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SERVICE UTILIZATION REVIEWRecruit And Retain Nursing Staff While Taking Control Of Patient Outcomes
Kristi Bajer BSN, RNMichael McGowan
It All Starts At The Start Of Care……
NURSE FRIENDLY SOC OASIS PROCESS THAT ALSO IMPROVES ACCURACY
….. WE ALL WIN.
OASIS—Why Is It So Important To Get It RightAcuity-
• If acuity is not correct at the SOC, an agency cannot show improvement at discharge.
VBP, STARS, ACO, etc.
Revenue- HHRG/ HIPPS• “M” questions--Get them right- don’t chart around them!• episode timing (until 2020)• coding • therapy utilization (until 2020)
Audit risk-• Submitting medically unbelievable edits.• Providing care that exceeds acuity in OASIS.• The SOC OASIS establishes medical necessity for the entire
episode--MBPM 40.1.1 Medical Necessity
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Why We Have A Problem…
• Average of 85 days to fill empty RN position.
• Cost of replacement is up to 58K.
• Vacancies often cause other staff RN’s to have burnout and overload trying to fill the gap.
• 17.2% RN turnover- over twice that of other industries and rising.
• 1 million vacant RN positions by 2022.
• Almost half of all new RN’s will not make it a year at their first position.
What your nurses are not telling you!
• “Most of this job is charting, and I don’t even get paid for it.”
• “I make great money but the charting comes home with me every day ….”
• “I feel that all of the documentation I have to do at home is like having homework and that it is hanging over my head. “
-- Allnurses.com
Nurses working over 40hrs/week are likely to leave within 1 year.
MOST COMMON CAUSES OF NURSE BURNOUT
• Lack of social support
• Inability to control schedule or
HOME HEALTH REQUIREMENTS
• OASIS visit and charting done alone
• Nurses are attracted to 8-5 self scheduling- however, charting Inability to control schedule or
assignments
• Chaotic job atmosphere
• Work/ life imbalance
sc edu g o e e , c a gusually requires working evenings and weekends
• Agencies being run by the field RN’s due to fear of staffing challenges
• Repeated corrections make the job “never-ending”
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STAGES OF NURSE BURNOUT
Physical and mental exhaustion
After hours and weekend charting required. RN unable to “unplug” during time off.
Shame and doubt
“I Quit!”
Constant repetitive corrections-that are often subjective. “Why can’t I get this right?”
Cynicism and callousness
Adversarial relationship with QA and nurse management.
Failure
Part 1A “CARE TEAM” Approach To H H lthHome Health
COLLABERATIONExpansion of the one
Question 1.
I am aware that it is my responsibility as the assessing clinician to complete the comprehensive assessment document that includes appropriate OASIS data items and the drug regimen review. Can I get help from my interdisciplinary team when collecting OASIS data and selecting responses?
Answer 1.
Yes. Effective January 1, 2018, as the assessing clinician, you may elicit input from the patient caregivers and other healthExpansion of the one
clinician conventionmay elicit input from the patient, caregivers, and other health care personnel, including the physician, the pharmacist and/or other agency staff to assist you in your completion of any or all OASIS items integrated within the comprehensive assessment document.
CMS guidance manual mentions collaboration 7 times!
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/Downloads/Expansion-of-the-Home-Health-One-Clinician-Convention-August-2017.pdf
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Bringing Two Worlds Together
Management needs-accurate OASIS to initiate patient care and bill RAP
Field Clinicians needs-To finish OASIS, take care of the patient, and get home on time to their families
What is a scribe?
A person who copies out documents, especially one employed to do this before printing was inventedprinting was invented.
Examples Include;Ancient HebrewAncient EgyptianMonks
Scribing Today• Widely used by
EDs/Cardiologists
• Became necessary with the advent of the EHR
• Increases productivity 57% increase without decreasing patient satisfaction*
• Takes the computer out from between the patient and the physician *https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3745291/
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Scribing in Home HealthA Home Health Scribe is an assistant to the field clinician; documenting in the EMR, gathering information for the patient's visit, and partnering with the clinician to provide more accurate patient care.p p
What Needs to be in Place
Policy and procedure for scribing in your agency
A scribe agreement containing the following;• Documenting under someone else’s log in is
prohibitedScribe service must include personal dated note;• Scribe service must include personal dated note;Identifies the scribe and the clinicianAttests the notes are recorded live as the clinician preforms the serviceSigned and dated by both the scribe and the clinician
A job description for scribes
Part 2A “CARE TEAM” Approach to OASIS CollectionOASIS Collection
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OASIS Process Overview
• Scribe works with the clinician through the OASIS following the EMR
• Clinician updates the medication list with the scribe
• QA is preformed in real time by QARN scribe or automated QA• QA is preformed in real time by QARN scribe or automated QA software and scribe
• Results are reviewed with clinician, any needed corrections are made in EMR by scribe- while the clinician is in the home
• OASIS and Plan of Care are returned when complete for the assessing clinician to review and sign
Scribing starts when referral is accepted byhome health agencyOASIS Pre-fill
•Patient identifiers
•AllergiesAllergies
•Primary diagnosis
•Homebound Status
•Medications
•Other H&P Information
Nurse arrives-Prior to Scribing
• Permits signed
• Medications reconciled
Vital Signs and• Vital Signs and physical assessment
• OASIS WALK
• Vital signs retaken
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OASIS WALK• Ask the patient to walk in their home. Pay special attention to the patient’s ability to use the bathroom safely.
