Achieving Optimal Clinical Management and Financial Balance Pat Laff, CPA, Managing Principal Lynda Laff, RN, BSN, COS-C, Principal.

Achieving Optimal Clinical Management and Financial Balance

Pat Laff, CPA, Managing Principal

Lynda Laff, RN, BSN, COS-C, Principal

• Federal Register/Vol. 74, No. 44, Monday, March 9, 2009– CMS ultimately plans to create a standard patient assessment that

can be used across all post-acute care settings. • New Process Measures -

• OASIS – C was not intended to impact payment policy and OASIS items used in the payment algorithm were assessed to make sure they were not changed in a way that would affect the payment algorithm. Once OASIS data are collected it will be possible to assess whether they could be useful for refinements to the case mix adjustor.

• All information in OASIS –C will be considered for use in the updated risk-adjusted models that will be applied to OASIS – C based outcome measures in Home Health Compare, OBQI and OBQM measures.

OASIS –C: Public comments & Responses

OASIS-C…Fast Track to P$P

• “Provide the right amount of care efficiently and effectively to achieve anticipated or desired patient & financial outcomes”

Clinical Episode Management Goal

Human Resources…

• Make sure you have the right people in the right positions

• All registered nurses are NOT case management material– A warm body doesn’t cut it!

• All PTs are NOT team players….• An experienced nurse is not always a qualified coder or

quality review nurse…• An excellent field clinician is not always an excellent

manager• A scheduler is NOT a manager of patient care

• Clinical Management Information – Key Indicators– Routine Reports

• Education– Clinical assessment– OASIS Accuracy

• Supervision & Oversight - Vigilance– Documentation Timeliness – Care Plan Development

• Continuity– Case management– Clinical model

• Accountability/ Responsibility– Reward / incentive– Corrective Action

Components of Clinical Episode Management

• Case Weight• Timeliness of RAP Submission• OASIS Errors by Clinician• OASIS Corrections Completed• Cases Managed per Clinician• % of Therapy Visits per Threshold• Average visits per episode• Outcomes Improvement • Patient Declines• Productivity by discipline - Actual Actual

Key Management Indicators

• OASIS education must be thorough, credible and ongoing

• The cost to educate properly will be a fraction of the dollars you will lose… if you don’t!

• OASIS accuracy or inaccuracy goes right to the bottom line.

• Put your money where it will have the most effect..• SOC assessment determines revenue and outcomes• Value Based Purchasing – SOC = risk adjustment• Declines will be even more expensive in P4P

Education

Oasis ACCURACY IS THE KEY

• OASIS accuracy is a key driver of clinical and financial performance

• OASIS – C is the New Key Driver for payment under Value Based Purchasing

• Clinician assessment accuracy is critical to patient outcome improvement AND agency financial success

– Clinician assessment determines case weight and revenue– Clinician assessment determines non-routine supply revenue– Clinician assessment and completion of OASIS - C process Clinician assessment and completion of OASIS - C process

items will affect aggregated score for VBPitems will affect aggregated score for VBP

CMS - Value Based Purchasing

• Currently hospital payment is contingent upon;– Aggregation of performance with process measures,

patient care measures and patient satisfaction measures (HCAHPS)

• Home Health Care P4P– OASIS-C provides Home Health Care P4P information

• Outcome Measures• Process Measures

• Implementation of – HH-CAHPS

Process Outcome MeasuresHome Health Compare

Timely Initiation Of Care(Timely Care)

% of home health episodes of care during which the start or resumption of care date was either on the physician-specified date or within 2 days of the referral date.

(M0102) Date of Physician-ordered Start of Care(M0104) Date of Referral(M0030) Start of Care Date(M0032) Resumption of Care Date(M0100) Reason for Assessment

Depression Assessment Conducted(Assessment)

% of home health episodes of care during which patients were screened for depression (using a standardized depression screening tool) at start of home health car

(M1730) Depression Screening

Multifactor Fall Risk Assessment Conducted For Patients 65 And Over(Assessment)

Percentage of home health episodes of care in which patients 65 and older had a multi-factor fall risk assessment at the start of care/resumption of care.

