presented by: lynda laff pat laff laff associates 2011 2011 annual meeting want to improve your...

Presented by:Lynda Laff

Pat Laff

Laff Associates 2011

2011 Annual Meeting

Want To Improve YourFinancial Outcomes – Manage Smarter!

1

Managing Smarter Efficient Home Care Means…

Less care?Fewer staff?Cut middle management? Eliminate PI programs?Hiring freeze?Eliminate all educational travel?No IT system upgrades???No “tools”?

REALLY?Laff Associates 2011 2

How Did We Get Here?

Escalating health care costs – all sectors of the delivery system

CMS identified home care “behavioral changes” to influence payment

Practice variation among providersContinued potentially avoidable eventsSlow outcomes improvementContinued re-hospitalization

Laff Associates 2011 3

Continued Increase In Home Health Care Utilization

1997 2000* 2009 1997–2000

2000–2009

Agencies 10,917 7,528 10,961

-31% 46%

Total spending (in billions)

$17.7 $8.5 $18.9 -52% 123%

Users (in millions) 3.6 2.5 3.3 -31% 32%

Number of visits per user

72.6 36.8 39.4 -49% 7%

% of FFS beneficiaries who used home health services

10.5% 7.4% 9.4% -30% 27%

Number of visits (in millions)

258.2 90.6 129.6 -65% 43%

Visit type (percent of total)

Skilled Nursing 41% 49% 55%

Home Health Aide 48% 31% 16%

Therapy 10% 19% 28%

Medical Social Services 1% 1% 1%


Costs Increase But… Outcomes Do Not Improve

Costs continue to escalate with little improvement in outcomes

Major variations in the cost of care delivery vs. patient outcomes

No substantial improvement in re-hospitalization rates

High numbers of potentially avoidable events Inadequate communication and coordination of

patient care


Cost Savings

Cost of hospital readmissions $15 Billion Annually

Potentially avoidable hospital readmissions 13.3%

Savings if potentially avoidable hospital readmissions were prevented

$12 Billion Annually

6Laff Associates 2011

Statistics Don’t Lie

Medicare hospital patients in 2006 – 2007, readmitted for the same conditions that prompted their initial hospitalization” (AHRQ 2010)

25%

Medicare hospital patients were readmitted in 30 days in 2009 20%Medicare patients re-hospitalized within 90 days 34%Medicare patients experiencing multiple hospital admissions (AHRQ, 2010).

42%

Medicare patients experiencing multiple emergency department (ED) visits. (AHRQ, 2010).

38%

30-day Medicare readmission rates varied (2009)

http://medpac.gov/documents/Jan11_RegionalVariation_report.pdf

12.9% Oregon

22.7% D.C.


http://medpac.gov/documents/Jan11_RegionalVariation_report.pdf

MedPAC Findings

Volume of services continued to rise Beneficiaries without a prior hospitalization

account for a rising share of episodes * Changes in therapy distribution

“Providers target therapy visit thresholds used to adjust home health payments”.

“Volume changes since implementation of PPS provide evidence of providers targeting the ranges that appear most profitable”.

Conclusion: overutilization and inadequate careFYI- Check out your coding process and marketing strategies!


MedPAC Recommendations

1. Increased medical review in counties with aberrant home health utilization; suspend payment and limit provider enrollment.

2. Establish a per episode co-pay for home health episodes that are not preceded by hospitalization or post-acute care use.

3. Begin a two-year rebasing of home health rates in 2011 for implementation in 2014

4. Modify the home health payment system to protect beneficiaries from stinting or lower quality of care in response to rebasing..