• Ask the patient to open a pill bottle, identify the color of the pill and read the labeled instructions.
• End walk in the patient’s bedroom where you can assess skin/wounds while asking the patient to demonstrate dressing ability.
• Remember to take the patient’s VS again AFTER the walk. A change can help you document a “taxing effort” on the patient’s part when ambulating.
Connect with Scribe
Introduce the scribe to the patient as part of the “Care Team” using speaker phonespeaker phone
1. Confirm OASIS walk completed ***providing accountability to staff
2. Review need for patient participation and compliance ***providing accountability to patient
3 Explain qualifications for Medicare covered HH services;
Scripting review with clinician, scribe, and patient
3. Explain qualifications for Medicare covered HH services;
• Homebound
• Require services by a licensed professional
• Have a physician’s order
• OASIS determines need, disciplines, and frequency of care
***A PHYSICIAN ORDER ALONE DOES NOT QUALIFY THE HH BENEFIT.
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Scripting for review with clinician, scribe and patient
Make the Call
4. Primary diagnosis
reason for home health- should be on F2F
5. 30 day readmission prevention including;
• Call your nurse first– 24H RNMake the Call y
• Zone Tools
• Remote patient monitoring
/ telephonic monitoring
OASIS Scribing
One ear bud in ear-Phone in your pocketThis allows;
• the scribe to lead the clinician through the OASIS.
• the scribe to “overhear” the patient responses.
• the scribe to speak privately with the nurse.
• the nurse to speak to both the patient and the scribe.
OASIS Completion- after the call1. Clinician
Clinician reviews disciplines and frequency with patient
2. Office QA
Completes coding and
Builds POC using an evidence based care plan
3. OASIS and POC Returned to clinician for review and signature
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Scribing TechniquesBeginning
Beginners usually go question by question.
Experienced
Experienced scribing worksby body system reports.
SENSORY STATUS
Scribe-Was the patient able to read the medication label either with or without glasses? (0) Did they have to pull out a magnifying glass to read or where they unable to read?(1) Unable to see use touch or hearing instead? (2)
Clinician- The patient read his medication label to me accurately using his glasses
Beginner
(M1200) Vision (with corrective lenses if the patient usually wears them):
Enter Code0 Normal vision: sees adequately in most situations; can see medication labels, newsprint.
1 Partially impaired: cannot see medication labels or newsprint, but can see obstacles in
path, and the surrounding layout; can count fingers at arm's length.
2 Severely impaired: cannot locate objects without hearing or touching them, or patient
nonresponsive.
SENSORY STATUS
(M1400) When is the patient dyspneic or noticeably Short of Breath?
RESPIRATORY STATUS
Scribe;Did you notice Mr. Smith was SOB while talking to you or on the OASIS walk?
Nurse; Mr. Smith seemed fine while sitting still, but I noticed he was a little winded when he was talking to me. He became very SOB while walking to the bathroom. He uses O2 at 2L continuously.
Enter Code1. Patient is not short of breath
2. When walking more than 20 feet, climbing stairs
3. With moderate exertion (for example, while dressing, using commode or bedpan, walking distances less than 20 feet)
4. With minimal exertion (for example, while eating, talking, or performing other ADLs) or withagitation
5. At rest (during day or night)
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Scribe;Please tell me about Mr. Smith’s OASIS walk.Clinician;Mr. Smith took approximately 32 seconds to get out of his chair and ambulate 10 feet, return to the chair and sit down. I noticed his walker was a little too far in front of him when he was getting out of the chair. His gait was shuffling and he also held onto the couch when we walked by it. He was a little shaky getting his pants out of his chest of drawers and seemed unsteady while doing it. He laughed while trying to reach over and demonstrate putting on his socks and said, “I haven’t been able to reach my feet since I was 70”. He has a shower chair in the bathtub and was able to use it with his wife’s assistance. There was one point I thought they were both going to fall. The walk seemed to tire him out and made him SOB. I don’t think he is safe doing much without at least a standby assist. (M1800) Grooming: Current ability to tend safely to personal hygiene needs (specifically: washing face and hands, hair care, shaving or
make up teeth or denture care or fingernail care)
Experienced
ADL/IADLs
make up, teeth or denture care, or fingernail care).