(M1910) Multi-factor Fall Risk Assessment(M0066) Birth Date(M0090) Date Assessment Completed

Pain Assessment Conducted(Assessment)

Percentage of home health episodes of care during which the patient was assessed for pain, using a standardized pain assessment tool, at start/resumption of home health care

(M1240) Pain Assessment using a standardized pain assessment tool


Pressure Ulcer Risk Assessment Conducted(Assessment)

% of home health episodes of care in which the patient was assessed for risk of developing pressure ulcers at start of care/resumption of care.

(M1300) Pressure Ulcer Risk Assessment

Pressure Ulcer Prevention In Plan Of Care(Care Planning)

% of home health episodes of care in which interventions to prevent pressure ulcers were included in the physician-ordered plan of care for patients assessed to be at risk for pressure ulcers.

(M2250) f. Intervention(s) to prevent pressure ulcers plan of care

Diabetic Foot Care And Patient/Caregiver Education Implemented During Short Term Episodes Of Care(Implementation)

% of short term home health episodes of care during which diabetic foot care and education specified during the physician-ordered care plan was implemented for patients with diabetes.

(M0100) Reason for Assessment (M2400) a. Diabetic foot care intervention(s)


Heart Failure Symptoms Addressed During Short Term Episodes Of Care(Implementation)

Percentage of short term home health episodes of care during which patients exhibited symptoms of heart failure for whom appropriate actions were taken

(M0100) Reason for Assessment (M1510) Heart Failure Follow-up:

Pain Interventions Implemented During Short Term Episodes Of Care(Implementation)

Percentage of short term home health episodes of care during which the patient had pain and pain interventions were included during the care plan and implemented by the end of the episode.

(M0100) Reason for Assessment (M2400) d. Intervention(s) to monitor and mitigate pain

Drug Education On High Risk Medications Provided To Patient/Caregiver At Start Of Episode(Education)

Percentage of patients/caregivers educated about high-risk medications at start/resumption of care and instructed on how to monitor the effectiveness of drug therapy, how to recognize potential adverse effects, and how and when to report problems.

(M2010) Patient/Caregiver High Risk Drug Education


Drug Education On All Medications Provided To Patient/Caregiver During Short Term Episodes Of Care(Education)

Percentage of short term home health episodes of care during which patient/caregiver was instructed on how to monitor the effectiveness of drug therapy, how to recognize potential adverse effects, and how and when to report problems

(M0100) Reason for Assessment (M2015) Patient/Caregiver Drug Education Intervention

Influenza Immunization Received For Current Flu Season(Prevention)

Percentage of home health episodes of care during which patients received influenza immunization for the current flu season

(M1040) Influenza Vaccine(M1045) Reason Influenza Vaccine not received

Pneumococcal Polysaccharide Vaccine Ever Received(Prevention)

Percentage of home health episodes of care during which patients were determined to have ever received Pneumococcal Vaccine (PPV).

(M1050) Pneumococcal Vaccine (M1055) Reason PPV not received


Potential Medication Issues Identified And Timely Physician Contact At Start Of Episode(Prevention)

Percentage of patients whose drug regimen at start or resumption of home health care was assessed to pose a risk of clinically significant adverse effects or drug reactions and whose physician was contacted within one calendar day.

(M2002) Medication Follow-up

Potential Medication Issues Identified And Timely Physician Contact During Short Term Episodes Of Care(Prevention)

Percentage of home health episodes of care in which the patient's drug regimen during the episode was assessed to pose a risk of significant adverse effects or drug reactions and whose physician was contacted within one calendar day.

(M0100) Reason for Assessment (M2004) Medication Intervention

Pressure Ulcer Prevention Implemented During Short Term Episodes Of Care(Prevention)

Percentage of home health episodes of care in which interventions to prevent pressure ulcers were included in the physician-ordered plan of care and implemented since the previous OASIS assessment.

