presented by: lynda laff pat laff laff associates 2011 2011 hhfma financial management conference...

Presented by:Lynda Laff

Pat Laff

Laff Associates 2011

2011 HHFMA Financial Management Conference

Optimize Clinical & Financial Outcomes by Enhancing Episode Management

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

How Did We Get Here?

Escalating health care costs – all sectors of the delivery systemCMS identified home care “behavioral changes” to influence paymentPractice variation among providersContinued potentially avoidable eventsSlow outcomes improvementContinued re-hospitalization


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 outcomesMajor variations in the cost of care delivery vs. patient outcomesNo substantial improvement in re-hospitalization ratesHigh numbers of potentially avoidable eventsInadequate communication and coordination of patient care


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

Statistics Don’t LieMedicaid patients experienced multiple hospital admissions 23%Medicaid patients went to the ED more than once” (AHRQ, 2010).

50%

Hospitalized patients over 65 discharged to a long term care or other institution

21%

Medicare SNF residents readmitted to the hospital 25%Individuals with chronic conditions—may see multiple physicians in one year

16 MDs

Medicare hospital patients in 2003 that saw 10 or more physicians during their stay.

41.9 – 70%

Medicare patients readmitted within 30 days that do not receive any post-discharge care before readmission

64%

Medicare patients readmitted within 30 days did not have a physician follow-up visit

50%

Patients who have problems with medicationswithin the 1st week of discharge

70%

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

MedPac FindingsCapacity and supply of providers: Agency participation is at record levels

In 2010, HHAs numbered more than 11,400 with a net increase of 527 agencies. “Number of agencies has exceeded the high watermark of the 1990s, when the number of agencies exceeded 10,900. The high rate of growth is particularly concerning because new agencies appear to be concentrated in areas with fraud concerns, including California, Texas, and Florida”.


MedPac Findings

Volume of services continues 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”.


MedPac Findings & Conclusions

Outcomes improve on functional measures but the rate of adverse events is unchanged ????? Payments increase by more than costs in 2009 Medicare continues to overpay for home health services High margins for home health in 2011 reflect that payments substantially exceed costs and that reductions and administrative adjustments by CMS have not significantly reduced payments. Conclusion: overutilization and inadequate care

Encourage appropriate use of the home health benefit


MedPac Recommendations

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

2. Begin a two-year rebasing of home health rates in 2013 and eliminate the market basket update for 2012.

3. Revise the home health case-mix system to rely on patient characteristics to set payment for therapy and non-therapy services; no longer use the number of therapy visits as a payment factor.


MedPac Recommendations

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

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


Method To the Madness…

Where is CMS going and will YOU be there when they get there?

Cost Reimbursement 1999PPS 2000Home Health Compare - 2003 PPS Refinement 2008RAC and ZPIC audits – 2009OASIS – C – process measures - 2010Billing code changes - G Code additions – 2011Face to Face visits at SOC and therapy thresholdsDiagnosis coding – ICD-10 - 2013PPS Refinement 2013? 2014?Value Based Purchasing – 2013?


Can You Afford Afford The Affordable Care Act?

ACA Establishes: Hospital Readmissions Reduction Program Hospital Value-Based Purchasing program and plans for a home health and skilled nursing Value-Based Purchasing program Medicare Shared Savings Program (Accountable Care Organizations)

Heart Failure

Heart failure is the most common diagnosis associated with 30-day readmission among Medicare beneficiaries (Hernandez et al., 2010).

30-day readmission rates for heart failure patients have increased while LOS decreasedIn-hospital mortality rates have decreasedLess marked reductions in 30-day mortality rates

HospitalValue Based Purchasing

ACA – will reduce hospital payment in 2013 for Medicare admissions by 1% if hospital readmissions are above national average for AMI, Heart Failure and Pneumonia beginning with discharges on or after Oct. 1, 2012.Penalties to hospitals will increase to 3% in 2015What happens in the acute care setting will happen What happens in the acute care setting will happen in home care!in home care!

Affordable Care Act (ACA)

Facilitate care transitions across the continuum to;Optimize choice and control of servicesEnsure that decisions are based on patient needs Provide coordinated, high quality care with seamless transitions between settingsReward excellence - pay for quality measures- P4P (VBP)Recognize role of family care givingUtilize health information technologyImprove Patient Safety Promote Evidence Based Best PracticesFocus on Error Prevention -PAE


Clinical Management Information Key IndicatorsRoutine Reports

EducationClinical assessment OASIS Accuracy

Supervision & Oversight Documentation Timeliness Care Plan Development

ContinuityCase managementClinical model

Accountability/ ResponsibilityReward / incentiveCorrective Action

Manage Smarter


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


Smart MovesPatient Centered CarePatient Outcomes at or above state and national averagesBest 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 educationEliminate “warm body syndrome”Stop “fixing”

Implement and integrate Telehealth


Primary case management – Clinician – with F2F 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


Case WeightCase weight variance – SOC to EOEEOE case weight

Re-certifications and LOSVisit Utilization Averages

Ratio nursing/therapyActual Revenue versus Anticipated RevenuesTimeliness of RAP Submission% of Therapy Visits per ThresholdAverage visits per episodeProductivity by discipline - Actual # of Patients Cases Managed per Clinician –

WHO IS REALLY MANAGING THE PATIENT?

