Outcome-Based Pathway Outcome-Based Reimbursementhealthcareathome.ca/serviceproviders/en/Documents/OBP OBR Process and... · pathway will be discontinued and a second payment released

October 16, 2013 Page 1

Outcome-Based Pathway Outcome-Based Reimbursement

Business Processes and Guidelines (Using CHRIS 2.3 Enhancements)

Version 1v0


Table of Contents Acknowledgement .................................................................................................................................................................. 4

Glossary of Terms/Acronyms .................................................................................................................................................. 5

Business Rules, Business Configuration and Design Review ............................................................................................... 7

OBP/R Scenarios: CCAC & SPO Actions: OBP/Service Authorization and Offer Processes ................................................... 11

New Referral with single OBP ........................................................................................................................................... 11

New Referral: .................................................................................................................................................................... 11

THR Pre-Op ........................................................................................................................................................................ 11

New Referral with two or more wound OBP of same or differing etiology (Option 1) .................................................... 12

New Referral with two or more wound OBP of same or differing etiology (Option 2) .................................................... 12

Existing OBP-R Patient requires additional OBP ordered ................................................................................................. 13

Existing OBP-R Patient requires service related or unrelated to the OBP ........................................................................ 14

Existing OBP-FSS Patient requires service associated with OBP ....................................................................................... 14

Existing OBP-R Patient requires service related to OBP but SPO does not have the service available in consolidated

services .............................................................................................................................................................................. 15

Existing OBP-FFS Patient requires service and the SPO does not have the service available .......................................... 15

Existing Nursing Patient (i.e. on Dialysis) develops a wound and requires OBP-FFS ........................................................ 15

Patient requires same OBP after supervening event occurs ............................................................................................ 16

OBP/R Scenarios: CCAC & SPO Actions: Interval Management & Discontinue OBP Processes ............................................ 17

Transfer to correct OBP .................................................................................................................................................... 17

Patient not willing to adhere to wound care/rehab based on best practices .................................................................. 18

Patient has met Day X, OBP outcomes have not yet been achieved ................................................................................ 18

Returning from Hospital or Vacation Hold less than 14 days ........................................................................................... 19

Supervening Event (OBP discontinued) ............................................................................................................................ 19

SPO visits OBP-OBR patient and determines patient needs are complex within 7 days .................................................. 19

Patient moves to another treatment location within the same CCAC/LHIN .................................................................... 20

Patient with two FFS OBPs ................................................................................................................................................ 21

Appendix 1 ............................................................................................................................................................................ 22

DRAFT OBR Off-Ramping Process ..................................................................................................................................... 22

Background: .................................................................................................................................................................. 22

Proposed Business Rules/Assumptions: ....................................................................................................................... 22

Criteria ........................................................................................................................................................................... 23

Common Questions & Answers: ................................................................................................................................... 24


Scenario #1 (Wound Care) ............................................................................................................................................ 25

Electronic Reporting Example ....................................................................................................................................... 26


Acknowledgement This document has been developed collaboratively by Service Provider Organizations and the CCACs with special acknowledgements to Central CCAC, North Simcoe Muskoka CCAC and Closing the Gap Health Care Group.

Clinic Models TBD Equipment and Supplies inclusion/exclusion TBD


Glossary of Terms/Acronyms Billing File A billing invoice file received from SPOs to invoice CCAC for visits/purchased services.

CC Care Coordinator

CCAC Community Care Access Centre

Calendar is built Service frequency added to calendar under service level in CHRIS for billing purposes.

CHRIS Patient Health Record Information System

Confirmation Visit(s) Visits made by an SPO prior to confirmation of an OBP, for the purpose of confirming an OBP assignment. More than one confirmation visit can be made. These visits will result in a confirmed OBP assignment for a patient, or a transition of the patient to fee for service (Applicable to the Wound Assessment OBP).

Activity Notification Submitted in an interval report by a SPO or CCAC on behalf of the SPO. Activity notifications are intended to notify the CCAC that the SPO or Client is arranging an activity such as an inter-professional referral.

Activity Request Submitted in an interval report by a SPO or CCAC on behalf of the SPO. Activity requests are intended to direct the performance of an activity by the CCAC such as arranging a community referral.

CHP Community Health Portal

Day “0” Also referred to as Pathway Start Date. The date the SPO has the ability to take ownership for provision of care under the OBP. This should be set at the Service Offer Date unless a patient is in hospital, when the pathway start date should be set at the later of either Hospital Discharge or Service Offer Date. Date is editable in CHRIS up until the first interval report submission.

Day “X” The total amount of time the SPO has to achieve all payment-linked outcomes. The pathway will be discontinued and a second payment released if payment-linked outcomes are not achieved at the end of this time period (length of pathway +50%).

FFS - OBP Fee for service reimbursement. Payment based on fee for service using OBP electronic reporting and outcome-based care approach.

FFS - Regular Fee for service reimbursement.

Payment based on fee for service and regular CCAC service ordering/payment practice.

