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Achieving Optimal Clinical Management and Financial Balance


Achieving Optimal Clinical Management and Financial Balance Pat Laff, CPA, Managing Principal Lynda Laff, RN, BSN, COS-C, Principal * * * * * * * OASIS EDITS - P4P ... – PowerPoint PPT presentation

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Title: Achieving Optimal Clinical Management and Financial Balance

Achieving Optimal Clinical Management and
Financial Balance
Pat Laff, CPA, Managing Principal Lynda Laff,
RN, BSN, COS-C, Principal
OASIS-CFast Track to PP
  • Federal Register/Vol. 74, No. 44, Monday, March
    9, 2009
  • CMS ultimately plans to create a standard patient
    assessment that can be used across all post-acute
    care settings.
  • New Process Measures -
  • OASIS C was not intended to impact payment
    policy and OASIS items used in the payment
    algorithm were assessed to make sure they were
    not changed in a way that would affect the
    payment algorithm. Once OASIS data are collected
    it will be possible to assess whether they could
    be useful for refinements to the case mix
  • All information in OASIS C will be considered
    for use in the updated risk-adjusted models that
    will be applied to OASIS C based outcome
    measures in Home Health Compare, OBQI and OBQM
  • OASIS C Public comments Responses

Clinical Episode Management Goal
  • Provide the right amount of care efficiently and
    effectively to achieve anticipated or desired
    patient financial outcomes

Human Resources
  • Make sure you have the right people in the right
  • All registered nurses are NOT case management
  • A warm body doesnt cut it!
  • All PTs are NOT team players.
  • An experienced nurse is not always a qualified
    coder or quality review nurse
  • An excellent field clinician is not always an
    excellent manager
  • A scheduler is NOT a manager of patient care

Components of Clinical Episode Management
  • Clinical Management Information
  • Key Indicators
  • Routine Reports
  • Education
  • Clinical assessment
  • OASIS Accuracy
  • Supervision Oversight - Vigilance
  • Documentation Timeliness
  • Care Plan Development
  • Continuity
  • Case management
  • Clinical model
  • Accountability/ Responsibility
  • Reward / incentive
  • Corrective Action

Key Management Indicators
  • Case Weight
  • Timeliness of RAP Submission
  • OASIS Errors by Clinician
  • OASIS Corrections Completed
  • Cases Managed per Clinician
  • of Therapy Visits per Threshold
  • Average visits per episode
  • Outcomes Improvement
  • Patient Declines
  • Productivity by discipline - Actual

  • OASIS education must be thorough, credible and
  • The cost to educate properly will be a fraction
    of the dollars you will lose if you dont!
  • OASIS accuracy or inaccuracy goes right to the
    bottom line.
  • Put your money where it will have the most
  • SOC assessment determines revenue and outcomes
  • Value Based Purchasing SOC risk adjustment
  • Declines will be even more expensive in P4P

  • OASIS accuracy is a key driver of clinical and
    financial performance
  • OASIS C is the New Key Driver for payment under
    Value Based Purchasing
  • Clinician assessment accuracy is critical to
    patient outcome improvement AND agency financial
  • Clinician assessment determines case weight and
  • Clinician assessment determines non-routine
    supply revenue
  • Clinician assessment and completion of OASIS - C
    process items will affect aggregated score for

CMS - Value Based Purchasing
  • Currently hospital payment is contingent upon
  • Aggregation of performance with process measures,
    patient care measures and patient satisfaction
    measures (HCAHPS)
  • Home Health Care P4P
  • OASIS-C provides Home Health Care P4P
  • Outcome Measures
  • Process Measures
  • Implementation of HH-CAHPS

