Transcript Basics of Quality Documentation Orientation

Nightingale and Aspire
Home Healthcare
QUALITY CARE
& DOCUMENTATION
2011-2012
HOME HEALTH SERVICES
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Covered under the Part A Medicare benefit.
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Are part-time, medically necessary skilled care
(Nursing, PT, OT, ST) ordered by a physician.
REPORTING HOME HEALTH QUALITY USES OASIS
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Beginning January 2010, agencies have been
required to collect OASIS-C data.
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CMS anticipates that OASIS C will promote the
use of evidence based practices in the home
health industry.
NEED FOR HOME HEALTH IS INCREASING
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In 2010, approximately 11,000 Medicare
certified home health agencies in the US
 2007:
3,095,899 beneficiaries received
114,198,915 visits.
 2010: 3,446,057 beneficiaries were served during
122,578,603 visits.
2012 CMS HOMECARE CUTS: 640 MILLION $
CMS plans dramatic changes for the industry.
Some Highlights:
 Remove Hypertension Codes: 401.1 & 401.9
 Reduce payments for high visit episodes: 510% reduction
 Standard episode rate reduced by $80
CMS IS REDEFINING QUALITY
Effectiveness
Achieving outcomes as supported by scientific evidence.
Efficiency
Maximizing the quality of health care achieved for $ used.
Equity
Providing equal quality to those with differences other than their clinical
condition or preferences for care.
Patient Centeredness
Meeting patients' needs, preferences, & providing education and support.
Safety
Relates to actual or potential bodily harm.
Timeliness
Relates to obtaining needed care while minimizing delays.
PAY-FOR-PERFORMANCE INITIATIVES ARE A CMS
PRIORITY
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Pay-for-performance is aimed at improving quality,
outcomes or safety based on measurements by
rewarding improvements.
Focuses on reducing need for more costly care
(hospitalization).
Monetary incentives will come from the net cost savings
to Medicare.
Incentives will be shared with agencies or partnerships
making the biggest improvements in patient care.
EXAMPLE: NATIONAL HOME HEALTH
COMPANY RECEIVES PAY-FOR-PERFORMANCE
AWARD
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On July 5, 2011 CMS announced it shared nearly $15
million in savings with more than 100 Home Health
Agencies that participated in the two-year Medicare Home
Health Pay for Performance demonstration.
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One company received $4.7 million from CMS based on its
performance during the second year of the Medicare Home
Health Pay for Performance demonstration.
OASIS MEASURES QUALITY
CMS posts some OASIS information on the
Medicare.gov website "Home Health Compare“
(HHC).
 Publicly-reported measures from OASIS include
Outcome & Process Measures.
 Potentially Avoidable Events and Patient
Satisfaction scores will be posted to in 2012.
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OUTCOME MEASURES
Outcome measures report a change (or lack of
change) in patient condition during an episode
of care.
 There are two types of outcomes--Utilization
outcomes and End-result outcomes:
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 Higher
values are preferable for end result
outcomes.
 Lower values are preferable for utilization
outcomes.
OUTCOME MEASURES
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Patient Outcomes are calculated comparing
scores from admission to a home health
agency (or a resumption of care) to scores at
discharge (or transfer to inpatient facility).
POTENTIALLY AVOIDABLE EVENT MEASURES
Potentially avoidable events are markers for
potential problems in care because of their
negative nature.
 Potentially avoidable events represent a
change in health status.
 Potentially Avoidable Event Measures are
adjusted for variations in patient acuity.
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PROCESS MEASURES
Process measures evaluate the use of
evidence-based processes of care.
 OASIS-C process measures focus on high-risk,
high-volume, problem-prone areas.
 Process measures are calculated starting at
admission to a home health agency (or a
resumption of care) compared to discharge or
transfer to an inpatient facility.
