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Presented by:Lynda Laff
Pat Laff
Laff Associates 2011
2011 HHFMA Financial Management Conference
Optimize Clinical & Financial Outcomes by Enhancing Episode Management
Managing Smarter
Efficient Home Care Means… Less care?Fewer staff?Cut middle management? Eliminate PI programs?Hiring freeze?Eliminate all educational travel?No IT system upgrades???No “tools”?
REALLY?Laff Associates 2011
How Did We Get Here?
Escalating health care costs – all sectors of the delivery systemCMS identified home care “behavioral changes” to influence paymentPractice variation among providersContinued potentially avoidable eventsSlow outcomes improvementContinued re-hospitalization
Laff Associates 2011
Continued Increase In Home Health Care Utilization
1997 2000* 2009 1997–2000
2000–2009
Agencies 10,917 7,528 10,961
-31% 46%
Total spending (in billions)
$17.7 $8.5 $18.9 -52% 123%
Users (in millions) 3.6 2.5 3.3 -31% 32%
Number of visits per user
72.6 36.8 39.4 -49% 7%
% of FFS beneficiaries who used home health services
10.5% 7.4% 9.4% -30% 27%
Number of visits (in millions)
258.2 90.6 129.6 -65% 43%
Visit type (percent of total)
Skilled Nursing 41% 49% 55%
Home Health Aide 48% 31% 16%
Therapy 10% 19% 28%
Medical Social Services 1% 1% 1%
Laff Associates 2011
Costs Increase But… Outcomes Do Not Improve
Costs continue to escalate with little improvement in outcomesMajor variations in the cost of care delivery vs. patient outcomesNo substantial improvement in re-hospitalization ratesHigh numbers of potentially avoidable eventsInadequate communication and coordination of patient care
Laff Associates 2011
Statistics Don’t Lie
Medicare hospital patients in 2006 – 2007, readmitted for the same conditions that prompted their initial hospitalization” (AHRQ 2010)
25%
Medicare hospital patients were readmitted in 30 days in 2009 20%Medicare patients re-hospitalized within 90 days 34%Medicare patients experiencing multiple hospital admissions (AHRQ, 2010).
42%
Medicare patients experiencing multiple emergency department (ED) visits. (AHRQ, 2010).
38%
30-day Medicare readmission rates varied (2009)
http://medpac.gov/documents/Jan11_RegionalVariation_report.pdf
12.9% Oregon
22.7% D.C.
Statistics Don’t LieMedicaid patients experienced multiple hospital admissions 23%Medicaid patients went to the ED more than once” (AHRQ, 2010).
50%
Hospitalized patients over 65 discharged to a long term care or other institution
21%
Medicare SNF residents readmitted to the hospital 25%Individuals with chronic conditions—may see multiple physicians in one year
16 MDs
Medicare hospital patients in 2003 that saw 10 or more physicians during their stay.
41.9 – 70%
Medicare patients readmitted within 30 days that do not receive any post-discharge care before readmission
64%
Medicare patients readmitted within 30 days did not have a physician follow-up visit
50%
Patients who have problems with medicationswithin the 1st week of discharge
70%
Cost Savings
Cost of hospital readmissions $15 Billion Annually
Potentially avoidable hospital readmissions 13.3%
Savings if potentially avoidable hospital readmissions were prevented
$12 Billion Annually
MedPac FindingsCapacity and supply of providers: Agency participation is at record levels
In 2010, HHAs numbered more than 11,400 with a net increase of 527 agencies. “Number of agencies has exceeded the high watermark of the 1990s, when the number of agencies exceeded 10,900. The high rate of growth is particularly concerning because new agencies appear to be concentrated in areas with fraud concerns, including California, Texas, and Florida”.
Laff Associates 2011
MedPac Findings
Volume of services continues to rise Beneficiaries without a prior hospitalization account for a rising share of episodes Changes in therapy distribution
“Providers target therapy visit thresholds used to adjust home health payments”.“Volume changes since implementation of PPS provide evidence of providers targeting the ranges that appear most profitable”.
Laff Associates 2011
MedPac Findings & Conclusions
Outcomes improve on functional measures but the rate of adverse events is unchanged ????? Payments increase by more than costs in 2009 Medicare continues to overpay for home health services High margins for home health in 2011 reflect that payments substantially exceed costs and that reductions and administrative adjustments by CMS have not significantly reduced payments. Conclusion: overutilization and inadequate care
Encourage appropriate use of the home health benefit
Laff Associates 2011
MedPac Recommendations
1. Increase medical review in counties with aberrant home health utilization; suspend payment and limit provider enrollment.
