5/28/2010 Increase Field Staff Productivity, OASIS Accuracy and - - PDF document

5/28/2010 1

Increase Field Staff Productivity, OASIS Accuracy and Resulting Case Weight Mix

• Jeff Brittain CTO, EVP, Select Data
• Susan Carmichael MS, RN, CHCQM, COS-C,

Executive Vice President, Quality and Standards Chief Compliance Officer, Select Data

Company History

• Previous large group of Home Care providers

in Southern California

• Have been in business since 1987

S i C id i 1994

• Serving Home Care providers since 1994
• Provide Clinically Driven Revenue Cycle

Management for providers throughout US

Measurements of Agencies Health

• Simple calculations to determine agency health

» Average revenue per visit » Average cost per visit » National a erages » National averages

• What can productivity do to help?
• Efficiencies that allow smaller agencies to act

like larger organizations

5/28/2010 2

Where it all begins: Integrated OASIS Assessment

• Important that all documentation is captured and that

evidence based process are encouraged.

• Evidenced based practices mean using the best

scientific evidence available as guidance for clinical g decision making. To do so, an in-depth assessment is required.

• Different mediums of capturing data

» Paper » Point-of-care

Efficiency vs Comprehensiveness

• Efficiency is a two way street

» Getting data to field staff » Getting data back into the office or EMR

• Depending on the medium, traditionally you

will see standard differences by the various methods

Efficiency vs Comprehensiveness

• Why is efficiency important?

» Cost of field staff » Having the ability to see data real time » Billing ad antages » Billing advantages » Provides agencies to utilize advantages such as scalability » Real time means real intervention

5/28/2010 3

Efficiency vs Comprehensiveness

• Why is comprehensiveness so important

» More accurate picture of the patient » Higher coding specificity » Allo ing o to capt re all co morbities » Allowing you to capture all co-morbities » Overall higher outcomes with patients » True accurate payment reimbursement for the episode » Reduce audit risk

Efficiency vs Comprehensiveness: Accurate Picture of the Patient

• An accurate portrait of the patient as well as

clarity are needed to establish appropriate care

• Need to clearly document the focus of care

h i h d d il d

• That starts with an accurate and detailed

assessment; an assessment that properly states

• conditions. (prompts and cues)
• Goals and interventions must be directed

toward those conditions

• This leads toward higher coding specificity

Efficiency vs Comprehensiveness: Coding Specificity and Co-morbidities

• The following are diagnoses/co-morbidites that should be

included and coded on a plan of care:

• DM
• CAD
• COPD
• CHF
• PVD
• Blindness
• HTN
• Upper and lower limb amputation status
• Chronic diseases such as Parkinsons, MS, Lupus
• Hx of neoplasm if care is directed toward a current neoplasm

Source: The Coding Clinic

5/28/2010 4

Efficiency vs Comprehensiveness: The Quality of Your Documentation…

• The quality of your documentation will dictate

reimbursement.

• The quality of your documentation determines

if you will survive an audit if you will survive an audit.

• It is not the revenue you generate that is as

important, as the revenue you will keep.

Efficiency vs Comprehensiveness: Reduce Audit Risk

• RACs are thought to be targeting…
• Services are medically unnecessary or there is

delayed implementation (Focus: Therapy)

• Patients are not Homebound

Patients are not Homebound

• Services are incorrectly coded and sequenced
• Failure to provide claim supportive

documentation

• Duplicate claims submitted
• Medicare secondary pay or improper payments
• Lack of order centricity

Efficiency vs Comprehensiveness: The Audit

• Denials for lack of medical necessity…
• Full or partial denial because the clinical

documentation: Did not support the medical necessity of the skilled Did not support the medical necessity of the skilled services billed Did not demonstrate a reasonable potential for change (improvement) in the medical condition or Sufficient time had been allowed for teaching or

• bservation of response to treatment in prior episodes
• f care.