Final Payment The final payment released to the SPO. This payment is dependent on payment-linked outcomes achieved by Day X.

First Core Payment The first payment released to the SPO by the CCAC. This payment is dependent on achievement payment-linked outcomes.

HPG Health Partner Gateway

Payment Linked Outcomes (PLO) Pathway outcomes that must be achieved in order for a payment to be released to the SPO.

OBP Outcome-based pathway. An identified trajectory of care for a specific population or condition which identifies expected evidence-informed outcomes that are likely to be achieved as part of the best practice care provided. While an Outcome-Based Pathway identifies expected outcomes, it does not necessarily specify clinical interventions that must be used to achieve the outcomes.

OBR Outcome-based reimbursement. Payment which is based on successful achievement of outcomes at identified


intervals on an Outcome-Based Pathway.

OBS Outcome-Based service(s): ‘Outcome-Based Wound’ and ‘Outcome-Based Ortho’

SDT Service Delivery Type: includes: “in-home nursing visits”, “in-home pt visits”, etc.

SPO Service Provider Organization. An organization contracted by a CCAC to provide care for a patient.

Summary Note Submitted in an interval report by a SPO or CCAC. Summary notes contain additional information about the OBP course of treatment that cannot be captured elsewhere in the interval report.

Supervening Event Submitted in an interval report by a SPO or CCAC. Supervening events are events which occur independently of (i.e. are not caused by) the pathway itself that affect the quality of treatment and would interrupt the ability of the SPO to continue treatment. When submitted by SPO in HPG, d/c request is sent to CCAC. The system shall require CCACs to discontinue an OBP when reporting a supervening event.

Variance Submitted in an interval report by a SPO or CCAC. May also be submitted independent of outcomes. Must be submitted when outcomes reported as unmet.

Also known as Exceptions, resource barriers or risk factors that are affecting or may affect patient outcomes during the OBP course of treatment.

Visit Data Data submitted by the SPO that includes information for visits made during the OBP course of treatment. This data is used to determine payment implications when a supervening event occurs or the pathway is incorrect.


Business Rules, Business Configuration and Design Review OBP-R Process Overview:

1. SPO makes initial visit to confirm pathway. First payment released once PLO reported as “met”. Set at 50% of bundle price for wound and hip/knee.

2. SPO treats patient according to outcomes found within each interval. Reports back outcomes achieved, variances, etc. as well as details of each visit made.

3. Final payment will be released upon achievement of PLO. Set at 40+10% or 40% of bundle price for wound and hip /knee.

a. 40+10% is released when the SPO can achieve PLOs during the intervals of OBP, or up to X days after beginning of pathway. Day X will be different for each pathway and equals 150% of pathway length.

b. 40% is released when the SPO does not achieve the final PLOs by Day X, patient may be moved to FFS. 4. Pathway will end upon achievement of PLOs, or passing of X days, triggering final payment process.

Payment Linked Outcomes (PLO) Summary

Pathway Interval (Days) Payment Linked Outcome Day X (OBP LOS + 50%)

Diabetic Foot Ulcer 0 to 7 Correct outcome-based pathway confirmed

126 (84 + 42) 77 to 84 Wound is closed by 12 weeks (Wound measurement)

Pilonidal Sinus 0 to 7 Correct outcome-based pathway confirmed

90 (60+30) 53 to 60 Wound is closed by 8 weeks (Wound measurement)

Pressure Ulcer 0 to 7 Correct outcome-based pathway confirmed

189 (126 + 63) 119 to 126 Wound is closed by 18 weeks (Wound measurement)

Surgical Wound 0 to 7 Correct outcome-based pathway confirmed


Traumatic Wound 0 to 7 Correct outcome-based pathway confirmed


Venous Leg Ulcer

0 to 7 Correct outcome-based pathway confirmed


91 to 98 Patient is independent with long-term compression system by week 14

Post-Op Total Hip/Knee

Replacement

0 to 7 Completed Physiotherapy assessment

126 (84 + 42) 8 to 84

Patient demonstrates a functional level of safe mobility with or without gait aid

Surgical wound is closed with no signs of infection

OBP-R vs. OBP-FFS If a pathway is not eligible for OBR, FFS applies. All elements of OBP are the same from both reimbursement frameworks except for compensation:

OBP-R OBP-FFS

Activities

Driven by best practice

Centred around achievement of outcomes

Reporting

Outcomes

Supervening Events

Variances

Activity Requests

Submission of visit data

Compensation

Two core payments (50 and 50 or 40%) upon achievement of PLOs

Based on FFS


Eligibility for OBP-R (determined by CHRIS, if one of the criteria below is not met, system will restrict the OBP to FFS):

1. Patient is categorized as Short Stay (CCM) 2. Patient has no other active service assignments or OBPs within the referral 3. Patient is over the age of 19 years 4. The OBP being assigned is eligible for OBR

OBPs Eligible for OBP-R

DFU, VLU, Pilonidal, Surgical, Traumatic, Pressure Ulcer, TKR & THR Post-Op OBPs Not Eligible for OBP-R (FFS applies)

