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Home Care Alliance of Massachusetts
Financial Management Conference
December 9, 2010
Meeting the Financial Challenges
Of Implementing OASIS-C
Pat Laff, CPA
Managing Principal
OASIS-C
Is Costing You More
Reduced Revenue and Increased Cost Factors
are driven by:
– Inadequate initial and continuing education
Supervisory personnel
Quality personnel
Field clinician personnel
Clinical Management Model
Case Conferencing Model
OASIS-C
The Key Issues
OASIS-C is a moving target……
Education of Clinical Staff
– Supervisory
– Quality
– Field clinicians
Clinical Management Model
Case Conferencing Model
Incentive Compensation
Cost Drivers
Education
The Costs of Education…doing it right up front is
far less costly!
“Train the Trainer”
– Unless the “trainers” are RN, COS-C’s
– Did the “trainers” remember all that was taught?
– Did the “trainers’ teach all the they remembered?
– Have there been timely and periodic follow-up
sessions, including updates from latest Q&As?
Cost Drivers
Education
Expert Teaching onsite (by RN, COS-C)
– Private sessions provided to the entire staff
Staggered shifts including RNs and all therapists
Consistently delivered education content with Q&As
– Timely follow-up as new CMS interpretations are
revealed during monthly Q&As
– Expertise developed internally at the Quality level
– Educational tools provided to educate new staff
– Continuing resource
Cost Drivers
OASIS-C Inaccuracy
Incorrect DX codes
– May not be using a certified coder
– Must have home care RN oversight to correctly
use coding conventions and ensure presence of
support for code
Other case mix items
– Use a data scrubber to assist with OASIS
inconsistencies
– Cost is recouped by finding 1 or 2 inaccuracies
Cost Drivers
OASIS-C Inaccuracy
Reasons for OASIS inaccuracy include
– Inadequate education
– Clinical Management Model
– OASIS workflow process
Therapist involvement and timing
Quality Review
Repeatedly “fixing” errors is more costly than doing it
correctly
– Case Conference Model
Cost Drivers
OASIS-C Inaccuracy
Start The Episode On Top
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
Don’t forget…Value Based Purchasing is coming
soon to your agency!
Here Is How An Incorrect OASIS Might Impact
Episode Revenue and Outcomes…
Elizabeth Allen
Elizabeth Allen is an 85 year old woman who was admitted to
home care following hospitalization for an ORIF due to a hip
fracture as a result of a fall at home. She has insulin
dependent Diabetes Mellitus, she had an acute exacerbation
of COPD while in the hospital and the MD stated she also had
Mild Senile Dementia. She was referred to home care for
surgical wound care for an infected surgical wound, 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. She will be seen by nursing for daily dressing changes to
her surgical wound, 3xwx4 by therapy for transfer training,
gait training, strengthening and ambulation.
Elizabeth Allen
Clinician Diagnosis Coding
Diagnosis
Points
M1020 a V58.31 Aftercare for change of surgical
dressings
0
M1022 b 781.2
Gait Abnormality
0
M1022 c 250.00 Diabetes Mellitus
2
M1022 d 496.00 COPD
0
M1022 e 290.00 Dementia
0
M1022 f
0
Elizabeth Allen
OASIS
Case Mix Variables
M1030 IV Therapy
OASIS Score
Points
4
0
(None of the Above)
M1200 Vision
0
0
M1242 Pain (Daily but not constantly)
3
1
M1308 Pressure Ulcers
0
0
M1320 Most Problematic Pressure Ulcer
0
0
M1330 Stasis Ulcer
0
0
M1342 (Most Problematic) Surgical Wound
3
4
Elizabeth Allen
OASIS
M1400 Dyspnea
1
0
M1620 Bowel Incontinence
0
0
M1630 Ostomy
0
0
M1700 Cognitive Functioning*
2
N/A
1
N/A
0
N/A
0
0
When walking 20 feet or climbing stairs
Requires assistance and some direction in specific situations
M1740 Behaviors*
Significant memory loss so that supervision is required
M2020 Oral Medications*
Able to independently take correct medications at correct times
M2030 Injectable Drug Use*
Able to independently take the correct medications at correct times
Total Clinical Points
7
Elizabeth Allen
Functional Scores
M1810 / 1820 Upper OR Lower Body Dressing
1
2
2
M1830 Bathing
2
3
M1840 Toilet Transferring
2
2
M1850 Transferring
2
0
M1860 Ambulation
2
1
Total Functional Points
8
Elizabeth Allen
Revenue
Table 6 NRS Points = 14
C2 F3 S5
(Non healing surgical wound)
(Table 6) NRS Severity Level = 2
Case Weight = 1.7737
HHRG + NRS Revenue =
(Table 6) NRS Revenue =
Revenue =
$51.96 + $4,102.46
Total Revenue =
$51.96
$4,102.46
$4,154.42
Elizabeth Allen
OASIS EDITS - VBP
The Quality Review staff identified the following issues;




M1342 was a score 3 (Non Healing Surgical Wound) and there was
no diagnosis listed in M1020 or M1022 to support the (complicated)
non-healing surgical wound
ICD-9 496.00 is a general DX with no associated points for revenue.