CMS Proposed Rule 2012

1. Base rate reduction of to $2,112.37 from $2,192.07 ($79.70 or 3.64%)

2. Revise the case weight structure to decrease emphasis on therapy thresholds and misuse of HTN codes Eliminate HTN codes 401.1, 401.9 from case mix Redistribute dollars/weights for clinical and functional

levels Remove weighting of therapy thresholds Decelerate therapy resources with higher weights


Manage Smarter

To be profitable management must: Know what it costs to provide services — by

discipline

Monitor and manage ALL aspects of agency operations from intake to billing

Create appropriate efficiencies

Prevent redundancy and unnecessary hand-offs

Promote standardization for entire agency


Clinical Management Information Key Indicators Routine Reports

Education Clinical assessment OASIS Accuracy

Supervision & Oversight Documentation Timeliness Care Plan Development Clinical Quality - Accuracy

Continuity Case management Clinical model

Accountability/ Responsibility Reward / incentive Corrective Action

Manage Smarter


Smart Moves Patient Centered Care

Patient Outcomes at or above state and national averagesEnd result outcomesProcess measuresHHCAPS

Best Practice implementation “Right-size”

May or may not add or eliminate positionsFocus on function and responsibility Invest in people

Right person for the position Invest in education


Smart Moves

Eliminate “warm body syndrome” Stop “fixing”

Implement and integrate Telehealth Increase focus on preventing emergent care Increase focus on timely intervention and preventing

Potentially Avoidable Events Increase efficiency by increasing case capacity of case

managerDecrease unnecessary utilization


Case WeightCase weight variance – SOC to EOE less than 2%EOE case weight - (NOT SOC) is the case weight to “hang

your hat on” % of re-certifications and LOS

Worry if you have a LOS over 60 days! Visit Utilization Averages

Ratio nursing/therapy - shoot for 5-7 SN vs. 3-4 therapy Average visits per episode

Worry if average total visits per episode is over 17Be aware that it must be improved if average IS 17

Management Reports / Statistics


Management Reports / Statistics

Actual Revenue versus Anticipated RevenuesDowncodesActual revenue = EOE

Timeliness of RAP Submission Set a standard of 7-14 days

% of Therapy Visits per Threshold Look for therapy threshold “clusters” (will likely disappear

in 2012)


Management Reports / Statistics Productivity by discipline

Actual # of patients visited (not weighted)

Cases Managed per Clinician Goal of 20 – 25 (without telehealth)Goal of 25-30 (with telehealth)WHO IS REALLY MANAGING THE PATIENT?

OASIS Errors by ClinicianYou cannot afford repeated errors!


Smartest Moves

Productivity expectations SN -Minimum average of 5 actual visits per day – 6 – 6.25

weighted visitsPT – Minimum average of 5.5 actual visits per day – 6.5

weighted visits Supervisor/Manager – 1 per 5-7 FTEs (depends on function)

OASIS Reviewer – w/data manager - 75 - 85 patients Adequate OASIS review process

Data management tool to decrease review time and increase accuracy


Management Statistics

OASIS Corrections CompletedDo you ask for justification when errors not corrected?

Outcomes Improvement Patient Declines – actual or documentation?Potentially Avoidable Events 2011 Surveyor Guidelines

Tier I PAEsEmergent care for injury caused by a fall at homeEmergent care for wound infections, deteriorating

wound status.


Potentially Avoidable EventsTier 2 PAEs

Emergent Care for Improper Medication Administration, Medication Side Effects

Emergent Care for Hypo/Hyperglycemia Substantial Decline in ≥ Three Activities of Daily Living Discharged to the Community Needing Wound Care or Medication

Assistance Discharged to the Community Needing Toileting AssistanceDischarged to the Community with Behavioral Problems Have you audited each of them?Are your audits documented?What have you done to prevent them in the future?


You May Be At Risk If…. A review of operations and records indicates

presence of one or all of the following;Many OASIS item inconsistencies Large variance in SOC/EOE DX Coding errorsVery low average EOE case weight - 1.100High LUPA rate – over 12%Higher than average therapy utilization LOS average over 60 days / multiple re-certificationsMultiple recertifications per patient with “rotating primary

DX” Skilled service provided to large % of patients is

“Observation & Assessment”


Primary case management – Clinician – with patient contact May be RN or PTMust be accountable for patient and financial outcomesAccurate assessmentAppropriate care planConstant knowledge of;

Goals of care Projected visits vs. actualTeam performance – Therapists must be included in the team Patient response to careNeed for change in plan

Accountability


Smart Moves

OASIS AccuracyAccuracyWho is reviewing the OASIS?