(M0100) Reason for Assessment (M2400) e. Intervention(s) to prevent pressure ulcers

Cardiac Status

(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the previous OASIS assessment? ⃞ 0 - No [ Go to M2004 at TRN; Go to M1600 at DC ] ⃞ 1 - Yes ⃞ 2 - Not assessed [Go to M2004 at TRN; Go to M1600 at DC ] ⃞ NA - Patient does not have diagnosis ofheart failure [Go to M2004 at TRN;Go to M1600 at DC

Time Points: Transfer/D/CLaff Associates 2009 15

Heart Failure Follow Up

(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond? (Mark all that apply.) ⃞ 0 - No action taken

⃞ 1 - Patient’s physician (or other primary care practitioner) contacted the same day ⃞ 2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room) ⃞ 3 - Implemented physician-ordered patient-specific established parameters for treatment ⃞ 4 - Patient education or other clinical interventions ⃞ 5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)

Time Points: Transfer/D/C

Laff Associates 2009 16

(M2250) Plan of Care Synopsis: Does the physician-ordered plan of care include the following: Time Points: SOC/ROC

Plan / Intervention No Yes N.A Not Applicable

a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings

0 1 2

Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical 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 2 Patient is not a diabetic or is a bi-lateral amputee

c. Falls prevention interventions 0 1 2 Patient is not assessed to be at risk for falls

d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment 0 1 2 Patient has no diagnosis or symptoms of depression

e. Intervention(s) to monitor and mitigate pain 0 1 2 No pain identified

f. Intervention(s) to prevent pressure ulcers 0 1 2 Patient is not assessed to be at risk for pressure ulcers

g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician

0 1 2 Patient has no pressure ulcers with need for moist wound healing.


(M2400) Intervention Synopsis: Since the previous OASIS assessment,were the following interventions BOTH included in the physician-ordered

plan of care AND implemented? Time Points: Discharge/Transfer

(M2400) Intervention Synopsis: (Check only one box in each row.) Since the previous OASIS assessment,

were the following interventions BOTH included in the physician ordered plan of care AND implemented?

Plan / Intervention No Yes N/A Not Applicable

a. 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 2 Patient is not a diabetic or is a bi-lateral amputee

b. Falls prevention interventions 0 1 2Formal multi-factor Fall Risk Assessment indicates the patient was not at risk for falls since the last OASIS assessment

c. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment

0 1 2Formal assessment indicates patient did not meet criteria for depression AND patient did not have diagnosis of depression since the last OASIS assessment

d. Intervention(s) to monitor and mitigate pain 0 1 2 Formal assessment did not indicate pain since the last OASIS assessment

e. Intervention(s) to prevent pressure ulcers 0 1 2Formal assessment indicates the patient was not at risk of pressure ulcers since the last OASIS assessment

f. Pressure ulcer treatment based on principles of moist wound healing

0 1 2Dressings that support the principles of moist wound healing not indicated for this patient’s pressure ulcers OR patient has no pressure ulcers with need for moist wound healing


• Education without validation and reinforcement is Money down the drain!

• How do you know?• What checks are in place?• How long does it take?• Who is validating what?• Were the suggested corrections actually made?• What “tools” do you use?• Are there repeated errors? If so – WHY?

– Repeated errors cost money

Supervise and Manage

• Average case weight – by month and by clinician on EOE• Clinician productivity – actual visits not equivalents!!!

– Expected versus actual– Number of patients managed by case manager over time– Total number of admissions (weekly, monthly)

• Documentation timeliness • Documentation accuracy• Average visits per patient within national benchmark or better• Outcomes better than state & national benchmark• Number or percent of OASIS errors• Number of OASIS corrections actually made (are you accepting excuses?)• LOS higher than national benchmark• Number of patient improvements & declines

Supervise & Manage

• Continuity = patient management• Admission Nurse Model

• Hand-offs = errors• The more staff involved – the less the accountability

• Clinical model must insure actual case management• Primary nursing• Adequate ratio of nurses/therapists to patients• Productivity expectations must be reasonable

Continuity

• Primary clinician• May be RN or PT

– Must be accountable for patient and financial outcomes

– Accurate assessment– Appropriate care plan– Constant knowledge of;

• Goals of care• Projected visits vs. actual• Team performance – Therapists must be included in the

team• Patient response to care• Need for change in plan

Accountability

• Review of patients on census – not a 2 hour meeting!• Expect clinician to be prepared• Manager must question;