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MEDICARE.GOV
2012 AGENCY FOCUS AREAS
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1. Quality of Care Benchmarks such as Home Health Compare Patient
Outcomes & Process Measures
2. Customer Satisfaction is Priority: Improvement in HHCAHPS scores;
Incidents; Complaints; & Pt needs met via other services utilized
3. Visits per Episode; Improvement in Utilization/Efficiency; LUPA/
Frontloading; Coding; Productivity
4. Reduction in Hospitalizations, Emergency Department Use, & Potentially
Avoidable Events
5. Supervisory Visits Compliance
6. Quality of Charting & Documentation; Paperwork Compliance
7. Communication; Case Conferencing & Care Coordination; Missed Visits;
Synching
Re-evaluation will be completed each Quarter
OBJECTIVES OF SESSION
Participants will develop understanding of:
 Processes
 Expectations
 Initiatives
OVERALL GOAL:
Clinicians understand quality of their impact is measured by each
patient’s presentation in routine charting, OASIS
documentation, and patient surveys
QUALITY ASSURANCE: MANAGER, AUDITOR, PEER
REVIEW ACTIVITIES
Chart Review
 Benchmarking Reviews
 OASIS, Plan of Care, and Order Review
 Focused Reviews (ex: wound care)
 Review of Hospitalizations
 Potentially Avoidable Event Review (ex: falls)
 Patient Outcomes Review (ex: ambulation)
 Review of Patient Survey Data (ex: HHCAHPS)
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QUALITY ASSURANCE &
PERFORMANCE IMPROVEMENT (QAPI)
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QAPI Programs address quality needs
Performance improvements are targeted from data
Measurable goals are set
Corrective actions are implemented
Re-evaluation, at least quarterly, assesses
effectiveness
Quality Improvement process is continual
TWO GOALS OF HOME HEALTH CARE
1)
2)
Replace acute needs of people who would otherwise
have to remain in, or enter, acute care facilities;
AND…
Assess & address patient needs with selfmanagement and prevention to avoid hospitalization
or re-institutionalization during and after their period
of care from home health ends.
GOALS ARE MORE EFFECTIVE IF THEY ARE
MEANINGFUL TO THE PATIENT
Share Information and emphasize any concerns. This will help the patient make
informed decisions.
Develop Shared Goals. Incorporate the patient’s perspective. Identify barriers
the patient perceives to reaching goals.
Develop an Action Plan = the Care Plan for your discipline.
What will be done, how, how often, by whom, and by what date. Discuss
barriers and strategize.
Remember: High risk/unstable pts deteriorate quickly. Have the patient report
on their progress toward the goals.
Ultimately, Documentation must show we helped patient to get better and
adapt to life with chronic illness.
ONGOING DOCUMENTATION TARGETS
Patient Education & Learning
Discharge Planning
Packet Paperwork completion
Skill; Homebound Status
Medication Reconciliation
Pain Assessment/Mitigation
Thorough Patient Assessment
Care Planning
Case Conference/Care Coordination
Supervision: LPN/LVN, PTA, COTA, HCA
Change in Condition/Problem Resolution
Adherence to Care Plan (Orders), including Visit Frequency
CMS MANDATES CLIENT EDUCATION
ABOUT HOME CARE
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Great outcomes start at the very first visit
At SOC, instruct the client about the short term, intermittent
nature of services
Pts must know goals of care & how goals will be achieved
Pts must understand the visit frequency and duration for each
discipline
Medicare pts must be informed Non-Coverage
At SOC, chart in your Visit Note Narrative that you reviewed the
Patient Booklet (note pertinent sections) and note the
patient’s understanding.
TIP: CARRY COMPLETED PAPERWORD EXAMPLE
FOR REFERENCE…
TIME POINTS – WHEN TO RECONCILE
MEDICATIONS?
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DRUG REGIMEN REVIEW must be completed at
SOC, ROC and Recertification, AND…
Any time medications change
Best Practice: Screen Each Visit - Document your
assessment of what is happening and the work
you do with Medications
Remember that we have an in-house Pharmacist
for ?’s
M2000 DRUG REGIMEN REVIEW:
Does a complete drug regimen review indicate
potential clinically significant medication issues, e.g., drug
reactions, ineffective drug therapy, side effects, drug
interactions, duplicate therapy, omissions, dosage errors, or
noncompliance?
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0 - Not assessed/reviewed [ Go to M2010 ]
1 - No problems found during review [ Go to M2010 ]
2 - Problems found during review
NA - Patient is not taking any medications [ Go to M2040 ]
TIP: M2000 on OASIS - Never mark “0” Not Assessed
M2000 BEST PRACTICES
Questions to ask Patients
 Do you have a list of current medications?
 Any confusion, dizziness, or upset stomach that you think might be related to
your medications?
 Do you have all the medications you are supposed to be taking?