5/28/2010 5

Efficiency vs Comprehensiveness: The Audit

Do therapy treatment plans and progress notes have:

• Clear functional goal statements?
• Document progress toward goals objectively?

How is care coordinated among therapists? Among all di i li ? disciplines? How can you support “reasonableness and medical necessity?” What are the patient treatments: diagnoses? Restoration/maintenance of function affected by illness? Frequency and duration of services consistent with home care client’s: medical history, disease, prior to end of episode level

• f function, and risk identification.

Efficiency vs Comprehensiveness: The Audit

• Is therapy consistent with the nature and severity of

the condition?

• Therapy services must be provided, expecting that the

condition of the patient will improve in a reasonable p p period of time.

• Documentation of medical necessity should be

documented through evaluation, treatment plan, and progress notes.

• Has your agency identified high risk diagnosis,

number of visits, or number of episodes?

Critical Thinking Skills

• Critical thinking requires logic, relevance,

significance, accuracy, and depth.

• Clinicians, after assessments, must give due

consideration to the evidence gained context consideration to the evidence gained, context

• f those judgments, with applicable and/or

appropriate methods.

• Software does not always allow the clinician to

raise questions, gather all relevant information,

• r formulate the problem clearly.

5/28/2010 6

Integrated OASIS Assessment Capture Tool

Point of Care / Laptop

Point-of-Care Current Challenges

• Synchronization (Store and forward)
• Internet access availability (Persistent)
• Productivity (Ease of use)
• Limited assessment questions (Lack of critical

thinking skills)

• Usability (Computer literacy)
• Security (HIPAA)
• Cost or Expense (Paying for partial use)

HIPAA and HITECH

• The Health Information Technology for Economic

and Clinical Health Act (HITECH) expands upon HIPAA and holds healthcare organizations to a g higher level of responsibility for breach of patient information.

5/28/2010 7

HITECH

• Under HITECH, if a breach compromises the

privacy and security of the patient’s information and poses a significant risk of financial reputational or other harm patient financial, reputational, or other harm, patient notification is required. Additionally, the Secretary of Health and Human Services and media outlets must be notified under specific circumstances.

Side Effects of Point of Care Challenges

• Spending capital for devices and licenses
• Relying on internet availability (can not enter

assessment) b f i i ( d i i )

• Lower number of visits (productivity)
• Reduced Critical Thinking Skills (effects
• utcomes)
• Nursing retention rates (positive and negative)
• HIPAA risk exposure (what is that worth)
• Still necessity of paper chart

Integrated OASIS Assessment Capture Tool

Traditional Paper Forms

5/28/2010 8

Traditional Form Capture Challenges

• Hand keying or entering of data
• Timeliness of data into the EMR
• Limited integrated OASIS assessment choices
• Incomplete data, missing skip patterns or M

questions

• Lack of forms available or cost of forms from

vendor

• Worse for the environment (killing trees)

Side Effects of Traditional Forms

• Additional FTE’s
• Data entry errors
• Getting RAP payments done in a timely

f hi fashion

• Cost of forms
• Nursing retention rates
• Outcome challenges depending on forms

What Were Our Goals?

• Decrease the cost of deployment
• Increase outcomes and document correctly
• Increase timeliness
• Decrease the need for additional FTE’s
• Increase data capture accuracy
• Increase clinical retention
• Lastly, allow agencies to keep their current

infrastructure (if they so choose)

5/28/2010 9

What was the Solution?

• We decided to come up with a Hybrid model
• Using technology and traditional form capture

tools Ch ll i l d d

• Challenges included:

» Increased number of M questions with OASIS-C » Method of getting written data into electronic data » Integrate with existing systems

Must Have Criteria

• Outcomes must be maintained
• Provide some type of cost containment or

savings i ld ff d i i

• Increase Field staff productivity
• Can not introduce new technology that agency

would have to support (IT staff)

• Not require replacement of current EMR or

billing engine

Integrated OASIS Capture Tool

• We choose to use forms as this would keep

productivity high

• Also we can easily deploy them. No

technology challenges with field staff or technology challenges with field staff or support personnel

• Allowed the clinician to use critical thinking

skills

5/28/2010 10

Information Gathering and Care Planning

• Information gathered on forms that encouraged

professional clinical assessment with discipline specific care planning…forms built upon clinician and leader input upon clinician and leader input

• Forms based upon Adult Learning Principles

A Form using Adult Learning Principles

• There is a need to make sense of things. Adults

learn better with a perceived need.