Her hospitalization information indicted an acute exacerbation of
chronic bronchitis (COPD).
ICD-9 290.00 DX is a non-specific general code with no associated
case mix points and her MD stated she had stated that she had
senile dementia.
An inconsistency was identified with a score of 2 at M1700 and a
score of 1 at M1740 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.
Elizabeth Allen
Coding Corrections
Diagnosis
Points (Table 2a)
M1020 a
998.59 Post Operative Infection
10
M1022 b
781.2 Gait Abnormality
0
M1022 c
250.00 Diabetes Mellitus
2
M01022 d
491.20 COPD (Chronic Bronchitis) 1+1 Amb. Score 2
M01022 e
331.2
2
1
Dementia
(Psych 2)
M021022 f
*(Aftercare codes are not used with wound complications)
Elizabeth Allen
Coding Corrections
4
M1930 IV Therapy
0
(None of the Above)
M1200 Vision
0
0
M1242 Pain
2
1
M1308 2 or ↑ Pressure Ulcers Stage 3 or 4
0
0
M1320 Problematic Pressure Ulcers
0
0
M1330 Stasis Ulcer
0
0
M1342 Surgical Wound
3
4
Elizabeth Allen
Coding Corrections
M1400 Dyspnea
When walking 20 feet or climbing stairs
1
0
M1620 Bowel Incontinence
0
0
M1630 Ostomy
0
0
M1700 Cognitive Functioning*
Requires assistance and some direction in specific situations
2
N/A
M1740 Behaviors*
Significant memory loss so that supervision is required
1
N/A
M2020 Oral Medications*
Able to independently take correct medications at correct
times
0
N/A
M2030 Injectable Drug Use*
Able to independently take the correct medications at
correct times
0
1
Total Clinical Points
21
Elizabeth Allen
No Change
M1810 / 1820 Upper OR Lower Body Dressing
1
2
2
M1830 Bathing
2
3
M1840 Toilet Transferring
2
2
M1850 Transferring
2
0
M1860 Ambulation
2
1
Total Functional Points
9
Elizabeth Allen
Coding Corrections
(Table 6) NRS Points = 37
HHRG Score = C3F3S5
(Table 6) NRS Severity Level = 4
NRS Revenue =
Case Weight = 1.9413
$211.69
Revenue =
$4,490.11
Total Revenue =
$4,701.80
+ $547.38
Elizabeth Allen
OASIS Edits/Corrections Revenue
Let’s Recap the Change After Editing:
– Change in the HHRG due to ↑in clinical points
C2 F3 S5 to a C3 F3 S5
$4,102.46 to = $4,490.11= + $387.65
– Change in NRS Revenue
Severity Level 2 to Severity Level 4
$51.96 to $211.69 =
+ $159.73
Total additional revenue =
$547.38
Questions Often Asked
Recommended Clinical Model:
– Primary Clinician – Care Management
Recommended Clinicians to Supervisor
– Up to 10 FTEs
Recommended Case Conference Model
– Every 14 Days (voice to voice) from SOC date
Productivity and Case Capacity
– RNs:
minimum 25 – 27 visits (hands on) / week
25 – 30 Patients (without Telemedicine)
– PTs & OTs: minimum 27 – 30 visits (hands on) / week
Educate Managers
Home Care Management (including Supervisors) must
have a solid understanding of:
–
–
–
–
–
–
–
–
–
–
–
OASIS-C Process Measures
Case Weights
Timeliness of RAP Submission
OASIS Errors by Clinician
OASIS Corrections Completed
Cases Managed per Clinician
Average # of Therapy Visits per Episode
Average Visits per Episode
Productivity by Discipline – Actual
Outcomes Improvement
Patient Declines
Weekly Management Report
Mon
Total Referrals
No. of Admissions – (Intake – Managers)
No. of Ended Episodes Transmitted (Finance)
Average Closed Episode Revenue (Finance)
No. of Telephone Calls made to patients seen 1x w or less
(documentation required to support call)
No. of Tele-monitors in Use (on day specified) (Managers)
Total no. of Actual Visits made by all RNs (Managers)
No. of Transfer OASIS completed (by clinicians)
No. of Patient Transfers (unplanned hospitalizations- reasons for transfers –
attach short audit form – send to PI)
No. of OASIS transmitted (Business Office – Finance)
Total % of OASIS Errors corrected (data scrubber system)
Total no. of OASIS Errors Not Corrected –outstanding (data scrubber system)
Caseload/Census by Case Manager (separate list)
No. of Actual Visits made by RNs (List by Team and Name below)
Tue
Wed
Thu
Fri
Sat
Sun
Total
Financial Impact of
OASIS-C
Differences in the types of visits (and OASIS C) effect per
visit costs
–
–
–
–
–
Admission – takes longer due to added process measures
Follow-up – may take longer due to new incentives to assess
for pain and other ongoing issues
Resumption – takes longer due to need for more thorough
assessments and medication reconciliation and contact with
MD
Recertification
Discharge – may take longer due to need to “look back” into
the episode to answer some OASIS questions.
