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October 20, 2014NAHC Annual Conference, Phoenix, AZ

Finding the information needed for smart management and operational changes.

Karen Gomes, RN, MS, CPHQ,Jayne Baugher, OT, MBA

and David J. Merk, MA

Extremely challenging environmentG t t ti li i l lit t Great expectations – clinical, quality, customer service and financialIncreased transparencyFrequently changing regulationsMounting regulatory pressuresLess revenue

Never been more important for agencies to make decisions based on firm grasp of factual data

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Lots and lots of dataP t d H m H lth C mp r r ultPosted Home Health Compare resultsProfit Margin benchmarkingPatient Satisfaction measuresAdmission and Visit recordsCustomer relationship dataAssessment scrubbing resultsAssessment scrubbing resultsAnd the whole rest of the Medical Record!

Use the power of the computer for 100% reviewreviewMake use of data you need to gather to participate in the Medicare programUse the small stuff to learn about the big stuffGo granularFocus on operational trends

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Monitor a variety of metrics; drill to the detail to further review

Oasis – skeletal clinical picture but routinely availableavailableBillable Visits – who did what when and for whom - directly impacts reimbursementNon-billable visits – may signal breakdowns in the treatment processN i i ff iNon-visit staff time

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The earlier, the better!G th r d t d il t fi pi d in pr grGather data daily to fix episodes in progressReview OASIS assessments before they are finalized for submission to the stateIdentify “at risk” patients right after admissionReview episodes for compliance issues before billing

Reports provided by your vendorG i R t W it lik C t l R tGeneric Report Writers like Crystal ReportsDatabase programs like MS AccessTools designed specifically for Home Health data analysis needs

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Compare, compare, compareC t f ith th Compare one part of your agency with another to determine where improvements are neededDon’t ignore the “flat” linesCompare your performance over time on a large number of metrics to spot slips before h f h dthey get out of hand

Compare services and results from one cohort of patients to another to make sure you are matching treatment to patient needs

When results or metrics are obtainable via multiple programs identify which data source multiple programs, identify which data source is most reliable or provides the best perspective on the data and then stick with itEnsure your methodology and timing are consistent when running the same metrics across time pointsacross time pointsWhen data seems questionable or doesn’t match your intuition, cross check using other methods

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“Canned” reports have limitations:Rigid tim fr mRigid timeframesPrescribed data elements

Need flexibility in massaging your data:Report “answers” usually raise more questionsUse follow-up questions to narrow your focus and anticipate decision implicationsanticipate decision implications

Need quick turnaround

Action-oriented benchmarking: not just a grade but a suggestiongrade, but a suggestionMicro measures as well as macro measuresOperational measuresShould be measures which are also readily available for the various components of your agencyOne warning: Apt to be a large number of measures to digest, but it jump-starts your improvement process

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Meet Triple Aim goals for:i d litimproved qualityimproved care for populations, and lower cost

Improve compliance, avoid regulatory triggers and enhance ability to adequately respond to regulatory probesregulatory probesIdentify and solidify partnerships for future growth

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Measured primarily as outcomes and adherence to best practice (process measures)adherence to best practice (process measures)Quality Improvement Process

Identify area(s) needing improvementSet goals (benchmarking)Identify action steps to meet those goalsEnsure you have a way to monitor results to ensure Ensure you have a way to monitor results to ensure improvement is achieved long term

Accurate, timely, easily accessed data is critical

Goal : Take two of the lowest performing branches on Take two of the lowest performing branches on

the OASIS M2020 and increase non-risk adjusted scores to 60% or over in 6 month period of time. Current levels were 52% and 48%

Questions asked: What is level of understanding of M2020What is our process for medication reconciliationWhat happens at discharge

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Red denote Admit Nurses, Blue denotes Case Managers for the % of times they scored patients a “0” or independent in Medication management at SOC or ROC.  There is significant statistical evidence that Admit nurses score people with “0” or independent in med management less often than case managers. 