ALU, Maintenance, Non-Healing, Malignant, TKR & THR Pre-Op Assessment Pathway Assessment pathways are to be used when the wound etiology is not known at the time of referral. Assessment pathways should not be used when the CCAC has information regarding the wound type. Once the pathway has been completed the SPO should then send a discontinue request for the assessment pathway with a reason of either:

1. Pathway Inappropriate (OBP service not appropriate); or 2. Transferred to other Pathway

FFS payments during OBP-R (patients with an OBP-R and a second OBP is required) Example: Patient assigned a VLU OBP under OBR. SPO confirms a Pressure Ulcer over course of treatment for VLU. Pressure Ulcer OBP assigned as OBP-FFS.

SPO visits patient and treats both wounds during visits.

Reports visits to CHRIS

System will prevent release of FFS payments during OBP-R pathway Other Services

Once an OBP-R pathway is assigned to a patient, all services received by the patient unrelated to the OBP are covered under the OBR bundle price, until outcomes are achieved or Day X is reached (or a supervening event occurs).

Once a patient is deemed eligible for OBP-OBR there are only two conditions that would warrant a patient to come off of OBR:

1. Supervening Event 2. The patient meets the criteria for OBR Off-Ramping Process


Supervening Event (Discontinuing a Pathway) Events can occur that prevent the pathway from continuing. Upon these events occurring, the provider’s compensation to-date will be compared to visits made by the SPO. The SPO will then be either paid-out (to a cap of: 90% of pathway value) or SPO will issue a refund to the CCAC:

Transfer to other CCAC (patient moves to another geographic location outside of the SPO designated area)

Admission to hospital >14 days

Vacation hold >14 days

Admission to LTCH

Patient refuses care (patient refuses to have the SPO visit, note this does not refer to a patient who is not adhering to best practices)

Death Supervening Event Compensation

Condition Payment Implication

SPO has delivered more service (based on FFS rates) then paid by CCAC under pathway.

CCAC pays SPO difference between service delivered under FFS rates and OBR paid to SPO. Compensation capped at core payments.

SPO has delivered less service (based on FFS rates) then paid by CCAC under pathway.

SPO refunds CCAC difference between OBR received to-date and service delivered under FFS rates.

Other Discontinuation reasons

Treatment complete – goals met

Treatment complete – goals not met (when Day “X” has arrived and PLOs are unmet)

Contract change required (e.g. clinic patient requires in-home service, SPO does not provide in-home service)

Pathway incorrect (results in transfer to new pathway and/or no pathway ordered) OBR Off-Ramping Process and Transition to OBP-FFS (error correction) (Appendix 1) A process whereby the SPO has the opportunity to request to the CCAC to change the reimbursement type from a bundled price to traditional FFS based on meeting the off-ramping criteria.

Proposed Business Rules/Assumptions:

OBR Off-ramping guideline will be used on an exception basis only and is not expected to be completed on every patient.

The CCAC is ultimately responsible for patient categorization using the CCM, the guideline is used as a communication tool to enable a consistent process for OBR Off-Ramping which is based on current CCAC intake processes. Based on the recommendation of the SPO, the CCAC will be responsible for determining whether the patient will be off-ramped.

A patient that is off-ramped from OBR is still eligible for use of the OBP but will transition to OBP-FFS, the CCAC will determine if the patient needs to be moved to a different/more appropriate caseload.

In alignment with regular OBP interval reporting, OBR Off-Ramping reporting will be completed electronically by the SPO using HPG and will require a telephone call to the CCAC to discuss the altered care plan when the guideline criterion are met.

This process is only applicable within Interval 1 of the OBP from 0 to 7 days

The SPO will have two scenarios where the patient may be considered for off-ramping from OBR to OBP-FFS, only scenario #1 uses the Off-Ramping Criteria.


1. It is identified that the patient has a substantial amount of additional care needs above and beyond the reason for the OBP and verified by the criteria within the Off-Ramping guideline of =/>5 items met. OR

2. The SPOs ability to achieve pathway outcomes is impeded by orders for wound care/rehab practices that do not align with published best practices despite the SPO and CCACs attempts to advocate for them.

Total Hip/Knee Replacement and OBR Problem: Given the variation in Care Models across LHINs and the populations selected for in-home vs. outpatient treatment, OBR should be limited to models where the CCACs are responsible for the entire episode of care through in-home care.