2. Begin a two-year rebasing of home health rates in 2013 and eliminate the market basket update for 2012.
3. Revise the home health case-mix system to rely on patient characteristics to set payment for therapy and non-therapy services; no longer use the number of therapy visits as a payment factor.
Laff Associates 2011
MedPac Recommendations
4. Establish a per episode co-pay for home health episodes that are not preceded by hospitalization or post-acute care use.
5. Modify the home health payment system to protect beneficiaries from stinting or lower quality of care in response to rebasing..
Laff Associates 2011
Method To the Madness…
Where is CMS going and will YOU be there when they get there?
Cost Reimbursement 1999PPS 2000Home Health Compare - 2003 PPS Refinement 2008RAC and ZPIC audits – 2009OASIS – C – process measures - 2010Billing code changes - G Code additions – 2011Face to Face visits at SOC and therapy thresholdsDiagnosis coding – ICD-10 - 2013PPS Refinement 2013? 2014?Value Based Purchasing – 2013?
Laff Associates 2011
Can You Afford Afford The Affordable Care Act?
ACA Establishes: Hospital Readmissions Reduction Program Hospital Value-Based Purchasing program and plans for a home health and skilled nursing Value-Based Purchasing program Medicare Shared Savings Program (Accountable Care Organizations)
Heart Failure
Heart failure is the most common diagnosis associated with 30-day readmission among Medicare beneficiaries (Hernandez et al., 2010).
30-day readmission rates for heart failure patients have increased while LOS decreasedIn-hospital mortality rates have decreasedLess marked reductions in 30-day mortality rates
HospitalValue Based Purchasing
ACA – will reduce hospital payment in 2013 for Medicare admissions by 1% if hospital readmissions are above national average for AMI, Heart Failure and Pneumonia beginning with discharges on or after Oct. 1, 2012.Penalties to hospitals will increase to 3% in 2015What happens in the acute care setting will happen What happens in the acute care setting will happen in home care!in home care!
Affordable Care Act (ACA)
Facilitate care transitions across the continuum to;Optimize choice and control of servicesEnsure that decisions are based on patient needs Provide coordinated, high quality care with seamless transitions between settingsReward excellence - pay for quality measures- P4P (VBP)Recognize role of family care givingUtilize health information technologyImprove Patient Safety Promote Evidence Based Best PracticesFocus on Error Prevention -PAE
Laff Associates 2011
Clinical Management Information Key IndicatorsRoutine Reports
EducationClinical assessment OASIS Accuracy
Supervision & Oversight Documentation Timeliness Care Plan Development
ContinuityCase managementClinical model
Accountability/ ResponsibilityReward / incentiveCorrective Action
Manage Smarter
Laff Associates 2011
Manage Smarter
To be profitable, management must:—Know what it costs to provide services — by discipline—Monitor and manage ALL aspects of agency operations
from intake to billing—Create appropriate efficiencies—Prevent redundancy and unnecessary hand-offs—Promote standardization for entire agency
Laff Associates 2011
Smart MovesPatient Centered CarePatient Outcomes at or above state and national averagesBest Practice implementation
“Right-size”May or may not add or eliminate positionsFocus on function and responsibility
Invest in people Right person for the position
Invest in educationEliminate “warm body syndrome”Stop “fixing”
Implement and integrate Telehealth
Laff Associates 2011
Primary case management – Clinician – with F2F contact May be RN or PTMust be accountable for patient and financial outcomesAccurate assessmentAppropriate care planConstant knowledge of;
Goals of care Projected visits vs. actualTeam performance – Therapists must be included in the team Patient response to careNeed for change in plan
Accountability
Laff Associates 2011
Case WeightCase weight variance – SOC to EOEEOE case weight
Re-certifications and LOSVisit Utilization Averages
Ratio nursing/therapyActual Revenue versus Anticipated RevenuesTimeliness of RAP Submission% of Therapy Visits per ThresholdAverage visits per episodeProductivity by discipline - Actual # of Patients Cases Managed per Clinician –
WHO IS REALLY MANAGING THE PATIENT?
Management Statistics
Laff Associates 2011
Management Statistics
OASIS Errors by ClinicianOASIS Corrections CompletedOutcomes Improvement Patient Declines – actual or documentation?Potentially Avoidable Events
Have you audited each of them?What did you do to prevent them in the future?
