Effects of Frontloaded Visits

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Best Practice Measures to Decrease Rehospitalizati
on Front Loading Visits, the OASIS Champion
Model and Effective Change Management
Joanne Rogers, RN, BSN, MA Director,
Coordinated Care University Hospitals Home Care
Services .
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Home Healths National Challenge

• We have a Carrot on a Stick
• Reducing avoidable Emergent Care and Acute Care
  Hospitalization equates to better public outcomes
  and P4P experience

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Home Healths National Challenge
OASIS ACCURACY
REFERRAL APPROPRIATE FOR HC
APPROPRIATE CARE COORDINATION
NO ACH AND PATIENT IS SAFE AT HOME
CLINICAL COMPETENCE OF VISITING STAFF
INDIVIDUALIZED PLAN OF CARE
EMERGENCY CARE PLANNING
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Front Loading Visits

• Best practice model
• Posted on the MedQIC website
• Proven to reduce the risk of ACH
• Early identification of signs and symptoms
• Early implementation of interventions
• Early initiation of patient education and
  emergency care planning

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Front Loading Visits Joint Study

• University Hospitals Home Care/Case Western
  Reserve
• Heart Failure
• Front Loaded
• -15.8 of the entire group was rehospitalized
• -on average only one rehospitalization per cert
  period
• Non- Front Loaded
• -39.4 of the entire group
• -on average 1.2 rehospitalizations per cert
  period with a range from 1-3 rehospitalizations

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Front Loading Visits Joint Study

• University Hospitals Home Care/Case Western
  Reserve University
• -Conclusions
• -Frontloading impact on rehospitalization for
  patients with heart failure
• ? rate
• ? number of rehospitalizations

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Front Loading Visits Joint Study

• Study conclusions continued
• -Front loading allowed for
• equivalent clinical outcomes
• fewer visits
• better utilization outcomes
• -Even with fewer visits overall, clinical
  outcomes and patient satisfaction were comparable

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Why Should You Front-load Visits?

• Dramatic increase in acuity of patients
• Examination of
• OBQI
• OBQM
• CMS Risk Adjustment
• Balance utilization and outcomes

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Why Should You Front-load Visits?

• High incidence of chronic diseases presenting
  with co morbidities
• High volume
• High cost
• High acuity
• High readmission rate

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Why Should You Front-load Visits?

• If you always do what you always didyou will
  always get what you always got.
• Author Unknown

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Definition of Front Loading Visits

• Front-loading
• University Hospitals Home Care defines this as a
  planned visit frequency of 60 or more of visits
  occurring in the first 14 days
• Note Each agency may define this differently

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Front Loading What Patients to Focus On

• Patients with
• Chronic Diseases
• Multiple co morbidities
• EX
• HF patients have been documented to have
  rehospitalization rates ranging from 25-40
• Most critical time is the first 1-3 weeks

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Care Paths

• Time specific plans for a sequence of
  nursing/therapy events that lead to a measurable
  outcome in the most efficient, effective manner

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Common Pathway Elements

• Coordination of care
• Assessment
• Intervention
• Patient education
• Telehealth/Telemonitoring
• Measurable outcomes of care delivery

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Telehealth

• Telehealth
• -Documented to be most successful among the
  elderly
• Enables patients do more self-management
• Enhances overall compliance
• Promotes ? Quality of Life
• -A means of extending services to patients
  rapidly and more frequently

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Benefits of Telehealth

• - Communicate with high-risk patients more
  frequently
• - Early intervention for patients found to be
  declining
• - Resource/Utilization management

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Sample Care Path Incorporating Front Loaded
Visits

• Heart Failure

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Use of Heart Failure Care Path

• - Primary referral diagnosis of heart failure
• - Follows New York Heart Classification

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New York Heart Classification I

• Description
• No limitation
• Ordinary physical activity does not cause undue
  fatigue, SOB, palpitations

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New York Heart Classification IOASIS