OBP/R Scenarios: CCAC & SPO Actions: OBP/Service Authorization and Offer Processes

Scenario CCAC Action SPO Action -

Offer SPO Action –

Referral SPO Action –

Billing SPO Action - Reporting

CCAC Action - Reviewing

New Referral with single OBP (Example: known wound type or assessment pathway – single OBP initiated)

Orders OBS and assign OBP and sends offer via HPG (System determines if OBP is eligible for OBR or FFS) Confirms payment type prior to sending offer: If OBP-R:

No frequencies ordered If OBP-FFS:

Frequencies ordered for each SDT under the OB Contract as per CCAC practice

Pathway Start Date field (Day “0”) populated with the offer sent date or the expected date of discharge from hospital If specific start date is required related to wound, i.e. IV Therapy, Required First Visit Date field populated with the IV therapy start date

Receive and accept offer with OBS and OBP identified in HPG

Referral and incidentals received for OBP via HPG/Fax Check orders for visit requirement (i.e. for IV therapy) Referral includes:

Interval due dates for OBP

Billing code associated SDT

Payment type: (OBR or FFS)

Submit billing file using OBS Billing Code for visits made using SDT as per billing codes Receives reconciliation report on billing file submitted with rate: $0 Receives OBR reconciliation report with reimbursed rate from PLO achievement

SPO submits pathway report at scheduled intervals on outcome achievement via CHP

Variances/Risk Factors/Referrals and other comments reported electronically where appropriate

CC receives notification and completes Activity Response Section when variance/risk factor/referral flagged by SPO, once complete, system will send review confirmation to SPO

Follows up on request or report where appropriate

New Referral: THR Pre-Op (Start date of OBP will be no greater than 6 weeks prior to surgery otherwise Service Offer will indicate a delayed start date)

Orders OBS and assign OBP and sends offer via HPG (OBP-FFS) Once Pre-Op OBP is complete based on receipt of Review of authorization / discontinue requested OBP Systems Task in CHRIS, CC discontinues OBP but keeps the OBS and SPO active so that Post-OP THR OBP is assigned to the same SPO

Frequencies ordered for SDT under the OB Contract as per CCAC practice


Referral and incidentals received for OBP via HPG/Fax Referral includes:



Payment type is OBP-FFS

Submit billing file using OBS Billing Code for visits made using SDT as per billing codes Receives reconciliation report on billing file submitted with rate











New Referral with two or more wound OBP of same or differing etiology (Option 1) (OPTION 1: CCAC adds 1st OBP, SPO adds 2nd OBP) (OBP#1 will be the longest length of stay or largest wound – for OBR)

Orders OBS and OBP#1 including label in Additional Information of location of wound and information regarding multiple OBPs applicable using Provider Notification Notes, sends offer via HPG (System determines if is eligible for OBR or FFS) Confirms payment type for OBP#1 prior to sending offer: If OBP-R:



Pathway Start Date field (Day “0”) populated with the offer sent date or the expected date of discharge from hospital If service related to wound required, i.e. IV Therapy, Required First Visit Date field populated with the IV therapy start date

Receive and accept offer with OBS and pathway identified for OBP #1 in HPG

Referral received for OBP #1 and incidentals via HPG/Fax Referral includes:

Information regarding other OBPs applicable


Billing codes associated SDT


Adds request for additional OBPs as applicable via HPG

Submit billing file using OBS Billing Code for visits made using SDT as per billing codes Receives reconciliation report on billing file submitted with rate (dependant on OBP outcome type: OBR vs. FFS) Receives OBR reconciliation report with reimbursed rate from PLO achievement (dependant on OBP outcome type: OBR vs. FFS)

SPO submits pathway report on outcome achievement via HPG for each OBP




Once OBP #1 for OBP-R completed, SPO submits frequency requests using Additional Information field in HPG CC orders frequencies as requested by SPO for subsequent OBPs once OBP-R pathway is complete

New Referral with two or more wound OBP of same or differing etiology (Option 2) (OPTION 2: CCAC adds both OBPs) (OBP#1 will be

Orders OBS and assigns two (or more if known) OBPs with OBP #1 being the largest or longest length of stay, including label in Additional Information of location of wound, offers will be sent independently Provider Instructions should indicate that the second OBP is coming. Once the first offer is accepted by the SPO, the subsequent OBPs are sent via

Receive and accept offer with OBS and pathway identified for OBP #1 in HPG (additional OBP Referral Updates to be received for subsequent OBPs once acceptance for OBP#1 is sent to

Referral received for OBPs and incidentals via HPG/Fax Referral includes:

Information regarding other OBPs applicable


Submit billing file using OBS Billing Code for visits made using SDT as per billing codes Receives reconciliation report on billing file submitted with rate (dependant on

SPO submits pathway report at scheduled intervals on outcome achievement via CHP for each OBP









the longest length of stay or largest wound – for OBR)

Updated Referral (with BRN so that SPO can match with initial OBP) Confirms payment type for first OBP assigned prior to sending offer: If OBP-R:



Pathway Start Date field (Day “0”) populated with the offer sent date or the expected date of discharge from hospital If service related to wound required, i.e. IV Therapy, Required First Visit Date field populated with the IV therapy start date

CCAC)



OBP outcome type: OBR vs. FFS) Receives OBR reconciliation report with reimbursed rate from PLO achievement (dependant on OBP outcome type: OBR vs. FFS)


Once OBP #1 for OBP-R completed, SPO submits frequency requests using Additional Information field in HPG CC orders frequencies as requested by SPO for subsequent OBPs once OBP-R pathway is complete.