• Connect the problem/

i / i

• pportunity/new event with the planned care

for the specific desired result. Adults appreciate clarity. Clinical forms require clinical input. Appreciation for the complexity of the job must be appreciated.

A Form using Adult Learning Principles

• Two important principles for gathering and

providing patient information are simplicity and reinforcement.

• The forms drill down for specifics such as:
• Neuropathy? What kind? Who stated this?
• If the agency wants coding to the highest

level of specificity; it starts with the data captured.

5/28/2010 11

Adult Learning Principles and the Careplan

• Find patterns that connect for the patient..Let the

patient tell what he knows about the subject and related subjects. What are his experiences with the disease process? What does the patient and the clinician wish to accomplish over the next ___weeks.

• Construct the careplan together. Sit with the

patient and state: Let’s talk about your plan of care and what you and I will be doing the next ___weeks to accomplish these. Engage the patient to discuss how they will participate in the plan of care.

Technology Used

• We would use a technology called Optimal

Character Recognition (OCR) and Optimal Marking Recognition (OMR) and would turn written data into electronic data written data into electronic data

• This would eliminate the need to hand key as

well as increase accuracy (data entry errors)

• This would speed up the time it would take to

get data into the system

Technology Used continued

• Once data was into the system, we can use

tools like OCS edits to look for incongruencies and errors

• Also create workflows that allow for
• Also create workflows that allow for

centralized processing by the agency

• Goal was to allow the field staff to be as

efficient as possible

5/28/2010 12

Process

• Allow clinicians to have the pre printed forms

to complete

• Provide guidance in substantiating

patient/client conditions patient/client conditions

• Improve documentation detail required for

coding to higher level of specificity

• Forms provide integrated process of linking

assessment data to discipline specific careplans to the medical Plan of Care (POC)

What Were the Results?

• We were able to achieve higher case weight

mix due to a more accurate and compliant assessment

• We were able to reduce the number of FTE’s
• We were able to reduce the number of FTE’s

for data entry

• We were able to reduce the cost to support

point of care technology

• We were able to increase the number of visits

provided by the field staff

What Were the Results? (con’t)

• Days to RAP were decreased
• Reduced OASIS data entry from 20 mins to

less than 5 mins d d i f OC/ 48 f 4 i

• Reduced creation of POC/ 485 from 45 mins to

less than 12 mins

5/28/2010 13

Case Studies

• A Case Study of a large home health agency

that had positive results using the identified process.

• Health Care Technology Report “Agency Uses Scanning

Health Care Technology Report Agency Uses Scanning System to Reduce Days-to-RAP from 59 to 5”

» http://homecaretechreport.com/article.php?id=1029

• http://www.selectdata.com/press-media/case-studies/select-

data-provides-cash-flow-solution-for-addus-healthcare

What Can You Do?

• Do your own basic statistical analysis

» Analyze your field staff productivity » Determine days to RAP

D l iti l thi ki kill i

• Develop critical thinking skills in your

integrated OASIS Assessment tools

• Examine your average case weight mix

» Make sure your tools are comprehensive » Make certain you analyze your processes critically

Questions and Opinions

• Your experiences
• Different thoughts or philosophy

Thank you

5/28/2010 14

Faculty Contact Information

Jeff Brittain CTO, Select Data (714) 524-2500 jeff@selectdata com jeff@selectdata.com Susan Carmichael MS, RN, CHCQM, COS-C CCO, Select Data (714) 524-2500 susanc@selectdata.com