS-D, COS-C

Education Director, PPS Plus

September 21, 2017

KHCA Annual Meeting C3

Improving Outcomes

1All Rights Reserved. Copy with permission only.

Objectives• Understand the impact of OASIS responses on Outcome Measures.• Recognize the OASIS items and the item intent that affects Home Health

Compare Reports.• Recognize the OASIS items and the item intent that affects Star Rating Scores

and VBP Scores.

CMS' Thoughts on Pay for Performance“The goal is that, no matter where the care is delivered, it is supported by a payment system that rewards providers who deliver the highest-quality outcomes”.

Andy Slavitt,Acting CMS Administrator

HOME HEALTH COMPARE

Quality Reporting• The reporting of quality data by home health agencies (HHAs) is mandated by

Section 1895(b)(3)(B)(v)(II) of the Social Security Act (“the Act”). • This statute requires that ‘‘each home health agency shall submit to the

Secretary such data that the Secretary determines are appropriate for the measurement of health care quality. Such data shall be submitted in a form and manner, and at a time, specifi ed by the Secretary for purposes of this clause.’’

• OASIS reporting is mandated in the Medicare regulations, which requires HHAs to submit OASIS assessments and Home Health Care Consumer Assessment of Healthcare Providers and Systems Survey (HH CAHPS) data to meet the quality reporting requirements.

• The requirement that HHAs report quality data to CMS in order to receive the full annual payment update. (70%)

• HHAs that do not meet the reporting requirements are subject to a two (2%) percentage point reduction to the HH market basket increase.

• Such procedures shall ensure that a home health agency has the opportunity to review (via Casper Reports) the data that is to be made public with respect to the agency prior to such data being made public.’’

• To calculate quality measures from OASIS data, there must be a complete quality episode, which requires both a Start of Care (initial assessment) or Resumption of Care OASIS assessment and a Transfer or Discharge OASIS assessment.

• Failure to submit suffi cient OASIS assessments to allow calculation of quality measures, including transfer and discharge assessments, is failure to comply with the CoPs.

• HHAs do not need to submit OASIS data for those patients who are excluded from the OASIS submission requirements.

Exclusions• Patients receiving only non-skilled services;• Patients for whom neither Medicare nor Medicaid is paying for HH care

(patients receiving care under a Medicare or Medicaid Managed Care Plan are not excluded from the OASIS reporting requirement);

• Patients receiving pre- or post-partum services; or• Patients under the age of 18 years.

Climb Every Mountain:Improve Every OASIS Outcome

Improving Outcomes


Home Health Compare (HHC)There are 3 types of Outcome measures used in the HHC:

1. Improvement measures (i.e., measures describing a patient’s ability to get around, perform activities of daily living, and general health);

2. Measures of potentially avoidable events (i.e., markers for potential problems in care), and

3. Utilization of care measures (i.e., measures describing how often patients access other health care resources either while home health care is in progress or after home health care is completed).

Included Measures• 37 risk-adjusted measures including:

+ Outcome measures+ Process measures+ Potentially avoidable events

• 9 publicly reported measures including two measures which are claims based

Improvement Measures• Measures the percentage of patients where the response on the discharge or

transfer OASIS is numerically lower than the response on the SOC or ROC.• Stabilization of measure while not technically a dinge, is not an improvement

therefore does not help your scores.• Higher numbers are preferable• Improvement in:

+ Management of oral medications (M2020)+ Ambulation or locomotion (M1860)+ Pain interfering with activity (M1242)+ Status of surgical wound (M1342)+ Bathing (M1830)+ Transferring (M1850)+ Dyspnea (M1400)

Utilization of Care Measures• Claims-based utilization measures are a subset of outcome measures used in

the HH QRP. • They are calculated based on the fi rst home health claim that starts an episode

of care for a patient and include negative events such as hospitalization or emergency department care within a certain time frame.

• They evaluate the rate of potential problems in care that are indicated by the utilization of specifi c services.

• Lower values are preferable to higher values because they indicate fewer negative events for patients at that home health agency.

• HHAs with compliance levels below 70% for this period will see a two percentage point reduction in their annual payment update (APU) for calendar year (CY) 2017.