– Clinician “does not know patient”– “Cookie cutter” scheduling– Visits never increase or decrease – always a 60 day

episode– Patient declines occur frequently– Abundance of “missed visits”– LOS longer than national benchmark– Extraordinarily low case weight

Case Conference

Clinical Efficiency And Effectiveness

• Learn to be efficient AND effective– Higher base rate of $2,312.94

• Provide care the patient really needs!• Focus on newest technologies • Improve clinical knowledge, skills and practice

Operational Efficiency

Think “Process”• Accurate Care Planning

– Right number of home visits – no more – no less• Efficient workflow processes

– Focus on doing it right the first time – not constant correction for poor performance

– Don’t duplicate work processes– Right staff performing clerical tasks – time is money

• Use of Tele-monitoring – To identify incremental changes in the patient’s condition

• Intervene in a timely manner• Prevent unnecessary hospitalizations

– To provide the right amount of CARE most efficiently and effectively

• 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

• Manage the patient care episode by teaching case managers how to manage

• Hold them accountable…

Here Is How An Incorrect OASIS Might Impact Episode Revenue and Outcomes…

Start The Episode On Top

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.

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

Case Mix Variables OASIS Score Points

M1030 IV Therapy 4(None of the Above)

0

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

OASIS

OASIS

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 0

Total Clinical Points 7

Functional Scores

M1810 / 1820 Upper OR Lower Body Dressing 12

2

M1830 Bathing 2 3

M1840 Toilet Transferring 2 2

M1850 Transferring 2 0

M1860 Ambulation 2 1

Total Functional Points 8

Revenue

Table 6 NRS Points = 14(Non healing surgical wound)

C2 F3 S5

(Table 6) NRS Severity Level = 2 (Table 6) NRS Revenue = $51.96

Case Weight 1.7737 Revenue = $4,102.46

HHRG + NRS Revenue = $51.96 + $4,102.46

Total Revenue = $4,154.42

OASIS EDITS - P4P

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.

OASIS EDITS - P4P

The Quality Review staff discussed the patient with the clinician and the intake nurse; together they determined that wound care for the infected wound was the primary reason the patient was referred; physical therapy was the additional reason for the referral.

M1020 should be a non-healing surgical wound DX. They also discussed the diagnoses of COPD and Dementia with the intake staff and reviewed the referral documentation that indicated an acute exacerbation of CHF. They also noted that the MD has specifically indicated the patient had senile dementia, a DX with associated case mix points. They discussed the DX with the clinician and suggested a change in the DX codes.

They reviewed the scoring inconsistencies with the clinician and the clinician corrected the OASIS to reflect a score of 1 at M02020 (management of oral meds) and M2030 (management of injectable meds).

Without these corrections, outcomes in medication management would potentially have declined; with the correction, outcomes will remain stable (no decline) and P4P will not be in jeopardy.

→ With OASIS accuracy - look what happened to the episode revenue….

Coding Corrections

Diagnosis Points (Table 2a)

M1020 a 998.59 Post Operative Infection 10M1022 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 2M01022 e 331.2 Dementia (Psych 2) 1

M021022 f*(Aftercare codes are not used with wound complications)

Coding Corrections

M1930 IV Therapy4

(None of the Above)

0

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

Coding CorrectionsM1400 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

No Change

M1810 / 1820 Upper OR Lower Body Dressing 12

2

M1830 Bathing 2 3

M1840 Toilet Transferring 2 2

M1850 Transferring 2 0

M1860 Ambulation 2 1

Total Functional Points 8

Coding Corrections = $547.38

(Table 6) NRS Points = 37 HHRG Score = C3F3S5

(Table 6) NRS Severity Level = 4 NRS Revenue = $211.69

Case Weight = 1.9413 Revenue = $4,490.11

(HHRG Revenue + NRS $ = Episode Revenue)

$4, 490.11 + $211.69 =Total Revenue = $4,701.80

+ $547.38

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

• “Provide the right amount of care efficiently and effectively to achieve anticipated or desired patient & financial outcomes”