Process Outcome Measures Home Health Compare
Process Outcome Measures Home Health Compare
Process Outcome Measures Home Health Compare
Process Outcome Measures Home Health Compare
Process Outcome Measures Home Health Compare
Cardiac Status
  • (M1500) Symptoms in Heart Failure Patients If
    patient has been diagnosed with heart failure,
    did the patient exhibit symptoms indicated by
    clinical heart failure guidelines (including
    dyspnea, orthopnea, edema, or weight gain) at any
    point since the previous OASIS assessment?
  • ? 0 - No Go to M2004 at TRN Go to M1600 at DC
  • ? 1 - Yes
  • ? 2 - Not assessed Go to M2004 at TRN Go to
    M1600 at DC
  • ? NA - Patient does not have diagnosis of heart
    failure Go to M2004 at TRN Go to M1600 at DC
  • Time Points Transfer/D/C

Heart Failure Follow Up
  • (M1510) Heart Failure Follow-up If patient has
    been diagnosed with heart failure and has
    exhibited symptoms indicative of heart failure
    since the previous OASIS assessment, what
    action(s) has (have) been taken to respond? (Mark
    all that apply.)
  • ? 0 - No action taken
  • ? 1 - Patients physician (or other primary care
    practitioner) contacted the same day
  • ? 2 - Patient advised to get emergency treatment
    (e.g., call 911 or go to emergency room)
  • ? 3 - Implemented physician-ordered
    patient-specific established parameters for
  • ? 4 - Patient education or other clinical
  • ? 5 - Obtained change in care plan orders (e.g.,
    increased monitoring by agency, change in visit
    frequency, telehealth, etc.)
  • Time Points Transfer/D/C

(M2250) Plan of Care Synopsis Does the
physician-ordered plan of care include the
following Time Points SOC/ROC
(M2400) Intervention Synopsis Since the previous
OASIS assessment, were the following
interventions BOTH included in the
physician-ordered plan of care AND implemented?
Time Points Discharge/Transfer
  • (M2400) Intervention Synopsis (Check only one
    box in each row.) Since the previous OASIS
  • were the following interventions BOTH included in
    the physician ordered plan of care AND

Supervise and Manage
  • Education without validation and reinforcement is
    Money down the drain!
  • 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

Supervise Manage
  • Average case weight by month and by clinician
    on EOE
  • Clinician productivity actual visits not
  • Expected versus actual
  • Number of patients managed by case manager over
  • Total number of admissions (weekly, monthly)
  • Documentation timeliness
  • Documentation accuracy
  • Average visits per patient within national
    benchmark or better
  • Outcomes better than state national benchmark
  • Number or percent of OASIS errors
  • Number of OASIS corrections actually made (are
    you accepting excuses?)
  • LOS higher than national benchmark
  • Number of patient improvements declines

  • Continuity patient management
  • Admission Nurse Model
  • Hand-offs errors
  • The more staff involved the less the
  • Clinical model must insure actual case management
  • Primary nursing
  • Adequate ratio of nurses/therapists to patients
  • Productivity expectations must be reasonable

  • Primary clinician
  • May be RN or PT
  • Must be accountable for patient and financial
  • Accurate assessment
  • Appropriate care plan
  • Constant knowledge of
  • Goals of care
  • Projected visits vs. actual
  • Team performance Therapists must be included in
    the team
  • Patient response to care
  • Need for change in plan

Case Conference
  • Review of patients on census not a 2 hour
  • Expect clinician to be prepared
  • Manager must question
  • Clinician does not know patient
  • Cookie cutter scheduling
  • Visits never increase or decrease always a 60
    day episode
  • Patient declines occur frequently
  • Abundance of missed visits
  • LOS longer than national benchmark
  • Extraordinarily low case weight

Clinical Efficiency And Effectiveness
  • Learn to be efficient AND effective
  • Higher base rate of 2,312.94
  • Provide care the patient really needs!
  • Focus on newest technologies
  • Improve clinical knowledge, skills and practice