• The following two claims-based utilization measures are currently reported in Home Health Compare+ Acute Care Hospitalization (ACH)+ Emergency Department (ED) Use without Hospitalization

Improving Outcomes


Process Measures• Process measures evaluate the rate of home health agency use of specifi c

evidence-based processes of care. • The HH QRP process measures focus on high-risk, high-volume, problem-prone

areas for home health care. • These include measures pertaining to all or most home care patients, such as

timeliness of home care admission, immunizations, and use of risk assessment tools for falls, pain, depression, and pressure ulcer development.

• There are also measures for specifi c diagnoses (heart failure, diabetes, pressure ulcers) and measures of care planning and clinical interventions delivered for patients experiencing certain symptoms (pain, depression).

• Not risk-adjusted because the processes being measured are appropriate for all patients included in the denominator (patients for whom the measure is not appropriate are excluded).

• Process measures:+ Timely Initiation of Care (M0102 & M0104)+ Depression assessment conducted (M1730)+ Fall risk assessment (M1910)+ Diabetic foot care (M2250b)+ Flu vaccine received for current year (M1046)+ Pneumonia vaccine ever received (M1051)+ Medication teaching (M2016)

VALUE-BASED PURCHASING (VBP)The overall purpose of the HHVBP Model is to improve the quality and delivery of home health care services to Medicare benefi ciaries with specifi c goals to:

+ Provide incentives for better quality care with greater effi ciency;+ Study new potential quality and effi ciency measures for appropriateness in the

home health setting; and,+ Enhance the current public reporting process.

Included Measures• 3 Process measures assess the performance of activities that have been

demonstrated to contribute to positive health outcomes for patients.• 9 Outcome measures refer to the effects that care had on patients• 5 HHCAHPS measures assess patients' perception of the quality of care they

have received and their satisfaction with the care experience in the HH setting• 3 new measures reported through a special web portal

Process Measures

Influenza Immunization Received for Current Flu Season M1046 (Influenza vaccine received)Pneumonia Vaccine Ever Received M1051 (Pneumonia vaccine)Drug Education on All Meds Provided to Patient/ M2015 (Patient caregiver drug education Caregiver During All Episodes interventions)

OASIS Item Data SourceTitle

Improving Outcomes


Outcome Measures

Improvement in Ambulation-Locomotion M1860 (Ambulation-Locomotion) Improvement in Bed Transferring M1850 (Transferring)Improvement in Bathing M1830 (Bathing) Improvement in Dyspnea M1400 (Shortness of Breath) Discharged into the Community M2420 (Discharge disposition)Acute Care Hospitalization: Unplanned hospitalization during first 60 days of HH; Claims Data hospitalization during first 60 days of HH;Emergency Dept. Use without Hospitalization Claims DataImprovement in Pain Interfering with Activity M1242 (Frequency of Pain Interfering)Improvement in Management of Oral Meds M2020 (Management of Oral Meds)

Title OASIS Item Data Source Other Data Source

HHCAHPS Measures

Care of Patients HHCAHPS

Communications between Providers & Patients HHCAHPS

Specific Care Issues HHCAHPS

Overall Rating HHCAHPS

Willingness to Recommend HHCAHPS

Data SourceTitle

New Measures

Influenza Vaccination Coverage for HH Care Personnel New measure, reported through web portal

Herpes Zoster (Shingles) Vaccination: New measure, reported through web portalHas patient ever received shingles vaccination?

Advance Care Plan New measure, reported through web portal

Title Data Source

VBP Initiative Details• Effective January 1, 2016, The Centers for Medicare & Medicaid Innovation

(CMS Innovation Center) implemented the Home Health Value-Based Purchasing (HHVBP) Model.

• This new model is designed to support greater quality and effi ciency of care among Medicare-certifi ed Home Health Agencies (HHA) across the nation.

• The HHVBP Model was developed in an effort to build a health care system that delivers better care, spends health care dollars more wisely, and results in healthier people and communities.

• Demo began January 1, 2016 and runs through CY 2022 • Payment adjustments tied to quality performance +/- 3% in the fi rst year• HHAs are scored based on quality of care delivered to all patients receiving

services compared to: - performance of their peers within their state, defi ned by the same size cohort, and - their own past performance on the measures.

• All Medicare-certifi ed HHAs providing services in Massachusetts, Maryland, North Carolina, Florida, Washington, Arizona, Iowa, Nebraska, & Tennessee will compete on value in the HHVBP model, where payment is tied to quality performance.

