Home Care Alliance of Massachusetts Financial Management Conference December 9, 2010 Meeting the Financial Challenges Of Implementing OASIS-C

Pat Laff, CPA Managing Principal

OASIS-C Is Costing You More

Reduced Revenue and Increased Cost Factors are driven by: – Inadequate initial and continuing education Supervisory personnel Quality personnel Field clinician personnel Clinical Management Model Case Conferencing Model

OASIS-C The Key Issues

OASIS-C is a moving target…… Education of Clinical Staff – Supervisory – Quality – Field clinicians Clinical Management Model Case Conferencing Model Incentive Compensation

Cost Drivers Education

The Costs of Education…doing it right up front is far less costly! “Train the Trainer” – Unless the “trainers” are RN, COS-C’s – Did the “trainers” remember all that was taught?

– Did the “trainers’ teach all the they remembered?

– Have there been timely and periodic follow-up sessions, including updates from latest Q&As?

Cost Drivers Education

Expert Teaching onsite (by RN, COS-C) – Private sessions provided to the entire staff Staggered shifts including RNs and all therapists Consistently delivered education content with Q&As – – Expertise developed internally at the Quality level – Timely follow-up as new CMS interpretations are revealed during monthly Q&As Educational tools provided to educate new staff – Continuing resource

Cost Drivers OASIS-C Inaccuracy

Incorrect DX codes – May not be using a certified coder – Must have home care RN oversight to correctly use coding conventions and ensure presence of support for code Other case mix items – Use a data scrubber to assist with OASIS inconsistencies – Cost is recouped by finding 1 or 2 inaccuracies

Cost Drivers OASIS-C Inaccuracy

Reasons for OASIS inaccuracy include – Inadequate education – Clinical Management Model – OASIS workflow process Therapist involvement and timing Quality Review Repeatedly “fixing” errors is more costly than doing it correctly – Case Conference Model

Cost Drivers OASIS-C Inaccuracy

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 Don’t forget…Value Based Purchasing is coming soon to your agency!

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.

Elizabeth Allen Clinician Diagnosis Coding

Diagnosis Points

M1020 a V58.31 Aftercare for change of surgical dressings M1022 b 781.2 Gait Abnormality 0 0 M1022 c 250.00 Diabetes Mellitus M1022 d 496.00 COPD M1022 e 290.00 Dementia M1022 f 2 0 0 0

Case Mix Variables

Elizabeth Allen OASIS

OASIS Score M1030 IV Therapy M1200 Vision M1242 Pain (Daily but not constantly) M1308 Pressure Ulcers M1320 Most Problematic Pressure Ulcer M1330 Stasis Ulcer M1342 (Most Problematic) Surgical Wound 4 (None of the Above) 0 3 0 0 0 3 Points 0 0 1 0 0 0 4

M1400 Dyspnea

When walking 20 feet or climbing stairs

M1620 Bowel Incontinence M1630 Ostomy

M1700 Cognitive Functioning* Requires assistance and some direction in specific situations M1740 Behaviors* Significant memory loss so that supervision is required M2020 Oral Medications* Able to independently take correct medications at correct times

M2030 Injectable Drug Use* Able to independently take the correct medications at correct times Total Clinical Points

Elizabeth Allen OASIS

1 0 0 0 0 2 1 0 0 0

N/A N/A N/A

0

7

Elizabeth Allen Functional Scores

M1810 / 1820 Upper OR Lower Body Dressing 1 2 M1830 Bathing 2 M1840 Toilet Transferring M1850 Transferring M1860 Ambulation Total Functional Points 2 2 2 2 3 2 0 1

8

Elizabeth Allen Revenue

C2 F3 S5

Table 6 NRS Points = 14 (Non healing surgical wound) (Table 6) NRS Severity Level = 2 (Table 6) NRS Revenue = $51.96

Case Weight = 1.7737

Revenue = $4,102.46 HHRG + NRS Revenue = $51.96 + $4,102.46

Total Revenue = $4,154.42

Elizabeth Allen OASIS EDITS - VBP

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 dementia.