Operational Efficiency
  • Think Process
  • Accurate Care Planning
  • Right number of home visits no more no less
  • Efficient workflow processes
  • Focus on doing it right the first time not
    constant correction for poor performance
  • Dont duplicate work processes
  • Right staff performing clerical tasks time is
  • Use of Tele-monitoring
  • To identify incremental changes in the patients
  • Intervene in a timely manner
  • Prevent unnecessary hospitalizations
  • To provide the right amount of CARE most
    efficiently and effectively

Start The Episode On Top
  • OASIS errors set the scene for negative revenue
    and patient outcomes
  • Revenue and patient outcomes can not improve if
    the initial episode is submitted incorrectly
  • Manage the patient care episode by teaching case
    managers how to manage
  • Hold them accountable
  • Here Is How An Incorrect OASIS Might Impact
    Episode Revenue and Outcomes

Elizabeth Allen
  • Elizabeth Allen is an 85 year old woman
    who was admitted to home care following
    hospitalization for an ORIF due to a hip fracture
    as a result of a fall at home. She has insulin
    dependent Diabetes Mellitus, she had an acute
    exacerbation of COPD while in the hospital and
    the MD stated she also had Mild Senile Dementia.
    She was referred to home care for surgical wound
    care for an infected surgical wound, physical
    therapy, supervision and management of her COPD
    and stabilization and monitoring of her Diabetes
    and monitoring of her response to a change in her
    insulin dose. Mrs. Allen lives alone but has a
    daughter who lives 2 miles away and checks on her
    each day. She has been independent in her home
    with daily checking and meal assistance from her
    daughter and granddaughter until she fell and
    fractured her hip. She will be seen by nursing
    for daily dressing changes to her surgical wound,
    3xwx4 by therapy for transfer training, gait
    training, strengthening and ambulation.

Clinician Diagnosis Coding
Functional Scores
  • The Quality Review staff identified the
    following issues
  • M1342 was a score 3 (Non Healing Surgical Wound)
    and there was no diagnosis listed in M1020 or
    M1022 to support the (complicated) non-healing
    surgical wound
  • ICD-9 496.00 is a general DX with no associated
    points for revenue. Her hospitalization
    information indicted an acute exacerbation of
    chronic bronchitis (COPD).
  • ICD-9 290.00 DX is a non-specific general code
    with no associated case mix points and her MD
    stated she had stated that she had senile
  • An inconsistency was identified with a score of
    2 at M1700 and a score of 1 at M1740 indicating
    the need for assistance and some direction in
    specific situations and the inability to recall
    events of past 24 hours requiring supervision for
    some activities while her OASIS scores indicated
    she was able to take oral and injectable
    medications independently.

  • The Quality Review staff discussed the patient
    with the clinician and the intake nurse together
    they determined that wound care for the infected
    wound was the primary reason the patient was
    referred physical therapy was the additional
    reason for the referral.
  • M1020 should be a non-healing surgical wound DX.
    They also discussed the diagnoses of COPD and
    Dementia with the intake staff and reviewed the
    referral documentation that indicated an acute
    exacerbation of CHF. They also noted that the MD
    has specifically indicated the patient had senile
    dementia, a DX with associated case mix points.
    They discussed the DX with the clinician and
    suggested a change in the DX codes.
  • They reviewed the scoring inconsistencies with
    the clinician and the clinician corrected the
    OASIS to reflect a score of 1 at M02020
    (management of oral meds) and M2030 (management
    of injectable meds).
  • Without these corrections, outcomes in
    medication management would potentially have
    declined with the correction, outcomes will
    remain stable (no decline) and P4P will not be in
  • With OASIS accuracy - look what happened to the
    episode revenue.