Provide the Right Tools
“Point of Care”
Having a Wireless feature and “Air cards” for Clinician
laptops actually reduces cost per visit and facilitates:
Remote syncing to system
Access by all disciplines to most recent documentation
Email and team communications
Transmission of patient Admission information
Facilitates Clinical Case Conferencing
– Clinician and supervisor (team leader) referring to same patient records
Provides complete up to date patient records for oncall
Ordering non-routine medical supplies directly from vendor
At a cost of approximately $2.00 per day per clinician per day
versus lost visits due to office time and travel!
OASIS-C and the
Direct Cost per Visit
All OASIS visits require additional effort!
Relative OASIS visit weights have increased
Productivity of salaried and hourly staff has declined
Overtime compensation for non-exempt clinicians has
increased to accomplish the same number of average
visits per day
Staffing issues
– Covering visits
– Admitting patients
Compensation based upon effort versus time changes
this dynamic, improves productivity, improves
outcomes and controls the direct cost per visit!
Control the
Direct Cost per Visit
Incentive Based (Exempt) – Field Clinicians
Visit Rates
– Structured by Type and Weight of Visit, including Telephone
Follow-up Visits and Meetings
Case Management Fee for Cases Managed (RN, PT & ST)
in a Calendar Month
Paid Days Off Based Upon Average Daily Earnings
Quarterly (12 week) Incentives
– Visit Productivity
– Patient Cases Managed
– Outcomes Achieved
OASIS C measurements (real-time) & Home Health Compare scores
HHCHAPS results
Control The
Direct Cost per Visit
Incentives – Clinical Supervisors (Team Leaders, etc.)
Bonus Incentives – Staff achievement for Visit
Productivity, Cases Managed and Outcomes
Additional Incentives for staff achievements:
–
–
–
–
Admissions within 24 hours
Timeliness of submitted documentation
Reduction of corrections required for OASIS
HHCHAPS results
Questions Often Asked
Visit weighting – Based the Requirements and
Complexities of completing OASIS C
– Admission (evaluation) visit
– Resumption visit
– Recertification Visit
– Discharge Visit
– Follow-up Visit
– Virtual Telephone Visit (Telehealth)
1.90
1.30
1.20
1.25
1.00
0.25
Questions Often Asked
( Visit Weight – Time Equivalents Based upon OASIS C)
Visits per
Day
Follow-up
Admission
Resumption
Recert.
Discharge
Visit Value
1.00
1.90
1.30
1.20
1.25
5.00
96 minutes
1hr 36min
182.4 minutes
3 hrs 2min
124.8 minutes
2 hrs 5min
5.25
91.4 minutes
1hr 31 min
173.7 minutes
2hrs 54min
118.9 minutes
1hr 59min
109.7 minutes
1hr 50min
114.3 minutes
1hr 54min
5.50
87.3 minutes
1hr 27min
165.8 minutes
2hrs 46min
113.5 minutes
1hr 53min
104.7 minutes
1hr 45min
109.9 minutes
1hr 49min
5.75
83.5 minutes
1hr 23min
158.6 minutes
2hrs 39min
108.5 minutes
1hr 49min
100.2 minutes
1hr 40min
104.4 minutes
1hr 44min
6.00
80 minutes
1hr 20min
152 minutes
2hrs 32min
104 minutes
1hr 44min
96 minutes
1hr 36min
100 minutes
1hr 40min
115.2 minutes
1 hr 55min
120.0 minutes
2 hrs
All times include hands-on, documentation, travel, conference and case management time
Contact Information
Pat Laff, CPA
Managing Principal
Laff Associates
Consultants in Home Care & Hospice
Phone: (843) 671-4170
Email:
[email protected]
Website: www.laffassociates.com