Existing OBP-R Patient requires additional OBP ordered (Example: Existing Wound OBP-R patient develops another wound – of same or differing etiology – SPO orders additional OBP once determined)

Authorize new OBP based on receipt of Review of authorization / discontinue requested OBP Systems Task in CHRIS and send frequency update noting this. Add new OBP including label in Additional Information of location of wound System has determined pathway reimbursement type and frequencies will or will not be ordered, based on first OBP reimbursement type (if FFS: order frequencies, if OBP-R: no frequencies required)

None

Service Update received for OBP #2 and incidentals via HPG/Fax Service Update includes:



OBP Reimbursement type – FFS (frequencies not sent/rec’d

Submit billing file using OBS Billing Code for visits made using SDT as per billing codes Receives reconciliation report on billing file submitted with rate (dependant on OBP outcome type: OBR vs. FFS) Receives OBR reconciliation





Once OBP #1 for OBR is discontinued , second OBP is now paid under FFS framework SPO submits frequency requests







until 1st OBP is complete)

report with reimbursed rate from PLO achievement (dependant on OBP outcome type: OBR vs. FFS)

using Additional Information field in CHP CC orders frequencies as requested by SPO for subsequent OBPs once OBR OBP is complete

Existing OBP-R Patient requires service related or unrelated to the OBP (Example: New IV antibiotic order due to wound infection, OT for pressure redistribution, injections required unrelated to wound care etc.)

Receives new order for service associated with OBP (If need for service is within next 24 hours, phones SPO) Specifics for service sent as a Referral Update (medical orders and additional information sent via HPG/Fax) Orders equipment/supplies as per current practice

None Updated referral and incidentals via HPG/Fax received Take action and adjust the care plan

Submit billing file using OBS Billing Code for visits made using SDT as per billing codes





Existing OBP-FSS Patient requires service associated with OBP

Receives notification from SPO to add on additional service and frequency CCAC acts on notification, orders service under OBS additional service and include frequency

None Updated referral and incidentals via HPG/Fax received Take action and adjust the care plan

Submit billing file using OBS Billing Code for visits made using SDT as per billing codes



Include frequency updates CC receives notification and completes Activity Response Section when variance/risk factor/referral flagged by SPO, once complete, system will send review confirmation to SPO








SPO submits frequency requests using Additional Information field in CHP

Existing OBP-R Patient requires service related to OBP but SPO does not have the service available in consolidated services (interim process – until all SPOs can provide consolidated service)

Discontinue OBP with a discontinuation reason: Contract Change Required Sends offer via HPG for New Service: Fee For Service (FFS)

Discontinuation of OBP accepted Offer for FFS received & accepted in HPG

Referral for FFS received + incidentals via HPG/Fax

Submit billing file using FFS billing code

FFS Patient Service Report – same as usual practice

Existing OBP-FFS Patient requires service and the SPO does not have the service available

Determine that OBP is still appropriate and order regular service Sends offer via HPG to New SPO for New Service: Fee For Service (FFS)

None None Submit billing file using FFS billing code for services provided under OBP

FFS Patient Service Report – same as usual practice

Existing Nursing Patient (i.e. on Dialysis) develops a wound and requires OBP-FFS

Orders OBS and assign OBP and sends offer via HPG (System determines if OBP is eligible for OBR or FFS)


Referral and incidentals received for OBP via HPG/Fax Referral includes:



Payment type:

Receives reconciliation report on billing file submitted with rate: $0




Follows up on request or report where







(OBR or FFS) appropriate FFS Patient Service Report – same as usual practice (local decision regarding use of the electronic reporting or usual paper practice)

Patient requires same OBP after supervening event occurs (e.g. discharged from hospital after 14 days, wound still exists, no other service required)

Orders OBS, assign OBP and sends offer via HPG (System determines if OBP is eligible for OBR or FFS) Confirms payment type prior to sending offer: If OBP-R:



Pathway Start Date field (Day “0”) populated with the offer sent date or the expected date of discharge from hospital If specific start date is required related to wound, i.e. IV Therapy, Required First Visit Date field populated with the IV therapy start date


Referral and incidentals received for OBP via HPG/Fax Check orders for visit requirement (i.e. for IV therapy) Referral includes:




Submit billing file using OBS Billing Code for visits made using SDT as per billing codes Receives reconciliation report on billing file submitted with rate: $0 Receives OBR reconciliation report with reimbursed rate from PLO achievement






OBP/R Scenarios: CCAC & SPO Actions: Interval Management & Discontinue OBP Processes

Scenario CCAC Action SPO Action - Offer SPO Action – Referral SPO Action – Billing SPO Action - Reporting


Transfer to correct OBP (Example: transfer from assessment pathway to correct pathway, SPO Discontinues Assessment OBP, requests Authorization of new appropriate Wound OBP)