Laff Associates 2011
Smart Moves
OASIS AccuracyAccuracyWho is reviewing the OASIS?
Is that a primary function?Is that individual qualified?
Manual review or Data Scrubber?Duplicative functionsCorrections versus consequence….Management oversight
Laff Associates 2011
Adequate educationValidate and reinforce
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
Smart Moves
Laff Associates 2011
Do You EverHave Enough Staff?
How do you know???? It depends……..
Clinical ModelAgency Size and Scope
GeographyVolume
Paper or Point of CareClerical versus Clinical Function
Laff Associates 2011
When is Enough Enough?
The Clinical Director comes to you and says “I don’t have enough nurses to see all these new patients. What’s the first thing you do?
a. Call a temp agencyb. Put an add in the paper
c. Review statistics
Laff Associates 2011
Staffing-Statistics to Review
Number of ACTIVE patients on your census list“Clean” census listAll discharges removed at least weeklyIdentify why “old” patients remain
Expectations for staff productivityVisits per day, per week
Actual performance of staff – how many actual un-weighted visits per day did they perform last week?Identify “weakest links” and investigate why….
Laff Associates 2011
Standardize ProductivityDo you expect the same level performance from each clinician?
If not – why not?
Are your expectations per clinician met?Are they reasonable? Maybe too reasonable???
Do you use remote monitoring?Do you monitor and enforce the expectations?
Are you using the “warm body approach?”
Is there a consequence for non-performance?
Laff Associates 2011
Set Realistic Expectations
Number of visits per day is dependent upon clinical model
Do your field nurses case manage a census of patients”If so – is the number consistent among your staff?Do you have admission nurses?Do you use a point of care documentation system?How many miles does a clinician average per day/week?How are they compensated?How often are the patients’ care case conferenced?
Laff Associates 2011
You May Be At Risk If….
A review of operations and records indicates presence of one or all of the following;
Many OASIS item inconsistencies Large variance in SOC/EOE DX Coding errorsLow EOE case weightHigh LUPA rateHigher than average therapy utilizationLOS average over 60 days / multiple re-certificationsRotating primary DXSkilled service provided to large % of patients is “Observation & Assessment”
Laff Associates 2011
Smartest Moves…It Depends…
Primary Care Case ManagementClinician manages – 20 – 25 patients…it depends….
Effective use of Telehealth increase capacity
Responsible for entire episode of careResponsible for outcomesDon’t come into the office to get NRS
Adequate supervisionSupervision – primary responsibilityAbility to enforce process and policy for productivity, OASIS corrections, appropriate care delivery
Laff Associates 2011
Smartest Moves
Productivity expectationsSN -Minimum average of 5 actual visits per day – 6 – 6.25 weighted visitsPT – Minimum average of 5.5 actual visits per day – 6.5 weighted visitsSupervisor/Manager – 1 per 5-7 FTEs (depends on function)
OASIS Reviewer – w/data manager - 75 - 85 patients
Adequate OASIS review processData management tool to decrease review time and increase accuracy
Laff Associates 2011
Achieving Positive FinancialFinancial Outcomes
Good clinical outcomes lead directly to good financial outcomes!Required ingredients
Strong clinical management and staff oversightField clinician responsibility and accountability
Consistent and continuing oversight of episode frequencies and durations to achieve realistic outcome goals
Plan of Care consistently reviewed every 14 days!Adjusted to medical necessity and realistic outcome goals!
Consistent use of the “data scrubber” in OASIS reviewThe annual cost will be covered within a week!
Efficient use of the field clinician resources – no office time!Consider a “Weekender Program”
Laff Associates 2011
Achieving Positive FinancialFinancial Outcomes
Gross profit issuesThe majority of the direct cost/visit is compensation and related taxes (staff and direct supervision)The cost/visit of premium-based fringes is directly proportional to visits madeThe cost of mileage/auto reimbursement is directly related to geographically sequential patient scheduling, the size of the territory and a global vision of the entire weekAn agency specific formulary and trunk supply protocol, electronic ordering with independent oversight and patient specific direct delivery reduces costs and increases productivity
Laff Associates 2011
Weekender Program
Begins Friday at noon..ends Monday at noonFriday admissions – patients with weekend follow-up visitsMonday morning conference call with weekday RNs
Converts Agency from 5 days/ week plus weekends to 7 days/weekFrequencies spread over 7 days, not just 5 daysDo all weekend visitsTakes weekend on-callEliminates weekday staff weekend rotation and compensatory time
Laff Associates 2011
Weekender Program
Shares case management responsibilities with weekday RN – patients with weekend frequenciesWeekend differentials applyConsidered full-time for Fringe Benefits
Laff Associates 2011
Achieving Positive FinancialFinancial Outcomes
Who owns the patient?Using a combination of Admission and Visit RNs /LPNs challenges both good clinical and financial outcomes
Lacks care consistency and continuityLimited, if any, patient care oversightCause of patient dissatisfaction
Primary Care Case Management achieves all of the desired patient care outcome goals and is the best approach towards best financial outcomes
Completely integrates with incentive compensation for both the field clinician and their immediate supervisor!