 Do you take all the medications you are supposed to?
Optimal Strategy
 “Show me all of your medications , plus any over the counter items, like
creams, vitamins, herbs, or potions”.
 Patient must demonstrate where their meds are stored, how they get them
out, and what they do to remember to take them.
 Assess correct usage: Look at dates, number of refills used, & the number of
pills left
 Based on results, develop care plan interventions, consult the physician, and
work to resolve issues
M2010 PATIENT/CAREGIVER HIGH RISK
DRUG EDUCATION
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This process item is used to capture use of Best Practices
Identifies if clinicians instructed the patient and/caregiver
about the High Risk/Alert medications
Clinician must educate on high-risk medications as these may
have severe negative impacts on patient safety & health.
Tips
 Educate on high risk/alert, New and Changed meds. Check pt
understanding on following visits
 Carry the med teaching sheets. Document that you have provided
teaching sheets for reference
TIP: CARRY LIST OF HIGH ALERT MEDICATIONS
M1240: HAS THIS PATIENT HAD A FORMAL PAIN
ASSESSMENT USING A STANDARDIZED TOOL?
0 - No standardized assessment conducted
1 - Yes, and it does not indicate severe pain
2 - Yes, and it indicates severe pain
Item Intent
Identifies if a standardized pain assessment is conducted using an
appropriate tool and whether a clinically significant level of pain is present.
EXAMPLE :
M1240 TIPS
1. Conduct a pain assessment on every patient, all pain is of
concern
2. Use open ended questions & probe. Some examples:
“What medications/actions do you take for pain?”
“What level of pain is acceptable to you?”
“When was when the last time you took pain medication?”
3. Use the results of the assessment in care planning
4. Involve the physician when planning interventions for
monitoring and mitigating pain
5. Consider referral to rehab services and use of modalities to
mitigate pain
Orders/interventions must be specific.
EXAMPLE:
- Wound Number 1, Location, Treatment
- Wound Number 2, Location, Treatment
 Maintain wound numbering!
 Wound measures are required
 Call the Physician if no progress in two weeks
 You must contact physician for orders to use any
alternate treatment
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COMPREHENSIVE ASSESSMENT
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Assesses interrelated aspects of patient & environment
Provides a best base for care planning and delivery
Must (1) identify the patient’s need for home care; (2) meet
the patient’s medical, nursing, rehabilitative, social, and
discharge planning needs; and (3) for Medicare patients,
identify eligibility including Homebound status (each visit).
A good assessment states progress toward care plan goals
Temperature, Pulse, Respirations, and Blood Pressure are
assessed each visit. “WNL” or “No problems assessed” for
systems is substandard charting.
DISEASE MANAGEMENT GUIDELINES
ARE KEY IN HOME HEALTH
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Patients are often confused about actions to take
when they become symptomatic
Reinforce with your patients to contact you/office first
when symptoms begin
Assessment of problems: never underestimate the
value of face to face interaction
Have patients and caregivers “teach back” to you.
Provide reference materials & reinforce
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The CAREPLAN Form must be used with the Visit
note
Do not respond selectively to Care Plan Form items
“Met” means item was worked on/done during the
visit
“Not Applicable” may be selected for interventions
not attempted during that visit
“Not Met” applies to items attempted and not
accomplished; OR can describe pts status vs. longterm goals, but only if the clinician also documents
current measures of status
CASE CONFERENCE & CARE COORDINATION:
Requirement:“Case Conference must prove effective information
exchange and coordination of care”
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After you leave SOC/ROC visit, call your manager to report
Then from SOC, a Case Conference Call Log is completed by Case Manager
after consulting with Team members/their Manager if they are alone on
case:
 Case Conference as often as necessary,
 After you perform a discipline evaluation,
 When preparing for disc. or agency discharge
 A minimum of every 30 days!!
 When patient’s status or condition changes
 Care Coordination of assisted living patients is done weekly
Content of Call Log: 1. Who involved 2. Patient’s status for each disc.3.