 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.

Elizabeth Allen

Diagnosis

Coding Corrections

Points (Table 2a)

M1020 a 998.59 Post Operative Infection M1022 b 781.2 Gait Abnormality

10

0 M1022 c 250.00 Diabetes Mellitus M01022 d 491.20 COPD (Chronic Bronchitis) 1+1 Amb. Score 2 M01022 e 331.2 Dementia (Psych 2) M021022 f

*(Aftercare codes are not used with wound complications)

2

2 1

Elizabeth Allen Coding Corrections

4 (None of the Above) M1930 IV Therapy M1200 Vision M1242 Pain M1308 2 or ↑ Pressure Ulcers Stage 3 or 4 M1320 Problematic Pressure Ulcers 0 2 0 0 M1330 Stasis Ulcer 0 M1342 Surgical Wound 3 0 0 0 0 1 0 4

M1400 Dyspnea

When walking 20 feet or climbing stairs

M1620 Bowel Incontinence

Elizabeth Allen Coding Corrections

1 0 M1630 Ostomy M1700 Cognitive Functioning*

Requires assistance and some direction in specific situations

M1740 Behaviors*

Significant memory loss so that supervision is required

M2020 Oral Medications*

Able to independently take correct medications at correct times

M2030 Injectable Drug Use* Able to independently take the correct medications at correct times Total Clinical Points 0 2 1 0 0 0 0 0

N/A N/A N/A

1 21

Elizabeth Allen No Change

M1810 / 1820 Upper OR Lower Body Dressing 1 2 M1830 Bathing 2 M1840 Toilet Transferring M1850 Transferring M1860 Ambulation Total Functional Points 2 2 2 2 3 2 0 1

9

(Table 6) NRS Points = 37

Elizabeth Allen Coding Corrections

HHRG Score = C3F3S5 (Table 6) NRS Severity Level = 4 NRS Revenue = $211.69

Case Weight = 1.9413

Revenue = $4,490.11 Total Revenue = $4,701.80

+ $547.38

Elizabeth Allen OASIS Edits/Corrections Revenue

Let’s 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

Questions Often Asked

Recommended Clinical Model: – Primary Clinician – Care Management Recommended Clinicians to Supervisor – Up to 10 FTEs Recommended Case Conference Model – Every 14 Days (voice to voice) from SOC date Productivity and Case Capacity – RNs: minimum 25 – 27 visits (hands on) / week 25 – 30 Patients (without Telemedicine) – PTs & OTs: minimum 27 – 30 visits (hands on) / week

Educate Managers

Home Care Management (including Supervisors) must have a solid understanding of: – – – – – – – – – – – OASIS-C Process Measures Case Weights Timeliness of RAP Submission OASIS Errors by Clinician OASIS Corrections Completed Cases Managed per Clinician Average # of Therapy Visits per Episode Average Visits per Episode Productivity by Discipline – Outcomes Improvement Patient Declines Actual

Weekly Management Report

Mon Tue Wed Thu Fri Sat Sun Total Total Referrals No. of Admissions – (Intake – Managers) No. of Ended Episodes Transmitted (Finance) Average Closed Episode Revenue (Finance) No. of Telephone Calls made to patients seen 1x w or less (documentation required to support call) No. of Tele-monitors in Use (on day specified) (Managers) Total no. of Actual Visits made by all RNs (Managers) No. of Transfer OASIS completed (by clinicians) No. of Patient Transfers (unplanned hospitalizations- reasons for transfers – attach short audit form – send to PI) No. of OASIS transmitted (Business Office – Finance) Total % of OASIS Errors corrected (data scrubber system) Total no. of OASIS Errors Not Corrected –outstanding (data scrubber system) Caseload/Census by Case Manager (separate list) No. of Actual Visits made by RNs (List by Team and Name below)

Financial Impact of OASIS-C

– – – – – Differences in the types of visits (and OASIS C) effect per visit costs Admission – takes longer due to added process measures Follow-up – may take longer due to new incentives to assess for pain and other ongoing issues Resumption – takes longer due to need for more thorough assessments and medication reconciliation and contact with MD Recertification Discharge – may take longer due to need to “look back” into the episode to answer some OASIS questions.