Clinical Episode Management Goal

Clinicians and Finance…A Language Apart

• Patient Outcomes vs. Bottom Line• Home Health Compare Scores vs. Unit Costs• Case Weights vs. Realized Revenue• Diagnosis (Disease) Management vs. Episode Costs


Clinicians learned financial language quicker thanFinance has been learning clinical language andoperations because Clinicians already understand that:

• Accurate assessments generate the most appropriate Case Weights that translate into revenue

• Good outcomes with fewer visits reduces costs• Productivity, increased case capacity and efficiency

result in lower unit costs• Better Home Health Compare scores will mean

increased revenue under Value Based Purchasing


As a CFO you need to understand the Bottom Line Impactof…

– Disease Management…the most appropriate disease specific levels of care

– Patient Case Management…the most appropriate frequencies and duration of visits by discipline

– Primary Nursing Model…OASIS C implications and the consistency and continuity of care

– Positive Outcomes and Home Health Compare Scores..VBP– Staff Satisfaction…Positive Outcomes and recognition are a

“feel good”!

Knowledge is Everything!


How much time has your finance staff spent– In the field with Clinicians making visits?

• Have the CFO make an admission visit with a clinician!– At patient staff meetings to learn and truly

understand the ongoing care planning process?– Really trying to understand OASIS C? IT IS ADVANCED

ROCKET SCIENCE! – Understanding documentation requirements and the

time required? – Point of Care technology?– Travel patterns

Clinicians and Finance…A Common Language

Clinicians and Finance have to listen to each other and understand what is being said!

– A sincere willingness to learn– A willingness patiently teach without being

condescending– Improvement in the levels of understanding is

critical


The Clinicians generate the revenue and determinethe related unit expense components. They shouldunderstand:

• What contributes to Direct Costs of their discipline and those they case manage, and

• What comprises Indirect Costs, over which they have little control


The Finance staff need to learn and understand:• Differences in visits (and OASIS C) and how they effect

per visit costs– Admission– Follow-up– Recertification– Discharge

• How different diagnoses effect the length of a visit and the documentation requirements

• How visit frequency factors and diagnostically specific standards of practice effect productivity, efficiency and costs per visit and episode of care

Necessary Financial Drilldowns

• Revenue Recognition as Costs are incurred• Identify Accurate Direct Costs by Discipline, Supply

and Tele-health day• The Measure of Average Visits by Discipline and

Supply Use by Diagnosis and Cost

Calculating Direct Costs Per Visit

Calculating Direct Costs Per Visit

Calculating the Direct Cost Per Telemedicine Day

Elizabeth AllenRevenue and Cost Analysis

Discipline VisitsCharge

per Visit*Recognized

RevenueCost

Per Visit*Cost per

Discipline/NRSProfit(Loss)

Skilled Nursing - Admission 1 $ 175.00 $ 175.00 $ 121.10 $ 121.10 $ 53.90

Skilled Nursing – Follow-ups 9 $ 150.00 1,350.00 $ 121.10 1,098.90 251.10

Physical Therapy 15 $ 160.00 2,400.00 $ 120.34 1,805.10 594.90

Speech Therapy - $ 160.00 - $ 124.89 - -

Occupational Therapy - $ 160.00 - $ 124.66 - -

Medical Social Service - $ 160.00 - $ 117.60 - -

Home Health Aides 11 $ 55.00 605.00 $ 51.44 565.84 39.16

Adjustment(Visit Charge Variance) -39.89 -39.89

$ 4,490.11 $ 3,590.94 899.17

Non-Routine Supplies 186.23 169.30 16.93

Adjustment (Supply Charge Variance) 25.46 25.46

TOTAL* Actual charges and costs from a large VNA in the Northeast adjusted to base rate!

36 $ 4,701.80 $ 3,760.24 $ 941.56

Disease SpecificProfitability Analysis

• Disease specific Standards of Practice, subject to designed variation, quantifies the resources to be used and the cost of those resources

– Staffing– Incorporate telemedicine into a telehealth approach– Projected episode gross profit and net profit (loss)

• Profit planning (budget) and forecasting based upon case mix, not a single average case weight

– Determine average revenue for specific disease (average of the specific Case Weight values)

• Comparison of actual practice to designed standards– Should the standard be modified or was the variation patient specific?