Discontinuation of previous OBP (reason from drop-down list: Pathway incorrect) Authorize new OBP based on receipt of Review of authorization / discontinue requested OBP Systems Task in CHRIS (rate will be adjusted as per new OBP) System determines if OBP is eligible for OBR or FFS Confirms OBP reimbursement type: OBR:

No frequencies ordered FFS:


None

Updated referral and incidentals via HPG/Fax received

Submit billing file using OBS Billing Code for visits made using SDT as per billing codes Receives reconciliation report on billing file submitted with rate (dependant on OBP outcome type: OBR vs. FFS) Receives OBR reconciliation report with reimbursed rate from PLO achievement (dependant on OBP outcome type: OBR vs. FFS)

SPO reports outcomes that were achieved in the previous OBP within interval 1 of new wound OBP SPO submits pathway report on outcome achievement via HPG


SPO submits frequency requests using Additional Information field in HPG CC receives notification and completes Activity Response Section when variance/risk factor/referral flagged by SPO, once complete, system will send review confirmation to SPO





Patient not willing to adhere to wound care/rehab based on best practices

CCAC discusses with patient and SPO and either: Wound:

Continues care and moves patient to Maintenance/Non-Healing Wound OBP based on healability status upon reaching Day X

THR/TKR:

Continues care and moves patient to regular rehab services upon reaching Day X

Determine and move patient to appropriate caseload/CCM population to change

None None Change from OBR to FFS upon reaching Day X

SPO continues to assess and educate patient to reach concordance with best practice wound care/rehab until Day X arrives, then to discuss with CCAC regarding appropriate move to a recurring OBP or regular service

Patient has met Day X, OBP outcomes have not yet been achieved

CCAC discusses with SPO and either:

Discontinues OBS and determines if care to continue as regular service (as per current process), assign same SPO

Wound:

Move patient to Maintenance/Non-Healing Wound OBP based on healability status

Discontinue OBP, order appropriate recurring OBP as FFS

Determine and move patient to appropriate caseload/CCM population to change

Sends Discharge request of OBP-R Sends request for recurring OBP if appropriate

Receives Offer of :

New FFS regular service

OR

New recurring OBP-FFS

Change from OBR to FFS

FFS Patient Service Report – same as usual practice Recurring OBP SPO submits pathway report at scheduled intervals on outcome achievement via CHP







Returning from Hospital or Vacation Hold less than 14 days (No new population or caseload change required)

Service placed on hold in CHRIS and SPO informed as per usual local practice

Calls SPO to resume service and removes hold when patient discharged from hospital or returns from vacation and sends update to SPO as per usual local practice

None

No change

No reports submitted while patient in hospital or on vacation.

Supervening Event (OBP discontinued)

CCAC or SPO informs regarding supervening event via telephone call

If CCAC is first to be aware of event: sends exception/variance through HPG to SPO and calls SPO to confirm events/details of supervening event

If SPO is first aware of event: sends exception/variance through CHP and call CCAC to confirm events/details of supervening event Sends discontinue request and last report within 7 days.

Frequency Change received in HPG

Discontinue OBP as per usual CHRIS process

SPO visits OBP-OBR patient and determines patient needs are complex within 7 days (OBR-Off-Ramping Process)

NA NA Determines if patient meets OBR Off-Ramping Criteria (>5 items)

Change from OBR to FFS if deemed appropriate

SPO submits pathway report via CHP

Reports information regarding complexity guidelines

If criteria items met >5, SPO phones CCAC to discuss result CC receives notification and completes Activity Response




Valid within interval 1 of OBP ONLY

Section

Documents information regarding patient complexity and develops new care plan for patient

Transferred to appropriate Long-Stay Caseload

Discussion with HIM/HRAA to transition reimbursement type from OBP-R to FFS (same SPO)

Patient moves to another treatment location within the same CCAC/LHIN

Update patient’s treatment address in CHRIS. Contact SPO to notify of new treatment address. If SPO is able and willing to meet patient need at new address based on contract then CC Frequency Change through HPG updating the treatment address and start date at new address. If SPO is unable or unwilling to meet patient need at new address based on contract then OBP is discontinued based on Supervening Event reason: discontinue OBP and discharge SPO and add on FFS as required to meet patient’s needs

None unless provider is being discharged and new offer sent. If new offer sent, receive & accept in-home offer in Health Partner Gateway (HPG)

None unless new offer sent If new offer sent Referral received for in-home FFS and incidentals via HPG/Fax if required

Submit billing file using OBS Billing Code if no change in provider. If change in provider Submit billing file using OBS Billing Code for visits made to end date of pathway. For new provider Submit billing file using FFS billing code



If FFS: SPO submits frequency requests using Additional Information field in HPG CC receives notification and completes Activity Response Section when variance/risk factor/referral flagged by SPO, once complete, system will send review confirmation to SPO


If FFS: CC orders frequencies as requested by SPO via HPG (as per usual practice) for subsequent OBPs once OBR OBP is complete.