Red denote Admit Nurses, blue denotes Case Managers. Variability does exist within all groups, with a mix of CM/Admit nurses who DO find problems at drug review. 7/12 clinicians find NO problems at review approximately 60% or more of the time5/12 clinicians find NO problem at review approximately 40% of the time or less

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SOC/ROC d RECERT i d b th SOC/ROC and RECERT reviewed by the Patient Care Manager each week using “The Works”Standardizing review tools and changing previous habits to increase efficienciesReinforcing expectations of accurate OASIS Reinforcing expectations of accurate OASIS completion by clinical staffProvide education to staff through direct input and case conference review

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Evaluate individual clinicians by analyzing visit metrics to identify staff development visit metrics to identify staff development needsDrill down into problematic areas such as continuity of careEvaluate whether a new process has resulted in better quality outcomesbetter quality outcomesCompare teams to better understand and mitigate unique factors which result in different outcomes

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Improvement in Surgical Wound Status

Time Frame RateFY’12 81%FY’13 – Q1 and Q2 79%FY’13 – Q3 and Q4 85%FY’13 Overall 84%% Change FY’12 – FY’13 4%% Change FY’12 – Q3&4 5%

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Volume, Financial, and Quality DomainsG l 12 6 3 1 th t diGoals, 12, 6, 3, 1 month trendingTeam results and scoringTeam trends by monthMonthly report to Executive Team and all Clinical Teams – transparency about goals, priorities, results

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An example: Comparing Case Managers on a wide array of metrics

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Use data to ensure you are delivering the “right” care throughout the episoderight care throughout the episodeMonitor key outcomes such as hospitalization and target your at risk patientsLeverage technology effectivelyTrack and trend your agency’s key diagnoses

d di i and conditions

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ID LUPAs in progress and evaluate whether needs are being adequately addressedneeds are being adequately addressedEnsure rehab projections are on trackPrepare for recertification decisions

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3 Classifications:Di h rg d b g n LUPADischarged by agency as a LUPARecertifications – Ongoing LUPATransferred to a facility as a LUPA

Key Questions for all: What does (or did) the patient need?Did we meet clinical goals for the patient?Did we meet clinical goals for the patient?

Can you easily identify LUPA cases and analyze them using HHRG?

Was your Clinical Manager aware of the plan to D/C?to D/C?Was case discussed in case conference or IDTDo you have a way to ID LUPAs in progress?Did visit/discipline utilization match HHRG?Analyze d/c disposition reasonsTrend clinicians with LUPAsTrend teams/branchesTrend referral sources, clinical liaisons

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Discrete, infrequent skilled need, i.e. B12 injection, catheter changeLong term patients, often with complex needsMay have received therapy during past episodes – are current functional deficits addressed?Compare OASIS time points for changes in conditionEnsure staff are evaluating with a fresh eyeRehab: Is equipment safe and up to date? Pain managed? managed? SW: financial status and formal and informal supports can change over timeHHA: use a standardized tool to ID HHA opportunities

Was visit frequency and/or involved disciplines appropriatepp p

Low utilization at start of episode may have contributed to transfer

Are there trends in:DiagnosisTime frame in which transfer occurredFacility receiving patientTeam / Clinician/

Access to patient informationDo you know what happened after the transferMethod to recover referral and ensure patient returns within the episode

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Can you easily identify the following:Episodes with target primary diagnosesEpisodes with target primary diagnoses“Capture” rate – patients with target dx receiving TH

Can you compare metrics for patients with and without TH:

LOSRecertification RateCase MixTop DiagnosesVisit UtilizationOutcomes

Can you quickly review existing TH census for presence of hospice flags

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Telehealth Churn: Number of installs/removals per monthinstalls/removals per monthTelehealth Utilization: Units “on the shelf”Impact of TH:

Financial: LUPAs, Visit Utilization, RecertificationsClinical/Quality Outcomes:

Ti liTimelinessDyspneaMedication ManagementED / Hospitalization

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Metrics All Medicare

CHF COPD DM ChronicWounds

Episodes 8922 549 570 437 618Epi/Pt 0.8 1.1 0.8 1 1.2Acuity 1.34 1.26 1.34 1.16 1.22Avg VPE 17.5 18.2 17.8 28.0 24.6Timeliness 87% 84% 85% 84% 96%Imp Dyspnea