The Value of Telemedicine

• The acquisition cost (purchase or lease) should be considered an Operational Direct Cost, not a Capital Expenditure

• The physiological data, not an IT System scheduler, identifies when hands-on visit are needed

• Reduces the number of nursing visits per episode, depending upon specific Disease Management protocol

• Increases RN Case Capacity by approximately 5 patients• Increases patient observation to 7 days a week• Telehealth improves outcomes and reduces re-

hospitalizations

Diagnosis - CHF

• *Average Visits per Patient Episode (all diagnoses) 13.00• *Average Visits per CHF Episode 12.33• *Average Visits per “Frequent Flyer” CHF Episode

with Telehealth Disease Management Protocol (43 Episodes) 15.68

SN 9.30PT 3.90OT 0.95ST 0.09MSW 0.14HHA 1.30

The selected “frequent flyer” patients have a re-hospitalization rate of 10% -- What a great result!

* Based upon information and data from the VNA of Western Pennsylvania – December 1, 2009 – February 28, 2010

Diagnosis – CHFThe Cost

Standards of PracticeVNA of Western PA

Average Visits Average Visits all Episodes Telehealth Episodes

Visits Cost/Visit Cost Visits Cost/Visit Cost SN 5.95 $121.10 $ 720.55 9.30 $121.10 $1,126.23 PT 3.90 $120.34 469.33 3.90 $120.34 469.33 OT 0.95 $124.66 118.43 0.95 $124.66 118.43 ST 0.09 $124.89 11.24 0.09 $124.89 11.24 MSW 0.14 $117.60 16.46 0.14 $117.60 16.46 HHA 1.30 $ 51.44 66.87 1.30 $ 51.44 66.87 $1,392.88 $1,798.66

Are the Outcome results worth the additional $405.68 per episode tothe Agency? To the Hospital? To the patient and their family?

Questions Often Asked

• Recommended Clinical Model:Primary Nurse – Care Management

• 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

Questions Often Asked

• Visit weighting – Based the Requirements and Complexities of completing OASIS C

Visit Weight

Time

– Admission (evaluation) visit 1.90 182 min– Resumption visit 1.30 125 min– Recertification Visit 1.20 115 min– Discharge Visit 1.25 120 min– Follow-up Visit 1.00 96 min– Virtual Telephone Visit (Telehealth) 0.25 24 min

Weekly Management Report

Mon Tue Wed Thu Fri Sat Sun TotalTotal 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)

Performance Incentives for all Agency Staff

Design a Comprehensive Agency-wide IncentiveThat Will Unify the Agency Culture

These Incentives are Best Achieved using a Primary Nurse Care Model• Improved Clinical Outcomes

– Homecare Compare Scores– Outside Benchmarking– Reduced Non-planned Re-hospitalizations and Emergency

Department Incidents• High Risk Patients

– OASIS Timeliness and Accuracy– Development of Disease Management Standards of Practice Adopting

“State of the Art” Clinical Technology• Patient Satisfaction• Admission Within 24 Hours of Referral

Performance Incentives for all Agency Staff

Design a Comprehensive Agency-wide Incentive That Will Unify the Agency Culture

• Administrative and Financial Outcomes– Timeliness of OASIS Submissions, RAPs, Signed Orders, End of

Episode Billing (no recoupments)– Achieving Planned Costs per Unit of Service– Achieving Planned Process Productivity– Reduced Absenteeism – Sick Days

• Increased Referrals– New Referral Sources– Additional Referrals from Existing Sources

Lynda Laff, RN, BSN, COS-CPat Laff, CPA

Laff AssociatesConsultants in Home Care & HospicePhone: (843) 671-4170

Email: [email protected]@laffassociates.com

Website: www.laffassociates.com

Contact Information

Achieving Optimal Clinical Management and Financial Balance Pat Laff, CPA, Managing Principal Lynda Laff, RN, BSN, COS-C, Principal.

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