Improving Outcomes


VBP Savings ImpactHH VBP will reduce or increase Medicare payments by 3% the fi rst year and will eventually increase to 8% in subsequent years, depending on degree of quality performance in selected measures.

Adjustment Schedule

2016 2018 3%2017 2019 5%2018 2020 6% 2019 2021 7% 2020 2022 8%

Performance Years

Calendar Year for Payment Adjustment

Maximum Payment

Adjustment(up or down)

3 New Agency Reported Measures• New measures are worth 10% of Total Performance Score (TPS).• All or nothing scoring. Each is worth 10 points for submission, if not submitted,

worth 0 points.• Agency can earn 0, 10, 20, or 30 points total.• There is no penalty for not submitting/reporting the new measures, however the

HHA that does not report data on all three new measures can earn only up to 90% of the total possible points for the Total Performance Score.

STAR RATINGAgencies are rated on:

• 9 measures• 3 process measures• 6 outcome measures

Selected Measures

Process Measures Outcome Measures

Timely Initiation of Care Improvement in Ambulation

Drug Education on all Medications Improvement in Bed Transferring Provided to Patient/Caregiver

Influenza Immunization Improvement in Bathing Received for Current Flu Season

Improvement in Pain Interfering With Activity

Improvement in Dyspnea

Acute Care Hospitalization

Star Rating• CMS established the Home Health Compare (HHC) as a key tool for consumers to

use when choosing a home health care provider. It is designed to be an easy-to-access, convenient source of authoritative information on provider quality.

• However, there are so many measures and often diffi cult to determine which ones affect your needs.

• CMS has begun adding new tools to HHC in order to make the information there easier to use – “star ratings” that will summarize some of the current measures of health care provider performance that the site already offers.

Improving Outcomes


• The star ratings are an additional tool to support consumers’ health care decision-making; none of the current information on the site is being removed.

MethodologyThe Quality of Patient Care Star Rating methodology includes 9 of the 24 currently reported process and outcome quality measures. These measures were chosen based on the following criteria:

+ The measure should apply to a substantial proportion of home health patients and have suffi cient data to report for a majority of home health agencies.

+ The measure should show a reasonable amount of variation among home health agencies and it should be possible for a home health agency to show improvement in performance.

+ The measure should have high face validity and clinical relevance.+ The measure should be stable and not show substantial random variation over time.

• The Quality of Patient Care Star Ratings were fi rst published on Home Health Compare (HHC) in July, 2015, and will be updated quarterly thereafter based on the new data that are published on HHC.

• Provider preview reports showing the Quality of Patient Care Star Ratings and rating calculations for each agency are distributed to each agency approximately 3.5 months before the ratings are published on HHC.

• Agencies have several weeks to review and, if they can submit evidence that the data used to calculate the measures were inaccurate or incomplete to the extent that their star rating was affected, they can request CMS review of their rating.

Results• The Star Rating is a summary measure of a home health agency’s performance

based on how well it provides patient care in nine areas. Star Ratings are different from the consumer ratings that are seen on websites or apps for products like books, restaurants, or hotels that refl ect averages of consumer opinions.

• Across the country, most home health agencies fall “in the middle” with 3 stars − delivering good quality of care.

• A rating of 1 or 2 stars means that the agency’s performance was below the average of other agencies on selected measures; it doesn’t necessarily mean care is poor.

• A rating of 4 or 5 stars means that the agency’s performance was above the average of other agencies on selected measures.

RESPONSE SPECIFIC INSTRUCTIONS

M0102 – Date of Physician-Ordered Start of Care

(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified.

NA – No specific SOC date ordered by physician

/ /month day year

• Refers to the date that home care services are ordered to begin• Process measure: Timely initiation of care

Improving Outcomes


M0104 – Date of Referral

(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA.

__ __ /__ __ /__ __ __ __ month / day / year

• Refers to the most recent date that verbal, written, or electronic authorization to begin home care was received by the HHA

• Process measure: timely initiation of care

M1242 – Frequency of Pain

Enter Code0 Patient has no pain1 Patient has pain that does not interfere with activity or movement2 Less often than daily3 Daily, but not constantly4 All of the time

(M1242) Frequency of Pain Interfering with patient’s activity or movement:

Pain exclusions: HH episodes of care for which the patient, at start/resumption of care, had no pain reported, episodes that end with inpatient facility transfer or death, or patient is nonresponsive.