Enter Code1. Able to groom self unaided, with or without the use of assistive devices or adapted
methods.
2. Grooming utensils must be placed within reach before able to complete grooming activities.
3. Someone must assist the patient to groom self.
4. Patient depends entirely upon someone else for grooming needs.
(M1810) Current Ability to Dress Upper Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:
Enter Code1. Able to get clothes out of closets and drawers, put them on and remove them from the
upper body without assistance.
2. Able to dress upper body without assistance if clothing is laid out or handed to the patient.
3. Someone must help the patient put on upper body clothing.
4. Patient depends entirely upon another person to dress the upperbody.
(M1820) Current Ability to Dress Lower Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:
Enter Code
0
1
Able to obtain, put on, and remove clothing and shoes without assistance.
Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.
2 Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.
3 Patient depends entirely upon another person to dress lower body.
(M1830) Bathing: Current ability to wash entire body safely. Excludes grooming (washing face, washing hands, and shampooing hair).
Enter Code
0 Able to bathe self in shower or tub independently, including getting in and out of tub/shower.
1 With the use of devices, is able to bathe self in shower or tub independently, including
getting in and out of the tub/shower.
2 Able to bathe in shower or tub with the intermittent assistance of another person:
(a) for intermittent supervision or encouragement or reminders, OR
(b) to get in and out of the shower or tub, OR
(c) for washing difficult to reach areas.
3 Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.
4 Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode.
5 Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person.
6 Unable to participate effectively in bathing and is bathed totally by another person.
(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.
Enter Code
0 Able to get to and from the toilet and transfer independently with or without a device. Enter Code
1 When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.
2 Unable to get to and from the toilet but is able to use a bedside commode (with or without assistance).
3 Unable to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.
4 Is totally dependent in toileting.
(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, includes cleaning area around stoma, but not managing equipment.
Enter Code
0
1
Able to manage toileting hygiene and clothing management without assistance.
Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.
2 Someone must help the patient to maintain toileting hygiene and/or adjust clothing.
3 Patient depends entirely upon another person to maintain toileting hygiene.
(M1850) Transferring: Current ability to move safely from bed to chair, or ability to turn and position self in bed if patient is bedfast.
Enter Code
0
1
Able to independently transfer.
Able to transfer with minimal human assistance or with use of an assistive device.
2 Able to bear weight and pivot during the transfer process but unable to transfer self.
3 Unable to transfer self and is unable to bear weight or pivot when transferred by another person.
4 Bedfast, unable to transfer but is able to turn and position self in bed.
5 Bedfast, unable to transfer and is unable to turn and position self.
Scribe; Tell me about the patient’s GU/GI statusNurse;Mr. Smith is free from Urinary infections. M1600He reports urination is normal and his urine is pale yellow. He reports occasional stress incontinence. M1610He has daily bowel movements, including this morning.
Experienced
gDenies any bowel incontinence. M1620 His bowel sounds are present and normal x4 quad.
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You front load your visits– why not your QA?
• Allow your field clinician to finish one OASIS before starting another
• Documentation is made at the time service is provided for increased accuracy
• Give your field staff and QA, a process that encourages team work and stops the adversarial loop
• Give your clinicians their evenings and weekends back
• Train clinicians with immediate feed back– they don’t learn from corrections 3-5 days later
• Improve your agencies ability to capture correct acuity and better prove medical necessity
•Decrease your days to RAP to 1 to 2 days
Part 3Evidence Based Practice for CarePractice for Care Planning
Traditional PPS Care Planning
Patient Specific
• Interventions and goals vary with nurse
• Interventions and goals are built individually off of body system assessments (MOST EMRS)
• Cause delays in care often leading to readmissions
• Increase length of stay
• Encourages over Utilization
• Will not provide consistent outcomes
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Traditional PPS- locator 21
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Evidence Based Care PlanningPDGM / VBP/ ACO/ COPs
Diagnosis specific
•Uses evidence based practice
•Builds care plan of off PRIMARY DIAGNOSIS (PDGM ready)
•Expedites care plan creation
•Puts agencies in control of care plans
•Can be used to justify continuing care(if needed)
•Ensures outcomes
•Decreases 30 day re-admissions
Evidence Based Care Plan21. Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)Skilled Nurse 2w2,1w2. VS parameters per agencySOC visit;SN to review required teaching per COPs.SN to define primary dx: Congestive Heart Failure.SN to introduce zone tool for CHF management.SN to review 30-day hospital readmission prevention plan.SN to review and reconcile patient's medications.SN to ask and document patient's goals for HH.SN to review agency goal of disease self-management.SN to teach patient importance of compliance with plan of care to reach goals.SNV 2;SN to teach CHF in terms easily understoodSN to teach CHF in terms easily understood.SN to teach signs and symptoms of CHF exacerbation.SN to teach CHF medications.SN to teach CHF self-management strategies; daily weights and zone tools.SNV 3;SN to assess and teach patient use of weight log using teach back technique.SN to teach diet and nutrition guidelines for CHF management.SNV 4:SN to assess patient knowledge and application ability of the zone tool.SN to introduce and teach the BORG scale.SNV 5;SN to teach on the importance of exercise in CHF management, per physician's guidelines.SNV 6;SN to assess and reinforce patient's CHF self-management understanding and guidelines.SN discharge teaching to include; medications, diet, exercise, daily weights, use of zone tools and BORG scale, how/when to take action and keep physician appointments.