Coding Corrections
Coding Corrections
Coding Corrections
No Change
Coding Corrections 547.38
OASIS Edits/Corrections Revenue
  • Lets Recap the Change After Editing
  • Change in the HHRG due to ?in clinical points
  • C2 F3 S5 to a C3 F3 S5
  • 4,102.46 to 4,490.11 387.65
  • Change in NRS Revenue
  • Severity Level 2 to Severity Level 4
  • 51.96 to 211.69 159.73
  • Total additional revenue 547.38

Clinical Episode Management Goal
  • Provide the right amount of care efficiently and
    effectively to achieve anticipated or desired
    patient financial outcomes

Clinicians and Finance A Language Apart
  • Patient Outcomes vs. Bottom Line
  • Home Health Compare Scores vs. Unit Costs
  • Case Weights vs. Realized Revenue
  • Diagnosis (Disease) Management vs. Episode Costs

Clinicians and Finance A Language Apart
  • Clinicians learned financial language quicker
  • Finance has been learning clinical language and
  • operations because Clinicians already understand
  • Accurate assessments generate the most
    appropriate Case Weights that translate into
  • Good outcomes with fewer visits reduces costs
  • Productivity, increased case capacity and
    efficiency result in lower unit costs
  • Better Home Health Compare scores will mean
    increased revenue under Value Based Purchasing

Clinicians and Finance A Language Apart
  • As a CFO you need to understand the Bottom Line
  • of
  • Disease Managementthe most appropriate disease
    specific levels of care
  • Patient Case Managementthe most appropriate
    frequencies and duration of visits by discipline
  • Primary Nursing ModelOASIS C implications and
    the consistency and continuity of care
  • Positive Outcomes and Home Health Compare
  • Staff SatisfactionPositive Outcomes and
    recognition are a feel good!
  • Knowledge is Everything!

Clinicians and Finance A Language Apart
  • How much time has your finance staff spent
  • In the field with Clinicians making visits?
  • Have the CFO make an admission visit with a
  • At patient staff meetings to learn and truly
    understand the ongoing care planning process?
  • Really trying to understand OASIS C? IT IS
    advanced rocket science!
  • Understanding documentation requirements and the
    time required?
  • Point of Care technology?
  • Travel patterns

Clinicians and Finance A Common Language
  • Clinicians and Finance have to listen to each
    other and
  • understand what is being said!
  • A sincere willingness to learn
  • A willingness patiently teach without being
  • Improvement in the levels of understanding is

Clinicians and Finance A Common Language
  • The Clinicians generate the revenue and determine
  • the related unit expense components. They should
  • understand
  • What contributes to Direct Costs of their
    discipline and those they case manage, and
  • What comprises Indirect Costs, over which they
    have little control

Clinicians and Finance A Common Language
  • The Finance staff need to learn and understand
  • Differences in visits (and OASIS C) and how they
    effect per visit costs
  • Admission
  • Follow-up
  • Recertification
  • Discharge
  • How different diagnoses effect the length of a
    visit and the documentation requirements
  • How visit frequency factors and diagnostically
    specific standards of practice effect
    productivity, efficiency and costs per visit and
    episode of care

Necessary Financial Drilldowns
  • Revenue Recognition as Costs are incurred
  • Identify Accurate Direct Costs by Discipline,
    Supply and Tele-health day
  • The Measure of Average Visits by Discipline and
    Supply Use by Diagnosis and Cost

Calculating Direct Costs Per Visit
Calculating Direct Costs Per Visit
Calculating the Direct Cost Per Telemedicine Day
Elizabeth Allen Revenue and Cost Analysis
Disease Specific Profitability Analysis
  • Disease specific Standards of Practice, subject
    to designed variation, quantifies the resources
    to be used and the cost of those resources
  • Staffing
  • Incorporate telemedicine into a telehealth
  • Projected episode gross profit and net profit
  • Profit planning (budget) and forecasting based
    upon case mix, not a single average case weight
  • Determine average revenue for specific disease
    (average of the specific Case Weight values)
  • Comparison of actual practice to designed
  • Should the standard be modified or was the
    variation patient specific?