Patient with two FFS OBPs (For example: Pressure Ulcer and Diabetic Foot Ulcer as OBP-FFS)

Authorize new OBP based on receipt of Review of authorization / discontinue requested OBP Systems Task in CHRIS and send frequency update noting this. Add new OBP including label in Additional Information of location of wound System has determined pathway reimbursement type and frequencies will or will not be ordered, based on first OBP reimbursement type - FFS: order frequencies

None Service Update received for OBP #2 and incidentals via HPG/Fax Service Update includes:



OBP Reimbursement type – FFS

Same as FFS SPO submits pathway report at scheduled intervals on outcome achievement via CHP




CC orders frequencies as requested by SPO – frequencies ordered using one OBP report to capture visits for both wounds (i.e. if DFU requires 2 visits per week and the Pressure Ulcer requires 3 visits per week, the request is for 3 visits per week – similar to current practice)


Appendix 1

DRAFT OBR Off-Ramping Process Background: Within the OBR framework there is an assumption that SPOs will be responsible for serving eligible short stay

patients who require initialization of eligible OBPs related to healable wound care or total hip/knee replacements. Within this

framework, funding follows the patient and is not dependent on units of service. Payment will be based on an entire episode

of care: from assessment to recovery and would be inclusive of all services provided to the patient by the SPO during this

episode. It has therefore been identified that there needs to be a process whereby the SPO has the opportunity to request to

the CCAC to change the reimbursement type from a bundled price to traditional FFS.

The CCACs have the responsibility to complete a RAI Contact Assessment (RAI-CA) at intake in order to determine the appropriate plan of care for the patient within the Client Care Model (CCM). It is anticipated that although an appropriate intake process exists, there may be some instances where the patient is not streamed within the most suitable population (short stay versus long stay). In these instances, the SPO requires a process to Off-Ramp the patient from OBR. In an effort to prevent ambiguous rationale and to promote collaboration with the CCAC and SPO the following OBR Off-Ramping Criteria was created to assist the SPO and CCAC to identify objective items which may help to determine when a patient has a substantial amount of additional care needs above and beyond the reason for the OBP or when wound care or TKR/THR rehab is no longer the primary reason for service (complexity). This proposed criterion is based on the RAI-CA and specifically adapted from elements within the Assessment Urgency Algorithm. It is derived under a conceptual framework which identifies that complexity is not only based on comorbidity but also includes the numerous other influences that together help to predict when a patient may have greater care needs than initially anticipated. This criteria will seek to provide an objective and replicable approach, however it requires clinical judgment and is not meant to be 100% accurate nor is it a final iteration.

Proposed Business Rules/Assumptions:

OBR Off-ramping guideline will be used on an exception basis only and is not expected to be completed on every patient.

The CCAC is ultimately responsible for patient categorization using the CCM, the guideline is used as a communication tool to enable a consistent process for OBR Off-Ramping which is based on current CCAC intake processes. Based on the recommendation of the SPO, the CCAC will be responsible for determining whether the patient will be off-ramped.

A patient that is off-ramped from OBR is still eligible for use of the OBP but will transition to OBP-FFS, the CCAC will determine if the patient needs to be moved to a different/more appropriate caseload.

In alignment with regular OBP interval reporting, OBR Off-Ramping reporting will be completed electronically by the SPO using HPG and will require a telephone call to the CCAC to discuss the altered care plan when the guideline criterion are met.

This process is only applicable within Interval 1 of the OBP from 0 to 7 days

The SPO will have two scenarios where the patient may be considered for off-ramping from OBR to OBP-FFS, only scenario #1 uses the Off-Ramping Criteria.

1. It is identified that the patient has a substantial amount of additional care needs above and beyond the reason for the OBP and verified by the criteria within the Off-Ramping guideline of =/>5 items met.

OR

2. The SPOs ability to achieve pathway outcomes is impeded by orders for wound care/rehab practices that do not align with published best practices despite the SPO and CCACs attempts to advocate for them.


Criteria

Health Care Needs Health conditions that indicate the patient belongs in a specific Population/sub-population. E.g. Complex health conditions are

such that the patient has “complex medical, physical, cognitive and social conditions at risk for hospitalization, ALC or premature institutionalization”

1. Patient has any of the following health needs where the OBP is NOT the primary reason for service o Unable to take medications independently o Urinary Catheter (indwelling or in/out) o IV therapy o Oxygen Therapy

2. Patient has conditions which make cognition, ADL, mood or behaviour patterns unstable:

o No o Yes

Socioeconomic Factors Social supports, housing needs, finances, etc. may be determined during the assessment and may impact the selection of the more appropriate client categorization. E.g. the caregiver may also have some health or social issues that interfere with the

patient’s optimal functioning.

3. Patient has reported feeling sad, depressed and/or hopelessness in the past 3 days: o No o Yes

4. Patient’s caregiver/family/friends are overwhelmed by patient’s condition:

o No o Yes OR No caregiver/family/friends available

Degree of Independence These items are mandatory based on the Self-Reliance Index. These items indicate whether a patient is able to care for

themselves independently.