Progress since last conf. 4. Any needed changes to the plan
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Supervision of the Aide & review of Aide Care Plan is
done by the Case Manager. Example in Visit Note:
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If RN is on the case, then the RN must supervise Aide
Skilled cases will have HCA supe charted no less than
every two weeks with one per month being with the
HCA Present
Non-Skilled cases will have a monthly supervisory visit
at the minimum, with every other one Present
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Supe is documented by the same discipline: RN, PT, or OT
At the minimum, Skilled Supe is every 30 days for all disc.:
Specific Therapy Requirements:
 For IN: PT must also have daily contact with PTA. PT must
document daily in a Call Log in each patient’s MR
 For IN: OT & COTA must have weekly phone contact. OT
must document oversight in a Call Log in each pt’s MR
 For MN: PTA/COTA must have Present Supe every 6th visit
COMMUNICATION ON PATIENT CHANGES
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“Agency professional staff must promptly alert the physician to
any changes that suggest a need to alter the plan of care”
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Dr. Brar “Seven Circles of Appropriate Care”:
STEPS to resolve any issue with a patient …
->Issue addressed & documented
->Disciplines contacted & documented
->Physician informed & documented
->Clinical mgr informed & Case Conf documented
->Patient informed & documented
->Resolution achieved & documented
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Document in the Narrative of the visit note or in a Call Log
TIP: Always enter new clinical orders at the time you receive them
1. Look at “Medicare Week”, compared to Start & End dates of the
patient’s cert period. Make adjustments for short “weeks”.
2. Next, look at Start & End dates for each Order.
!! The software defaults order start and end dates and will not warn you
when you are writing bad visit orders !!
Hard to Fix: This is very time consuming for office RN’s and causes more
orders to be sent to the doctor.
The Agency can be cited if your frequency orders are not correct.
3. “Missed Visit” Call Logs are your responsibility. Missed Visits are
undesirable, so re-schedule! If Two Visits are missed in a row, you must
call the physician to give verbal report, notify your manager, plus
document in a Call Log
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§ 484.18 Medicare Condition of Participation: Standard is
Conformance with physician orders. Drugs and treatments are
administered by agency staff only as ordered by the physician
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Read your patient’s Care Plan prior to each visit , check e-mail
regularly
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If Evals are ordered but delayed or not completed, the physician
must be contacted for new orders to reschedule or cancel the
evaluation
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Directions on the plan of care are obtained from the physician
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Never leave patient/caregiver to coordinate care alone. That is
our responsibility.
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A 60 Day Summary is charted by clinician performing
the Recertification visit in the Visit Narrative. The
clinician must summarize patient’s progress, current
status, & need for continued home care. Paint a picture!
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CMS Skilled Services: “Reasonable and Necessary”
services : Must be provided by a nurse or therapist in
order to be safe and effective; and are necessary to the
treatment of the patient's illness or injury, or to the
restoration of function
HHCAHPS IS A PATIENT SURVEY THAT RATES
CARE: PATIENT SATISFACTION IS TOP PRIORITY
The survey asks for ratings of care and if the individual would recommend the
agency to family and friends.
It is mailed to patients who can decide if they wish to participate. Pt responses
can be anonymous & pts can add narrative comments.
Results are reported back to our Agency by Agency and Team:
 Do not attempt to influence patients answers to the survey.
 Do not tell patients to give you the best or highest rating.
 Do not offer incentives to any patient for participating.
 Do not help answer the survey questions, even if the patient asks.
 Do not ask patients about the ratings they have given the agency.
GAPS IN COMMUNICATION: WHAT HAPPENED TO
THE GOLDEN RULE?
STAFF MUST notify the patient in advance of a visit, either the
night before or morning of the day of the visit. If you are
running late, you must notify your patient of the change.
STAFF MUST notify patients of staffing changes in advance.
Everyone is responsible.
STAFF who give out their personal number are expected to call
the patient back and ensure coordination with office. This also
applies to days you are scheduled off work.
Resolve issues at the first sign of a problem: STAFF MUST follow
the 7 Circles of Care and resolve problems
GAPS IN PERCEPTION OF CARE AND CONCERN:
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Reinforce on a continual basis OR every visit:
 Home Safety
 D/C Planning
 Medications
 Satisfaction with Care
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Show Respect:
 Do not burden patients with personal or company business
 No text messaging OR non-care related phone calls during visits
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Report: Use Complaint and Incident reporting systems to report/address
patient and quality of care concerns
 Found on Nightingale Intranet
 Report anonymously through Mail, address to your Director
Thank you for investing in this training time
today.
Brenda Tea
866.334.7777, 1232
[email protected]