Is that a primary function?Is that individual qualified? - RN COS-C

Manual review or Data Scrubber? Duplicative functionsCorrections versus consequence….Management oversight


Adequate education Validate and reinforce

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

Smart Moves


Do You EverHave Enough Staff?

How do you know???? It depends……..

Clinical ModelAgency Size and Scope

GeographyVolume

Paper or Point of CareClerical versus Clinical Function


When is Enough Enough?

The Clinical Director comes to you and says “I don’t have enough nurses to see all these new patients. What’s the first thing you do?

a. Call a temp agencyb. Put an add in the paperc. Review statistics


Need More Staff???

Review Statistics!!!Validate Need Before You Jump the Gun!Must ensure you are adequately staffed…

but not over staffed!!!ManagementField Staff


Staffing-Statistics to Review

Number of ACTIVE patients on your census list “Clean” census listAll discharges removed at least weekly Identify why “old” patients remain – someone is not

“managing” well… Expectations for staff productivity

Visits per day, per week Actual performance of staff – how many actual un-

weighted visits per day did they perform last week? Identify “weakest links” and investigate why….


Standardize Productivity Do you expect the same level performance from

each clinician? If not – why not?

Are your expectations per clinician met?Are they reasonable? Maybe too reasonable???

Do you use remote monitoring? Do you supervise, monitor and enforce the

expectations?Or are you using the “warm body approach?”

Is there a consequence for non-performance?


Set Realistic Expectations

Number of visits per day is dependent upon your clinical model;Do your field nurses case manage a census of patients” If so – is the number consistent among your staff?Do you have admission nurses?Do you use a point of care documentation system?How many miles does a clinician average per day/week?How are they compensated?How often are the patients’ care case conferenced?


Smartest Moves…It Depends…

Primary Care Case ManagementClinician manages – 20 – 25 patients…it depends….

Effective use of Telehealth will increase clinician case capacityResponsible for entire episode of careResponsible for patient and financial outcomesDon’t come into the office to get NRS

Adequate supervision Supervision – primary responsibilityAbility to enforce process and policy for productivity,

OASIS corrections, appropriate care delivery


Achieving Positive FinancialFinancial Outcomes

Let’s talk about controlling costs…. Direct Cost per Visit by Discipline

Compensation methodology and incentivesProductivity and efficiency of staffCase CapacityOutcome achievement

Consider a Weekender Program! Appropriate utilization of services and supplies

Frequencies and durationsProvision of supplies

Clinical oversightLaff Associates 2011 32


Gross profit issues – Control the Direct Cost/Visit & NRS Direct Costs are the majority of agency’s total operating expenses The majority of the direct cost/visit is compensation and related

taxes (staff and direct supervision) The cost/visit of premium-based fringes is directly proportional to

visits made The cost of mileage/auto reimbursement is directly related to

geographically sequential patient scheduling, the size of the territory and a global vision of the entire week

An agency specific formulary and trunk supply protocol, electronic ordering with independent oversight and patient specific direct delivery reduces costs and increases productivity


Weekender Program

Begins Friday at noon..ends Monday at noon Friday admissions – patients with weekend follow-up visitsMonday morning conference call with weekday RNs

Converts Agency from 5 days/ week plus weekends to 7 days/week

Frequencies spread over 7 days, not just 5 days Do all weekend visits Takes weekend on-call Eliminates weekday staff weekend rotation and

compensatory timeLaff Associates 2011 34

Weekender Program

Shares case management responsibilities with weekday RN – patients with weekend frequencies

Weekend differentials apply Considered full-time for Fringe Benefits



Who owns the patient? Using a combination of Admission and Visit RNs /LPNs

challenges both good clinical and financial outcomes Lacks care consistency and continuity Limited, if any, patient care oversightCause of patient dissatisfaction

Primary Care Case Management achieves all of the desired patient care outcome goals and is the best approach towards best financial outcomesCompletely integrates with incentive compensation for both

the field clinician and their immediate supervisor!