• Probable OASIS assessment findings
• MO490 Dyspnea 0
• MO650 Ability to dress upper body 0
• MO660 Ability to dress lower body 0
• MO670 Bathing 0 or 1
• MO680 Toileting 0
• MO690 Transferring 0
• MO700 Ambulation/locomotion 0
• MO826 No

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New York Heart Classification IVisit Guidelines

• Recommended visit frequency and visit pattern
• 2-3 SN visits primarily for teaching
• or as allowed by commercial insurers

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New York Heart Classification II

• Description
• Slight limitation of physical activity
• Comfortable at rest
• Ordinary physical activity results in fatigue,
  SOB, palpitations, angina

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New York Heart Classification IIOASIS

• Probable OASIS assessment findings
• MO490 Dyspnea 1 or 2
• MO650 Ability to dress upper body 1
• MO660 Ability to dress lower body 1
• MO670 Bathing 2
• MO680 Toileting 1
• MO690 Transferring 0 or 1
• MO700 Ambulation/locomotion 1 or 2
• MO826 No

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New York Heart Classification IIVisit Guidelines

• Recommended visit frequency and visit pattern
• 7 SN visits and 3 telephone assessments
• SN frequency 2w2 then 3mo1 (for weeks 5,7,9)
  one telephone assessment for each of weeks 4,6,8
• or as allowed by commercial insurers
• (Note Adjust frequency to SOC day of week)

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New York Heart Classification III

• Description
• Marked limitation of physical activity
• Comfortable at rest although less than ordinary
  activity will lead to symptoms

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New York Heart Classification IIIOASIS

• Probable OASIS assessment findings
• MO250 Therapies 1 if IV cardiac meds being used
• MO420 Pain 2 if patient limiting movement to
  avoid angina
• MO490 Dyspnea 3
• MO650 Ability to dress upper body 2
• MO660 Ability to dress lower body 2
• MO670 Bathing 3
• MO680 Toileting 1 or 2
• MO690 Transferring 1 or 2
• MO700 Ambulation/locomotion 3
• MO826 Yes possible with PT and/or OT involvement

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New York Heart Classification IIIVisit
Guidelines

• Recommended visit frequency and visit pattern
• 8-9 SN visits and 4 telephone assessments,
  possibly 1-2 OT visits
• SN frequency 2-3 W2, 1w2 and 2mo1 one
  telephone assessment for each of weeks 3,4,6,8
• or as allowed by commercial insurers
• (Note Adjust frequency to SOC day of week)

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New York Heart Classification IV

• Description
• Inability to carry on physical activity without
  discomfort
• Symptoms of CHF are present even at rest
• ? discomfort is experienced with any physical
  activity

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New York Heart Classification IV

• - SN visits focus on comfort measures
• - May consider OT evaluation
• - Hospice referral often recommended

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New York Heart Classification IVOASIS

• Probable OASIS assessment findings
• MO250 Therapies 1 if IV cardiac meds being used
• MO420 Pain 2 or 3 if patient limiting movement
  to avoid angina
• MO490 Dyspnea 4
• MO650 Ability to dress upper body 3
• MO660 Ability to dress lower body 3
• MO670 Bathing 4 or 5
• MO680 Toileting 3 or 4
• MO690 Transferring 3, 4, or 5
• MO700 Ambulation/locomotion 4 or 5
• MO826 Yes possible with PT and/or OT involvement

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New York Heart Classification IVVisit Guidelines

• Recommended visit frequency and visit pattern
• 9-11 SN visits and 4 telephone assessments,
  possibly 1-2 OT visits
• SN frequency 3w2, 1w2, 2mo1 one telephone
  assessment for each of weeks 3,4,5,6
• or as allowed by commercial insurers
• (Note Adjust frequency to SOC day of weeks)

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Telehealth Tool

• Heart Failure

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Sample Carepath

• Diabetes

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Use of Diabetic Care Path

• - New diabetics, with or without complications
• - Primary referral diagnosis of diabetes