5. Making decisions regarding tasks of daily living (e.g. when to get up, when to have meals, which clothes to wear, which activities to do etc.):

o Independent o Modified independence or any impairment

6. Receives supervision or any physical help in ADLs:

o Bathing o Personal Hygiene o Dressing Lower Body o Locomotion

Risk of Experiencing Acute Episodes During assessment, it may be determined that the patient has a significant risk for experiencing hospitalization, urgent

placement or other acute illnesses that interfere with the patient’s ability to be cared for safely at home.

7. Significant risk for ER visit, hospital admission, urgent placement or other acute illness that interferes with the patient’s ability to be cared for safely at home:

o No o Yes

A minimum of 5 or more of the 7 criteria to be met in order to proceed with OBR Off-Ramping


Common Questions & Answers:

Q: Is the use of this process adding to the workload of the clinician? A: We are cognizant of clinical workload and in the best interest of the patient, would like to keep business process as efficient as possible. This guideline is only used on an EXCEPTIONAL basis, when the SPO identifies that the patient may have more care needs than initially anticipated. Q: Is this an additional assessment that the clinician is required to complete? A: This guideline is not meant to be an additional assessment; it should be inclusive of elements that are assessed during a Holistic Patient Assessment which is the first outcome of all would OBPs or a Physiotherapy Assessment for the THR/TKR OBPs. Q: Will the clinician require RAI training? A: This guideline embodies a conceptual framework which takes into account elements from the RAI-CA and Assessment Urgency Algorithm to determine which domains are pertinent to stratifying risk for patients with additional care needs but is not considered completion of a RAI tool. Q: Why can’t the SPO merely call the CCAC to request Off-Ramping? A: Without a guideline to follow, the decision to Off-Ramp a patient is too subjective. The SPO and CCAC require a common set of criteria to prevent ambiguous rationale and to promote collaboration between the CCAC and SPO. Q: Does this mean that the SPO is now responsible for categorizing patients? A: No, the CCAC is ultimately responsible for categorizing patients using the CCM, the Off-Ramping tool provides a consistent criteria for the SPO and CCAC to promote a collaborative discussion regarding the patients care needs in order for the CCAC to determine the appropriate population and care planning for the patient. Q: Does this mean that the SPO may off-ramp a patient with a complex wound? A: No, a complex wound is not a reason to off-ramp patients from OBR, also, it does not meet any of the supervening event reasons. The off-ramping criteria assists with identifying patients who have more complex care needs than initially anticipated and therefore assists with identifying the patient complexity as a whole, therefore, it does not address the complexity of the wound. Q: Why does this process only apply within the first interval of the OBP (within 7 days)? A: Since interval 1 of the OBPs includes achieving the outcome Holistic Patient Assessment or a Physiotherapy Assessment. It is during this assessment that the SPO must determine if Off-Ramping from the OBP is required. If the SPO feels the patient meets the criteria later in the patient’s episode of care, under the OBR framework, the SPO is responsible for the patients care unless a supervening event occurs. It is anticipated that given the stable and predictable nature of Short Stay patients, the occurrence of off-ramping from the OBP will occur only within a very small number of patient instances and will be considered when determining the price for OBR. Q: Does this apply to Clinic Patients? A: At this point, no, the Off-Ramping process only applies to patients receiving care in-home.


Scenario #1 (Wound Care)

DRAFT OBR Off-Ramping Process (example)

SPO

CC

AC

20130918

Referral received at intake for service.

Care Coordinator completes a telephone

RAI-CA/NCCT

Patient categorized:Short Stay –

Wound

Referral sent to SPO as per regular

process – patient eligible for OBR

Receives referral, initiates OBP-OBR

as per usual process

Completes face-to-face visit with patient, determines

that patient has more care needs other than the OBP

condition

Sends electronic report in HPG as per usual process with Variance identified and

completes a phone call with the CCAC

Receives information regarding items flagged in HPG and via

telephone call with SPO regarding a change in patients care plan and which criteria were met within

Patient receives appropriate CCAC service

with OBP-FFS

Follows process for Transition from OBR to FFS, transfers patient to appropriate caseload for CC to

complete RAI-HC

Completes Off-Ramping Criteria Checklist

>5 Criteria items met?

YES

Sends electronic report in HPG as per usual process aligned with interval reporting with

Variance identified

Continues with OBP-R as per regular process

NO

Based on SPO findings, Off-Ramp patient from OBR?

Yes

Continue with OBP-OBR with altered care plan to meet patients identified

care needs

No


Electronic Reporting Example

Example OBR Off-ramping report: -Unable to take insulin as prescribed due to apparent cognitive impairment. -Skips meals and not able to follow diabetic diet due to cognitive impairment. Daughter is the only caregiver and works during the day and is stressed about leaving patient alone. -Unable to complete bathing independently, dependent on daughter for assistance.

Unable to take

medications

independently

Unable to make

decisions regarding

meals independently

Cognitive issues

identified

Caregiver

overwhelmed by

patients’ condition

Receives assistance

with ADLs