Align Clinical and Case Conference Modelswith Compensation!

Incentive Compensation…Determines ownership of the patient, resource utilization

and care oversight and outcomes achievedMatches clinician responsibilities and achievements

Not based upon the length of time or just a fixed salary to accomplish their patient needs

Reinforces consistency and continuity of patient careReduces the direct cost of care for those disciplines



Key Ingredients! Effective Clinical Management (Supervisory) staff Primary Case Management Case Conference Model – Controls visit utilization

Every Patient…Every 14 days from SOC date!Reviews prior 14 days utilization and outcome achievementPlans next 14 days utilization and outcome goals

Tools for efficiency Laptops with power cords to car power source and air-cards Smart cell phonesPatient specific electronic ordering and delivery of NRS



Primary Care Case Managers are responsible for the: Case Management of their patients Primary visits, including admission, resumptions and

recerts, most follow-ups and the discharge. Achieve the desired patient outcomes and HH-CAHPs

results Self scheduling!

Places responsibility where it belongsProvides for more autonomy and control of clinician’s

day…Eliminates the cost of schedulers


Incentive Based Compensation

Compensates the staff for what they do, not for how long it takes them to complete what they do!

Rewards efficiency, productivity, capacity and clinical (HH-CAHP) outcomes achievement

Improves team chemistry…Encourages under-performing staff to improve or seek a successful career elsewhere

Assures that clinicians meet and exceed individual productivity and case capacity goals

Applies to Weekender staffIT WORKS!


Incentive Based Compensation

Can apply to all disciplines, depending upon patient census and discipline demand

Exempt status does not apply to LPNs, PTAs, COTAs and HHAs (FLSA)

Most effective for RNs, PTs and OTs– Supervisory responsibility– Visits are Unique– No portion of compensation is based on time

(Hourly)


Visit Weights

Visit weighting – Based the Requirements and Complexities of completing OASIS C– Admission (evaluation) Visit 1.90– Non-OASIS Evaluation Visit - mainly therapy 1.60– Resumption Visit 1.30– Recertification Visit 1.20– Discharge Visit 1.25– Follow-up Visit 1.00– Virtual Telephone Visit (Telehealth) 0.25


Questions Often Asked( Visit Weight – Time Equivalents Based upon OASIS C)

Visits /Day Follow-up Admission Resumption Recert. Discharge

Visit Value 1.00 1.90 1.30 1.20 1.25

5.00 96 minutes1hr 36min

182.4 minutes3 hrs 2min

124.8 minutes2 hrs 5min

115.2 minutes1 hr 55min

120.0 minutes2 hrs

5.25 91.4 minutes1hr 31 min

173.7 minutes2hrs 54min

118.9 minutes1hr 59min



5.50 87.3 minutes1hr 27min





5.75 83.5 minutes1hr 23min





6.00 80 minutes1hr 20min

152 minutes2hrs 32min

104 minutes1hr 44min

96 minutes1hr 36min

100 minutes1hr 40min

Includes hands-on, documentation, travel, conference and case management time


Incentive Based Compensation Bonus structure for Primary Care Case Managers

Calendar quarter or 12 week period (based upon payroll periods)Accumulated Visit Weights = $ per hands-on visit for every visitTotal Cases Managed = % of earnings for the measured periodOutcomes Achieved = % of earnings for the measured period

Bonus structure for their immediate “supervisors” Same as above, plusOther to address problem areas, such as

OASIS error ratesTimeliness of corrections, etc.Time to RAP and EOE billing


Case StudyAlterna-Care Home Health Agency

Located in Central Illinois Main office located in

Springfield, IL with branches in Jacksonville, and Litchfield, IL

Serves over 2000 patients annually in 31 contiguous counties

Free-standing for profit agency

Over 50 employees


Benefits of Incentive Compensation

Lost a nurse and didn’t have to be replaced Improved communication with nurses and supervisor Documentation is timely and better quality Telehealth is being used more consistently and the

telephone follow up visits are visit weighted Incentive compensation has improved ER and

Hospital outcomes


Incentive Compensation Results

Nursing productivity increased Timeliness of documentation improved. For the first time

anyone can remember, all nurses notes were completed within 24 hours.