• Consider cognitive items: M1700, M1710 & M1720

M1400 – Dyspnea

Enter Code

(M1400) When is the patient dyspneic or noticeably Short of Breath?

0 Patient is not short of breath1 When walking more than 20 feet, climbing stairs2 With moderate exertion (for example, while dressing, using commode or bedpan, walking distances less than 20 feet) 3 With minimal exertion (for example, while eating, talking, or performing other ADLs) or4 At rest (during day or night)

Dyspnea exclusions: Home health episodes of care for which the patient, at start/resumption of care, was not short of breath at any time, episodes that end with inpatient facility transfer or death

Improving Outcomes


M1830 – Bathing

0 Able to bathe self in shower or tub independently, including getting in and out of tub/shower.

1 With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of the tub/shower.

2 Able to bathe in shower or tub with the intermittent assistance of another person:(a) for intermittent supervision or encouragement or reminders, OR(b) to get in and out of the shower or tub, OR(c) for washing difficult to reach areas.

3 Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.

4 Unable to use shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode.

5 Unable to use shower or tub, but able to participate in bathing self in bed, at sink, in bedside chair, or on commode, with assistance or supervision of another person.

6 Unable to participate effectively in bathing and is bathed totally by another person.

Enter Code

(M1830) Bathing: Current ability to wash entire body safely. Excludes grooming (washing face, washing hands, and shampooing hair).

Bathing exclusions: Home health episodes of care for which the patient, at start/resumption of care, was able to bathe self independently, episodes that end with inpatient facility transfer or death, or patient is nonresponsive.

M1850 – Transferring

0 Able to independently transfer.1 Able to transfer with minimal human assistance or with use of an assistive device.2 Able to bear weight and pivot during the transfer process but unable to transfer self.3 Unable to transfer self and is unable to bear weight or pivot when transferred by

another person. 4 Bedfast, unable to transfer but is able to turn and position self in bed.5 Bedfast, unable to transfer and is unable to turn and position self.

Enter Code

(M1850) Transferring: Current ability to move safely from bed to chair, or ability to turn and position self in bed if patient is bedfast.

Transfering exclusions: Home health episodes of care for which the patient, at start/resumption of care, was able to transfer independently, episodes that end with inpatient facility transfer or death, or patient is nonresponsive.

M1860 – Ambulation/Locomotion

0 Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (specifically: needs no human assistance or assistive device).

1 With the use of a one-handed device (for example, cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs withor without railings.

2 Requires use of a two-handed device (for example, walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.

3 Able to walk only with the supervision or assistance of another person at all times.4 Chairfast, unable to ambulate but is able to wheel self independently.5 Chairfast, unable to ambulate and is unable to wheel self.6 Bedfast, unable to ambulate or be up in a chair.

Enter Code

(M1860) Ambulation/Locomotion: Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.

Ambulation exclusions: Home health episodes of care for which the patient, at start/resumption of care, was able to ambulate independently, episodes that end with inpatient facility transfer or death, or patient is nonresponsive.

Improving Outcomes


M2020 – Management of Oral Medications

Enter Code0 Able to independently take the correct oral medication(s) and proper dosage(s)

at the correct times. 1 Able to take medication(s) at the correct times if:

(a) individual dosages are prepared in advance by another person; OR(b) another person develops a drug diary or chart.

2 Able to take medication(s) at the correct times if given reminders by another personat the appropriate times

3 Unable to take medication unless administered by another person

NA No oral medications prescribed.

(M2020) Management of Oral Medications: Patient's current ability to prepare and take all oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. Excludes injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness.)

Medication exclusions: HH episodes of care for which the patient, at start/resumption of care, was able to take oral medications correctly without assistance or supervision, episodes that end with inpatient facility transfer or death, or patient is nonresponsive, or patient has no oral medications prescribed.

• Consider cognitive items: M1700, M1710 & M1720

Acute Care Hospitalization• Number of home health stays for patients who have a Medicare claim for an

unplanned admission to an acute care hospital in the 60 days following the start of the home health stay.

• Uses data from hospital claims.

Emergency Department Use• Number of home health stays for patients who have a Medicare claim

for outpatient emergency department use and no claims for acute care hospitalization in the 60 days following the start of the home health stay.

• Uses hospital claims data.