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Where do I start?
Top National DRG’s causing readmissions
CHF, COPD, Pneumonia, AMI CABG TKR/THRAMI, CABG, TKR/THR
Research the top DRG by cost in your county and offer your anchor hospital a solution https://data.cms.gov/mapping-medicare-disparities
Building Evidence Based Care PathwaysHome Health Quality Improvement– A CMS Initiative www.homehealthquality.org
Agency for Health Care Research and Quality– Department of Health and Human Services https://innovations.ahrq.gov
Delmarva Foundation - A subsidiary of “Quality Health Strategies,” Health Integrity (ZPIC) is another subsidiary http://www.delmarvafoundation.org
Quality Improvement Organization for Missour ( all states have one)TMF Quality Innovation Network800-725-9216http://www.tmfqin.org
Evidence Based Visit mapping Example
www.tmf.org/Health-Care-Providers/Home-Health-Agencies/Readmissions
https://www.homehealthquality.org/Special-Pages
CHF ExacerbationCHF ExacerbationSN Frequency: 2w2,1w2 =6 SNV
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CHF Self-Care workbook
Tools for self-care and managementDefine the diagnosisPersonal Goals and planMedicationsBORG ScaleDiet and NutritionEnergy Conservation
Your Goal Weight:Green Zone: All Clear
No shortness of breath No swelling No weight gain No chest pain No decrease in your ability to maintain your activity level
Green Zone Means:
Your symptoms are under control Continue taking your medications as ordered Continue daily weights Follow low salt diet Keep all physician appointments
Yellow Zone: Caution
If you have any of the following signs and symptoms:
Weight gain of 3 or more pounds in 2 days Increased cough Increased swelling Increase in shortness of breath with activity Increase in the number of pillows needed Anything else unusual that bothers you
Yellow Zone Means:
Your symptoms may indicate that you need an adjustment of your medications
Call OperaCare nurse right now!!Name:___________________________Number:__________________________Instructions: _______________________
Call your HH nurse if you are going into the YELLOW zone
Red Zone: Medical Alert
Unrelieved shortness of breath: shortness of breath at rest Unrelieved chest pain Wheezing or chest tightness at rest Need to sit in chair to sleep Weight gain or loss of more than 5 pounds in 2 days ConfusionCall your HH nurse/ or physician immediately if you are going into the RED zone
Red Zone Means:This indicates that you need to be evaluated by a physician right away
Call your nurse/ physician/ or 911 now
Physician___________________________Number____________________________
Care Planning for Service Utilization with Evidence Based Practice
• Use HHQI Best practice care pathways (BPIPS)
• Always use Zone Tools for patient self-management
• Include 90 minute intensive visit within 72 hours of admission
• Consider telephonic teaching of medications
• The “BACKBONE” of your care plan is the primary diagnosis–STOP i bj ti t l iSTOP using subjective assessment care planning
• Clearly define tasks to be completed at each visit, rather than specific teaching.
• Use “teach back” technique
• Always document patient’s goal for home health
• Start with 30 days “BACKBONE” then add patient specific changes-age, cognition, co-morbidities
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Michael McGowanPresident, Opera Care, [email protected] 888OPERA EXT 710888.888OPERA EXT 710
Kristi Bajer BSN, RNVP of Clinical [email protected] EXT 709
References
http://www.homehealthquality.org/Education/Best-Practices.aspx
WWW.scribeamerica.com/what_is_medical_scribe.html
https://www.tmf.org/Health-Care-Providers/Home-Health-Agencies/Readmissionshttps://
www.hsag.com/es/medicare-providers/home-health-agency/
https://data.cms.gov/mapping-medicare-disparities
http://www.hhnmag.com/articles/3253-four-measures-that-are-key-to-retaining-nurses
www.allnurses.com
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4598196/
https://www.ncbi.nlm.nih.gov/pubmed/25957370
https://rnbsnonline.unm.edu/articles/high-cost-of-nurse-turnover.aspx