MD verbal orders and recertifications were completed on time

Visit frequency orders were accurate Case loads increased per nurse Nurses made more visits per day and made more money Monitors were in patient homes and no longer on the

shelves47Laff Associates 2011

Average Patient Caseload 2009 vs. 2010

2009 -7.5 nurses with an average monthly case load of 36.3 (unduplicated patients)

2010 -6.5 nurses with an average monthly case load of 44.9 (unduplicated patients)

(excludes PT only patients)


Visit ProductivityAverage Visits Per Nurse

2009 Jan Feb Ma Apr May Jun July Aug Sept Oct Nov Dec

Avg. cases/RN 22 21 22 24 28 23 20 21 20 24 23 24

Monthly Undup. Census

223 233 229 240 253 229 205 208 195 216 210 213

No. of Nurses 10 11 10 10 9 10 10 10 10 9 9 9

2010Avg. Cases/RN 24 31 30 27 30 35 32 27 31 29 29 37

Monthly Undup. Census

216 252 242 222 247 279 264 237 241 257 260 257

No. of Nurses 9 8 8 8 8 8 8 9 8 9 9 7


HHCAHPS

HHCAPS HIGHER % ARE BETTER

% RANKING

Care of Patients 99% 92% (Top 8%)

Communications Between Providers and Patients 95% 90% (Top 10%)

Specific Care Issues 91% 82% (Top 18%)

% of Patients who Rated Agency 9 or 10 95% 83% (Top 17%)

% of Patients who would Recommend Agency 83% 56% (Top 44%)


Average Nurse 11 Month Salary

2009 - Average 11 month comp. was $ 38,4122010 - Average 11 month comp. was $ 46,362

Increase of $ 7,950 = 20.69%2009 - Total Per Diem comp was $ 31,0222010 - Total Per Diem comp was $ 10,119

Reduction of $ 20,903 = 67.38%2009 - Direct Cost per Nursing Visit - $ 79.71

2010 - Direct Cost per Nursing Visit - $ 63.90

Reduction of $ 15.81 = 19.83%51Laff Associates 2011

Incentive Compensation Results

Nurses did not complain! Comments:

“I’m really working hard”“It’s difficult to get your paperwork done with this

many patients”“But, I’m not complaining”Supervisor states nurses are contentNo problem getting nurses to see patients on

weekends!!!No push back when given a new admission in their

territory!


Incentive CompensationThe Results

The Direct and Total Cost per Visit were substantially reduced!

Visits per episode were effectively reduced Incentive compensation increased efficiency

throughout the entire organizationQuality of patient care was positively impactedAccounting department is able to bill timelyClinical staff are rewarded for their hard workCommunication with clinical managers improvedTelehealth being utilized to its fullest capabilities


Effective Episode Management

Reduces episode cost, increases efficiency and communication, and improves clinical and financial outcomes

Integrates:Clinical Supervisory Management and OversightPrimary Care Case ManagementGoals and Performance

Can enhance compensation and reward excellent performance


Lynda Laff, RN, COS-C Pat Laff, CPA Laff AssociatesConsultants in Home Care & HospicePhone: (843) 671-4170Email: [email protected]: [email protected] Website: www.laffassociates.com

Contact Information


presented by: lynda laff pat laff laff associates 2011 2011 annual meeting want to improve your...

Documents

home health care utilization

escalating health care

medicare hospital patients

home health episodes

home health services

home health aide481

home health payments

smarter efficient home