Management Statistics


Management Statistics

OASIS Errors by ClinicianOASIS Corrections CompletedOutcomes Improvement Patient Declines – actual or documentation?Potentially Avoidable Events

Have you audited each of them?What did you do to prevent them in the future?


Smart Moves

OASIS AccuracyAccuracyWho is reviewing the OASIS?

Is that a primary function?Is that individual qualified?

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


Adequate educationValidate 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 paper

c. Review statistics


Staffing-Statistics to Review

Number of ACTIVE patients on your census list“Clean” census listAll discharges removed at least weeklyIdentify why “old” patients remain

Expectations for staff productivityVisits 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 ProductivityDo 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 monitor and enforce the expectations?

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 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?


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 errorsLow EOE case weightHigh LUPA rateHigher than average therapy utilizationLOS average over 60 days / multiple re-certificationsRotating primary DXSkilled service provided to large % of patients is “Observation & Assessment”


Smartest Moves…It Depends…

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

Effective use of Telehealth increase capacity

Responsible for entire episode of careResponsible for outcomesDon’t come into the office to get NRS

Adequate supervisionSupervision – primary responsibilityAbility to enforce process and policy for productivity, OASIS corrections, appropriate care delivery


Smartest Moves

Productivity expectationsSN -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 visitsSupervisor/Manager – 1 per 5-7 FTEs (depends on function)

OASIS Reviewer – w/data manager - 75 - 85 patients

Adequate OASIS review processData management tool to decrease review time and increase accuracy


Achieving Positive FinancialFinancial Outcomes

Good clinical outcomes lead directly to good financial outcomes!Required ingredients

Strong clinical management and staff oversightField clinician responsibility and accountability

Consistent and continuing oversight of episode frequencies and durations to achieve realistic outcome goals

Plan of Care consistently reviewed every 14 days!Adjusted to medical necessity and realistic outcome goals!

Consistent use of the “data scrubber” in OASIS reviewThe annual cost will be covered within a week!

Efficient use of the field clinician resources – no office time!Consider a “Weekender Program”



Gross profit issuesThe 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 madeThe 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 weekAn 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 noonFriday admissions – patients with weekend follow-up visitsMonday morning conference call with weekday RNs

Converts Agency from 5 days/ week plus weekends to 7 days/weekFrequencies spread over 7 days, not just 5 daysDo all weekend visitsTakes weekend on-callEliminates weekday staff weekend rotation and compensatory time


Weekender Program

Shares case management responsibilities with weekday RN – patients with weekend frequenciesWeekend differentials applyConsidered 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 continuityLimited, 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 outcomes

Completely 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) staffPrimary Case ManagementCase Conference Model

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

Tools for efficiencyLaptops with power cords to car power source and air-cardsSmart cell phonesPatient specific electronic ordering and delivery of NRS



Primary Care Case Managers are responsible for the:Case Management of their patientsPrimary visits, including admission, resumptions and recerts, most follow-ups and the discharge.Achieve the desired patient outcomes and HH-CAHPs resultsSelf 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 achievementImproves team chemistry…Encourages under-performing staff to improve or seek a successful career elsewhereAssures that clinicians meet and exceed individual productivity and case capacity goalsApplies to Weekender staff

IT WORKS!



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

All times include hands-on, documentation, travel, conference and case management time


Bonus structure for Primary Care Case ManagersCalendar 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 IllinoisMain office located in Springfield, IL with branches in Jacksonville, and Litchfield, ILServes over 2000 patients annually in 31 contiguous countiesFree-standing for profit agencyOver 50 employees

Benefits of Incentive Compensation

Lost a nurse and didn’t have to be replaced Improved communication with nurses and supervisorDocumentation is timely and better qualityTelehealth is being used more consistently and the telephone follow up visits are visit weightedIncentive compensation has improved ER and Hospital outcomes

Incentive Compensation Results

Nursing productivity increasedTimeliness 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 timeVisit frequency orders were accurateCase loads increased per nurseNurses made more visits per day and made more moneyMonitors were in patient homes and no longer on the shelves

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%

Incentive Compensation Results

Nurses did not complainComments:

“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 reducedIncentive 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 outcomesIntegrates:

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 hhfma financial management conference...

Documents

medicare patients re

hospitalized patients

discharge care

escalating health care

cost of care delivery

smarter efficient home

care behavioral changes

long term care