Provide the Right Tools “Point of Care”

Having a Wireless feature and “Air cards” for Clinician laptops actually reduces cost per visit and facilitates: Remote syncing to system Access by all disciplines to most recent documentation Email and team communications Transmission of patient Admission information Facilitates Clinical Case Conferencing – Clinician and supervisor (team leader) referring to same patient records Provides complete up to date patient records for oncall Ordering non-routine medical supplies directly from vendor

At a cost of approximately $2.00 per day per clinician per day versus lost visits due to office time and travel!

OASIS-C and the Direct Cost per Visit

All OASIS visits require additional effort! Relative OASIS visit weights have increased Productivity of salaried and hourly staff has declined Overtime compensation for non-exempt clinicians has increased to accomplish the same number of average visits per day Staffing issues – Covering visits – Admitting patients

Compensation based upon effort versus time changes this dynamic, improves productivity, improves outcomes and controls the direct cost per visit!

Control the Direct Cost per Visit

Incentive Based (Exempt) – Field Clinicians Visit Rates – – Structured by Type and Weight of Visit, including Telephone Follow-up Visits and Meetings Case Management Fee for Cases Managed (RN, PT & ST) in a Calendar Month Paid Days Off Based Upon Average Daily Earnings Quarterly (12 week) Incentives Visit Productivity – – Patient Cases Managed Outcomes Achieved OASIS C measurements (real-time) & Home Health Compare scores HHCHAPS results

Control The Direct Cost per Visit

Incentives – Clinical Supervisors (Team Leaders, etc.) Bonus Incentives – Staff achievement for Visit Productivity, Cases Managed and Outcomes Additional Incentives for staff achievements: – Admissions within 24 hours – Timeliness of submitted documentation – Reduction of corrections required for OASIS – HHCHAPS results

Questions Often Asked

Visit weighting – Based the Requirements and Complexities of completing OASIS C – Admission (evaluation) visit – Resumption visit – Recertification Visit – Discharge Visit – Follow-up Visit – Virtual Telephone Visit (Telehealth) 1.90

1.30

1.20

1.25

1.00

0.25

Questions Often Asked

( Visit Weight – Time Equivalents Based upon OASIS C) Visits per Day Visit Value 5.00

5.25

Follow-up Admission 1.00

96 minutes 1hr 36min 1.90

182.4 minutes 3 hrs 2min 91.4 minutes 1hr 31 min 173.7 minutes 2hrs 54min 5.50

5.75

6.00

87.3 minutes 1hr 27min 165.8 minutes 2hrs 46min 83.5 minutes 1hr 23min 158.6 minutes 2hrs 39min 80 minutes 1hr 20min 152 minutes 2hrs 32min Resumption Recert.

1.30

124.8 minutes 2 hrs 5min 1.20

115.2 minutes 1 hr 55min 118.9 minutes 1hr 59min 109.7 minutes 1hr 50min 113.5 minutes 1hr 53min 108.5 minutes 1hr 49min 104 minutes 1hr 44min 104.7 minutes 1hr 45min 100.2 minutes 1hr 40min 96 minutes 1hr 36min Discharge 1.25

120.0 minutes 2 hrs 114.3 minutes 1hr 54min 109.9 minutes 1hr 49min 104.4 minutes 1hr 44min 100 minutes 1hr 40min All times include hands-on, documentation, travel, conference and case management time

Contact Information

Pat Laff, CPA Managing Principal Laff Associates Consultants in Home Care & Hospice Phone: (843) 671-4170 Email: [email protected]

Website: www.laffassociates.com