Laff Associates 2011
Achieving Positive FinancialFinancial Outcomes
Align Clinical and Case Conference Modelswith Compensation!Incentive Compensation…
Determines ownership of the patient, resource utilization and care oversight and outcomes achievedMatches clinician responsibilities and achievements
Not based upon the length of time or just a fixed salary to accomplish their patient needs
Reinforces consistency and continuity of patient careReduces the direct cost of care for those disciplines
Laff Associates 2011
Achieving Positive FinancialFinancial Outcomes
Key Ingredients!Effective Clinical Management (Supervisory) staffPrimary Case ManagementCase Conference Model
Every Patient…Every 14 days!Reviews prior 14 days utilization and outcome achievementPlans next 14 days utilization and outcome goals
Tools for efficiencyLaptops with power cords to car power source and air-cardsSmart cell phonesPatient specific electronic ordering and delivery of NRS
Laff Associates 2011
Achieving Positive FinancialFinancial Outcomes
Primary Care Case Managers are responsible for the:Case Management of their patientsPrimary visits, including admission, resumptions and recerts, most follow-ups and the discharge.Achieve the desired patient outcomes and HH-CAHPs resultsSelf scheduling!
Places responsibility where it belongsProvides for more autonomy and control of clinician’s day…Eliminates the cost of schedulers
Laff Associates 2011
Incentive Based Compensation
Compensates the staff for what they do, not for how long it takes them to complete what they do!Rewards efficiency, productivity, capacity and clinical (HH-CAHP) outcomes achievementImproves team chemistry…Encourages under-performing staff to improve or seek a successful career elsewhereAssures that clinicians meet and exceed individual productivity and case capacity goalsApplies to Weekender staff
IT WORKS!
Laff Associates 2011
Incentive Based Compensation
Can apply to all disciplines, depending upon patient census and discipline demandExempt status does not apply to LPNs, PTAs, COTAs and HHAs (FLSA)Most effective for RNs, PTs and OTs– Supervisory responsibility– Visits are Unique– No portion of compensation is based on time
(Hourly)
Laff Associates 2011
Visit Weights
Visit weighting – Based the Requirements and Complexities of completing OASIS C– Admission (evaluation) visit 1.90– Resumption visit 1.30– Recertification Visit 1.20– Discharge Visit 1.25– Follow-up Visit 1.00– Virtual Telephone Visit (Telehealth) 0.25
Laff Associates 2011
Questions Often Asked( Visit Weight – Time Equivalents Based upon OASIS C)
Visits /Day Follow-up Admission Resumption Recert. Discharge
Visit Value 1.00 1.90 1.30 1.20 1.25
5.00 96 minutes1hr 36min
182.4 minutes3 hrs 2min
124.8 minutes2 hrs 5min
115.2 minutes1 hr 55min
120.0 minutes2 hrs
5.25 91.4 minutes1hr 31 min
173.7 minutes2hrs 54min
118.9 minutes1hr 59min
109.7 minutes1hr 50min
114.3 minutes1hr 54min
5.50 87.3 minutes1hr 27min
165.8 minutes2hrs 46min
113.5 minutes1hr 53min
104.7 minutes1hr 45min
109.9 minutes1hr 49min
5.75 83.5 minutes1hr 23min
158.6 minutes2hrs 39min
108.5 minutes1hr 49min
100.2 minutes1hr 40min
104.4 minutes1hr 44min
6.00 80 minutes1hr 20min
152 minutes2hrs 32min
104 minutes1hr 44min
96 minutes1hr 36min
100 minutes1hr 40min
All times include hands-on, documentation, travel, conference and case management time
Incentive Based Compensation
Bonus structure for Primary Care Case ManagersCalendar quarter or 12 week period (based upon payroll periods)
Accumulated Visit Weights = $ per hands-on visit for every visitTotal Cases Managed = % of earnings for the measured periodOutcomes Achieved = % of earnings for the measured period
Bonus structure for their immediate “supervisors”Same as above, plusOther to address problem areas, such as