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Patient has Diabetes and is on insulinVisit
Frequency

• Recommended visit frequency and visit pattern
• 9-10 SN visits
• 2 prn visits for diabetic complications
• 4 telephone assessments
• SN frequency 4wk1, 2wk2, 2mo1 and one telephone
  assessment on weeks 2,3,4 and 6
• Or as allowed by commercial insurers

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Patient has Diabetes and is not on insulinVisit
Frequency

• Recommended visit frequency and visit pattern
• 7 SN visits
• 2 prn visits for diabetic complications
• 3 telephone assessments
• SN frequency 3wk1, 1w2 and 2mo1 and 1 telephone
  assessment on weeks 2,4 and 6
• Or as allowed by commercial insurers

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Telehealth Tool

• Diabetes

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There is always a better way.

• - Thomas Edison

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The OASIS Champion

• The OASIS has turned out to be a remarkable tool
  and is driving the home care industry
• The answers our clinicians code on the OASIS
  have changed the former reimbursement system and
  determined the 2008 PPS system of payment

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The OASIS Champion

• Our clinicians are our most vital resources,
  still they may not know how outcomes are
  calculated in terms of
• Outcomes
• Risk Adjustment

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Inter-Rater Reliability and Outcomes

• Outcomes are defined as a change or a lack of
  change in a patient condition during an episode
  of care
• Two categories
• Improvement (or stabilization) outcomes
• Utilization (event related) outcomes
• Emergent Care
• ACH
• Discharged to Community

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Inter-Rater Reliability and Risk Adjustment

• CMS Risk Adjustment/Publicly Reported Outcomes
• - Does your agency know
• how CMS risk adjustment works?
• what is the difference between your observed
  rates and your predicted rates?
• if the risk adjustment is working to your
• outcome advantage or against it?
• how dependent OASIS accuracy is to this risk
  adjustment model?

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What is an OASIS Champion?

• Concept introduced in an effort to
• improve accuracy
• enhance consistency
• in the way clinicians score the OASIS
• Additional benefits may be
• fosters a collaborative environment
• best possible outcomes are considered in
  advance

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What is an OASIS Champion?

• The Champion is the key person
• Responsible for inter-rater reliability
• Coaching peers
• Precepting less seasoned clinicians

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Why do you need inter-rater reliability?

• Inter-rater reliability is a process that
  maximizes the
• quality of OASIS data

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Why do you need inter-rater reliability?

• - The OASIS has been used by CMS extensively for
• Regulatory reasons
• Determining the quality of outcomes
• Reimbursement

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Why do you need inter-rater reliability?

• The Office of the Inspector General (OIG) work
  plan for fiscal year 2008, page 8
• We will review Medicare Claims submitted by
  HHAs to determine the extent to which the
  HHRGs that are used in determining payments to
  HHAs are accurate and supported by documentation
  in the medical record. Section 1895 of the SS
  Act governs the payment basis and reimbursement
  for claims submitted by HHAs including a
  case-mix adjustment using HHRGsEach HHRG has an
  assigned weight that effects payment rate. We
  will assess the accuracy of HHRG assignment and
  identify potential patterns of upcoding by HHAs
• (0E1 00-00-00000 expected issue date FY 2009
  new start)

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Why do you need inter-rater reliability?

• Literature suggests
• inter-rater reliability studies are necessary to
  ensure the accuracy of outcomes in home care
• Audits consistently show
• there are differences in the way clinicians and
  disciplines assess a patient and answer OASIS
  questions

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Why do you need inter-rater reliability?