70% 65% 64% 70% 56%DyspneaImp Med Mgmt

55% 56% 64% 50% 56%

ACH 28% 39% 39% 26% 39%

Analysis of common chronic disease diagnoses and outcomes

Identify key financial metrics and provide timely feedback to teamstimely feedback to teamsJustify staffing levels as they relate to revenue, marginsMeasure and understand the key inputs related to productivity, service utilization

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Look at visits per day in relation to non-visit activitiesactivitiesMeasure and monitor staff productivityMust factor in nature of caseload, other duties such as clinics, geography

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Visit patterns for selected cohortsVi it b tVisit use by case manager, teamLength, time of day of visits by disciplineStaging of visits during an episode, such as front-loading for cases with high risk of hospitalization

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Agencies are responsible for knowing regulations ensuring accuracy having proper regulations, ensuring accuracy, having proper controlsData elements can help agencies improve compliance, identify red flags

Check for missing assessmentsScan all episodes for situations commonly focused Scan all episodes for situations commonly focused on by post-payment auditsClosely examine “threshold cases” – 5-visit episodes; 20+ therapy episodes, etc.

Use data to identify key compliance risk areas such as such as

low HHRGlow utilizationOutlierslow functional scores with therapy delivery

Use exceptions to conduct in house pre pay Use exceptions to conduct in-house pre-pay auditing to improve denial rates, prevent escalating regulatory activity

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Compare different data elements gathered at the same timethe same timeCompare data across time pointsCompare the responses of different assessorsCompare your results with those from other agenciesMake sure assessors are addressing scrubbing audits

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MAC Audit: Pre-payment “near LUPA” S rub b f r billing u ing t l t ui kl Scrub cases before billing using a tool to quickly identify flagged episodes, monitor for appropriateness of care plan, potential for homebound issuesMonitor low-utilization episodes in progress to intervene when appropriate with increased frequency or additional disciplinesfrequency or additional disciplines

Monitor Red Flags as identified by OIG Work Plan and agency’s experience:Plan and agency s experience:

Multi-episode cases (continuous service > 1 year)High utilization, especially with low HHRGAccuracy of CBSACompliance:

Staff licensureStaff licensureSecurity of staff log ins, electronic signature verificationAbility to “copy forward” or “clone” documentation

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Compliance, cont’dF2F – content timingF2F content, timingPhysicians – eligibility (NPI, PECOS)Therapy reassessmentsBilling prior to signed ordersAudit activity related to quality reviews

D t i h i ( d i ’t) di Determine who is (and isn’t) sending you patientsGive feedback to:

Those who send you patientsThose who sign the ordersTh h ti ACOThose who are creating ACOs

Back up your funding requests with data

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Highlight data that is important to your referral partners:referral partners:

TimelinessClinical Risk MeasuresPotential for Hospice30 Day Rehospitalization

Analyze data to show which referral sources k tare key accounts:

Pay sourceUtilization / CostOutcomes

Need flexibility in your reporting Need flexibility in your reporting Answer the questions the ACO is asking:

“Readmitted within X days”“those with AMI, Heart failure, Pneumonia, COPD

Be prepared to speak to “what went Be prepared to speak to what went wrong” with readmitted, shared patients.

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With today’s data you can:E lu t th imp t f mp titi thr tEvaluate the impact of competitive threatsBuild budgetsEvaluate proposed changes in reimbursementIdentify areas requiring concerted performance improvement initiatives

Not all data is equalU k l d f i d t Use knowledge of industry, agency characteristics, landscape to shape your use of dataBe creativeMeet today’s challenges by using your data to d i d i i kidrive your decision-making

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Karen Gomes, RN, MS, CPHQVice President of Clinical ServicesHome Health VNA, Lawrence, MAk @h h lthf d tikgomes@homehealthfoundation.orgoffice: (978) 552-4101

Jayne Baugher, OT, MBAQuality and Compliance AnalystHome Health United, Madison, WIOffice: (608) 241-6933jbaugher@hhuvns.orgj g g

David Merk, MAPresidentThe Manager Inc., Waterville, MEdavid@homehealthgold.comoffice: (207) 872-4544