OASIS error ratesTimeliness of corrections, etc.Time to RAP and EOE billing
Laff Associates 2011
Case StudyAlterna-Care Home Health Agency
Located in Central IllinoisMain office located in Springfield, IL with branches in Jacksonville, and Litchfield, ILServes over 2000 patients annually in 31 contiguous countiesFree-standing for profit agencyOver 50 employees
Benefits of Incentive Compensation
Lost a nurse and didn’t have to be replaced Improved communication with nurses and supervisorDocumentation is timely and better qualityTelehealth is being used more consistently and the telephone follow up visits are visit weightedIncentive compensation has improved ER and Hospital outcomes
Incentive Compensation Results
Nursing productivity increasedTimeliness of documentation improved. For the first time anyone can remember, all nurses notes were completed within 24 hours.MD verbal orders and recertifications were completed on timeVisit frequency orders were accurateCase loads increased per nurseNurses made more visits per day and made more moneyMonitors were in patient homes and no longer on the shelves
Average Patient Caseload 2009 vs. 2010
2009 -7.5 nurses with an average monthly case load of 36.3 (unduplicated patients)
2010 -6.5 nurses with an average monthly case load of 44.9 (unduplicated patients)
(excludes PT only patients)
Visit ProductivityAverage Visits Per Nurse
2009 Jan Feb Ma Apr May Jun July Aug Sept Oct Nov Dec
Avg. cases/RN 22 21 22 24 28 23 20 21 20 24 23 24
Monthly Undup. Census
223 233 229 240 253 229 205 208 195 216 210 213
No. of Nurses 10 11 10 10 9 10 10 10 10 9 9 9
2010Avg. Cases/RN 24 31 30 27 30 35 32 27 31 29 29 37
Monthly Undup. Census
216 252 242 222 247 279 264 237 241 257 260 257
No. of Nurses 9 8 8 8 8 8 8 9 8 9 9 7
HHCAHPS
HHCAPS HIGHER % ARE BETTER
% RANKING
Care of Patients 99% 92% (Top 8%)
Communications Between Providers and Patients 95% 90% (Top 10%)
Specific Care Issues 91% 82% (Top 18%)
% of Patients who Rated Agency 9 or 10 95% 83% (Top 17%)
% of Patients who would Recommend Agency 83% 56% (Top 44%)
Average Nurse 11 Month Salary
2009 - Average 11 month comp. was $ 38,4122010 - Average 11 month comp. was $ 46,362
Increase of $ 7,950 = 20.69%
2009 - Total Per Diem comp was $ 31,0222010 - Total Per Diem comp was $ 10,119
Reduction of $ 20,903 = 67.38%
2009 - Direct Cost per Nursing Visit - $ 79.71 2010 - Direct Cost per Nursing Visit - $ 63.90
Reduction of $ 15.81 = 19.83%
Incentive Compensation Results
Nurses did not complainComments:
“I’m really working hard”“It’s difficult to get your paperwork done with this many patients”“But, I’m not complaining”Supervisor states nurses are contentNo problem getting nurses to see patients on weekends!!!No push back when given a new admission in their territory!
Incentive CompensationThe Results
The Direct and Total Cost per Visit were substantially reduced!Visits per episode were effectively reducedIncentive compensation increased efficiency throughout the entire organizationQuality of patient care was positively impactedAccounting department is able to bill timelyClinical staff are rewarded for their hard workCommunication with clinical managers improvedTelehealth being utilized to its fullest capabilities
Effective Episode Management
Reduces episode cost, increases efficiency and communication, and improves clinical and financial outcomesIntegrates:
Clinical Supervisory Management and OversightPrimary Care Case ManagementGoals and Performance
Can enhance compensation and reward excellent performance
Laff Associates 2011
Lynda Laff, RN, COS-C Pat Laff, CPA Laff AssociatesConsultants in Home Care & HospicePhone: (843) 671-4170Email: llaff@laffassociates.comEmail: plaff@laffassociates.com Website: www.laffassociates.com
Contact Information
Laff Associates 2011
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