• The OASIS Champion performs simultaneous
  assessements alongside less seasoned clinicians
• Scores between the two clinicians are compared
• Dialogue take place within a short time following
  the assessment
• Coaching/Education occurs
• Necessary corrections are made to the assessment
  and corresponding patient plan of care

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Choosing Your OASIS Champions

• Clinicians who qualify for this role
• are seasoned in home care
• are highly motivated
• enjoy being a preceptor/coach
• receive extensive OASIS training
• are encouraged to take the national exam to
  become Certified OASIS Specialists

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There will always be obstacles

• It still holds true that man is most uniquely
  human when he turns obstacles into
  opportunities.
• -Eric Hoffer

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There will always be obstacles

• It takes (too much) time!
• Putting your heads together
• Developing guidelines/action plans
• Guaranteeing management buy-in and support
• Monitoring
• staff compliance
• patient compliance
• outcomes

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There will always be obstacles

• It takes (too many) resources!
• Clinician shortages
• Staffing issues
• Weekend and vacation coverage
• Do your staff have the time, support and
  encouragement to attend inservices and to serve
  on committees?

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There will always be obstacles

• It takes (lots of) planning

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Change Management

• You are motivated and have great ideas but how
  can you most likely predict your success when you
  see something needs to change?

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Change Management

• Everyone thinks of changing the world, but no
  one thinks of changing himself.
• - Leo Tolstoy

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Three Phases of Any Change

• Current State
• -employees are most comfortable with and
  prefer to stay here
• Transition State
• -the transition state creates stress and anxiety
• Future State
• -the future state is unknown or not well
  understood

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Five Building Blocks for Successful Change

• Awareness
• Desire
• Knowledge
• Ability
• Reinforcement

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The Change Management Process

• Change management is similar to project
  management, but it is the people side of things
• When effective it
• increases the probability of success of a project
• manages employee resistance
• builds change competency into the organization

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Effective Change Management

• Leadership/Sponsorship

Change Management
Project Management
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This Change Has an Executive Sponsor

• Who
• The Project has a sponsor
• The sponsor has the necessary authority over the
  people, processes and systems to authorize the
  change
• Is willing and able to build a team for the
  change
• Is able to manage anticipated resistance
• Will actively and visibly participate with the
  project team throughout the entire change process
•  

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This Change Has an Executive Sponsor

• Who
• Will resolve issues and make decisions relating
  to the project implementation
• Will build awareness of the need for the change
  directly with those involved
• Has a clearly defined vision, strategy and
  implementation plan, which is aligned with the
  strategy and vision of the entire organization
• Has set project priorities and has communicated
  them in an effective manner
• Will visibly reinforce the change and celebrate
  the successes of the team and all impacted by the
  change

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The Change Project Has

• Been clearly define including what the change
  will look like and who will be impacted
• A clearly defined scope
• Specific objectives that define success
• Identified goals and a project time line
• An assigned project manager

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The Change Project Has

• A completed work breakdown
• Identified resources for the project team
• Regularly scheduled meetings to track progress
  and resolve issues
• An executive sponsor that is readily available to
  work on issues that impact the project goal
• A project plan that has been integrated with the
  change management plan

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The Change Management Plan

• A structured approach is being applied to the
  project
• An assessment of the change and the impact on the
  organization has been completed
• An assessment of the readiness for change of
  those persons being impacted has been completed
• Anticipated areas of resistance have been
  identified and tactics to decrease resistance
  have been developed
• A change management strategy, including a sponsor
  and team, has been developed

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The Change Management Plan

• Change management team members have been
  identified and trained
• An assessment of the strength of the team has
  been done
• Plans around communication, sponsorship,
  coaching, training and resistance management have
  been created
• Feedback processes have been established to
  gather information from employees to determine
  how effectively the change is being adopted
• Resistance to change is managed effectively

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The Change Management Plan

• Score interpretation Ideal score for each area
  30
• Scores of 25-30
• - High probability of success
•  Scores of 20-24
• - Some existing risk factors are present that may
  impede success
•  Scores of 1-19
• - Some areas of jeopardy may exist for the
  project

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To Predict Success

• Always Prepare for Change
• Develop your strategy
• Prepare your change team
• Assess
• Sponsorship
• Project Management
• Change Management
• Understand the employees perspective
• Know that resistance is normal

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• QUESTIONS?

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Advanced Care. Advanced Caring.? at home.