The Value of Telemedicine
  • The acquisition cost (purchase or lease) should
    be considered an Operational Direct Cost, not a
    Capital Expenditure
  • The physiological data, not an IT System
    scheduler, identifies when hands-on visit are
  • Reduces the number of nursing visits per episode,
    depending upon specific Disease Management
  • Increases RN Case Capacity by approximately 5
  • Increases patient observation to 7 days a week
  • Telehealth improves outcomes and reduces

Diagnosis - CHF
  • Average Visits per Patient Episode (all
    diagnoses) 13.00
  • Average Visits per CHF Episode 12.33
  • Average Visits per Frequent Flyer CHF Episode
  • with Telehealth Disease Management Protocol
  • (43 Episodes) 15.68
  • SN 9.30
  • PT 3.90
  • OT 0.95
  • ST 0.09
  • MSW 0.14
  • HHA 1.30
  • The selected frequent flyer patients have a re-
  • hospitalization rate of 10 -- What a great
  • Based upon information and data from the VNA
    of Western Pennsylvania December 1, 2009
    February 28, 2010

Diagnosis CHF The Cost
  • Standards of Practice
  • VNA of Western PA
  • Average Visits Average Visits
  • all Episodes Telehealth Episodes
  • Visits Cost/Visit Cost Visits
    Cost/Visit Cost
  • SN 5.95 121.10 720.55
    9.30 121.10 1,126.23
  • PT 3.90 120.34 469.33
    3.90 120.34 469.33
  • OT 0.95 124.66 118.43
    0.95 124.66 118.43
  • ST 0.09 124.89 11.24
    0.09 124.89 11.24
  • MSW 0.14 117.60 16.46
    0.14 117.60 16.46
  • HHA 1.30 51.44 66.87
    1.30 51.44 66.87
  • 1,392.88 1,798.66
  • Are the Outcome results worth the additional
    405.68 per episode to
  • the Agency? To the Hospital? To the patient
    and their family?

Questions Often Asked
  • Recommended Clinical Model
  • Primary Nurse Care Management
  • Productivity and Case Capacity
  • RNs minimum 25 27 visits (hands on) /
  • 25 30 Patients (without Telemedicine)
  • PTs OTs minimum 27 30 visits (hands on) /

Questions Often Asked
  • Visit weighting Based the Requirements and
    Complexities of completing OASIS C
  • Visit
  • Weight
  • Time
  • Admission (evaluation) visit 1.90 182 min
  • Resumption visit 1.30 125 min
  • Recertification Visit 1.20 115 min
  • Discharge Visit 1.25 120 min
  • Follow-up Visit 1.00 96 min
  • Virtual Telephone Visit (Telehealth) 0.25
    24 min

Weekly Management Report
Performance Incentives for all Agency Staff
  • Design a Comprehensive Agency-wide Incentive
  • That Will Unify the Agency Culture
  • These Incentives are Best Achieved using a
    Primary Nurse Care Model
  • Improved Clinical Outcomes
  • Homecare Compare Scores
  • Outside Benchmarking
  • Reduced Non-planned Re-hospitalizations and
    Emergency Department Incidents
  • High Risk Patients
  • OASIS Timeliness and Accuracy
  • Development of Disease Management Standards of
    Practice Adopting State of the Art Clinical
  • Patient Satisfaction
  • Admission Within 24 Hours of Referral

Performance Incentives for all Agency Staff
  • Design a Comprehensive Agency-wide Incentive
  • That Will Unify the Agency Culture
  • Administrative and Financial Outcomes
  • Timeliness of OASIS Submissions, RAPs, Signed
    Orders, End of Episode Billing (no recoupments)
  • Achieving Planned Costs per Unit of Service
  • Achieving Planned Process Productivity
  • Reduced Absenteeism Sick Days
  • Increased Referrals
  • New Referral Sources
  • Additional Referrals from Existing Sources

Contact Information
Lynda Laff, RN, BSN, COS-C Pat Laff, CPA Laff
Associates Consultants in Home Care
Hospice Phone (843) 671-4170 Email llaff_at_laffas Website