M1046 – Infl uenza Vaccine

Enter Code1 Yes; received from your agency during this episode of care (SOC/ROC to

Transfer/Discharge)2 Yes; received from your agency during a prior episode of care (SOC/ROC to

Transfer/Discharge)3 Yes; received from another health care provider (for example, physician, pharmacist)4 No; patient offered and declined5 No; patient assessed and determined to have medical contraindication(s)6 No; not indicated - patient does not meet age/condition guidelines for influenza vaccine7 No; inability to obtain vaccine due to declared shortage8 No; patient did not receive the vaccine due to reasons other than those listed in

responses 4 – 7.

(M1046) Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year’s flu season?

Infl uenza vaccine exclusions:• Home health episodes care for which no care was provided during Oct 1 –

Mar 31, OR the patient died, or the patient does not meet age/condition guidelines for infl uenza vaccine.

• Response 6

Improving Outcomes


M1051 – Pneumococcal Vaccine

Enter Code 0

1

(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination (for example, pneumovax)?

No Yes [Go to M1500 at TRN; Go to M1230 at DC]

Pneumococcal vaccine exclusions: Home Health episodes of care during which patient died, OR patient does not meet age/condition guidelines for Pneumococcal Polysaccharide Vaccine.

M1910 – Falls Risk Assessment

Enter Code 0 No.1 Yes, and it does not indicate a risk for falls.2 Yes, and it does indicate a risk for falls.

(M1910) Has this patient had a multi-factor Falls Risk Assessment using a standardized, validated assessment tool?

• Identifi es if a multi-factor falls risk assessment has been conducted. • Process measure: multi-factor falls risk assessment conducted

M2016 – Patient/Caregiver Drug Education Intervention

Enter Code 0 No1 YesNA Patient not taking any drugs

(M2016) Patient/Caregiver Drug Education Intervention: At the time of, or at any time since the most recent SOC/ROC assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, adverse drug reactions, and significant side effects, and how and when to report problems that may occur?

Drug-Education exclusions: Home Health episodes for which the patient was not taking any drugs since the last OASIS assessment prior to transfer/discharge, or the patient died.

M2250b – Diabetic Foot Care(M2250) Plan of Care Synopsis: (Check only one box in each row.)

Does the physician-ordered plan of care include the following:

Plan / Intervention No Yes Not Applicable a. Patient-specific parameters for notifying

physician of changes in vital signs or other clinical findings

0 1 NA Physician has chosen not to establishpatient-specific parameters for thispatient. Agency will use standardizedclinical guidelines accessible for all care providers to reference.

b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care

0 1 NA Patient is not diabetic or is missing lower legs due to congenital or acquired condition (bilateral amputee).

• Identifi es if the physician-ordered plan of care incorporates specifi c best practices• Process measure: M2250b – Diabetic Foot Care on POC

Improving Outcomes


M2420 – Discharge to Community

Enter Code1 Patient remained in the community (without formal assistive services)2 Patient remained in the community (with formal assistive services)3 Patient transferred to a non-institutional hospice4 Unknown because patient moved to a geographic location not served by this agencyUK Other unknown [Go to M0903]

(M2420) Discharge Disposition: Where is the patient after discharge from your agency? (Choose only one answer.)

• Number of home health episodes where the assessment completed at the discharge indicates the patient remained in the community after discharge.

CAHPS• Measures patient and caregiver-centered experience

- care of patients- communication between providers and patients- specifi c care issues- overall rating of home health care- willingness to recommend the agency to others

• No exclusions• Perception is reality

New Measures• Measures population and community health• Infl uenza coverage for HH personnel

- for current fl u season- exclusions apply

• Herpes Zoster (Shingles) vaccination: has the patient ever received the shingles vaccine?

• Advance care planning- ACP available or surrogate decision maker documented- applies to patients 60 & over

• Reported through HHA web portal

Getting Started• Prioritize the problems• Pick one problem to deal with• Educate staff using the item by item tips from OASIS Manual• Consider which discipline is completing OASIS• Know and educate on item exclusions• Review CASPER report and Star Rating Preview Reports• Evaluate business and clinical processes and operations to ensure compliance

- cost-effective delivery of services- improving benefi ciary experience and outcome

• QAPI- create tracking tools to identify areas of current excellence, areas needing

improvement, defi ciencies and/or documentation issues

Thanks for Attending!Feel free to contact us with any questions.Jennifer Warfield, BSN, HCS-D, COS-C

[email protected]

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