1. Seminar Code C-4 Managing Functional Outcomes Wednesday, October 10, 2007, 8:00 Lisa Bazemore, MBA, MS, CCC-SLP Director of Consulting Services AHCA/NCAL/MCEF 58 th Annual Convention and Exposition October 7-10, 2007, Boston, MA

2. Learning Objective As a result of this session, the participant will:  Identify strategies for gathering outcomes data for the skilled nursing patient.  Understand how to analyze outcomes data and utilize them for the growth of your program.  Apply outcomes analysis to your facility’s performance to ensure that positive changes are implemented that will improve the quality of life of your patients.

3. Data Analysis Why do we do it?  Accurate outcome data is a powerful tool that can be used to educate key decision makers in the hospital, potential patients, payers, and the community at large.  Marketing efforts are enhanced when outcome information is used during direct marketing calls.  The team benefits from use of outcome information by being able to see where they are the most effective and also by being able to focus improvement efforts.  Breaking down your performance may reveal opportunities to capture the burden of care and yield greater reimbursement.

4. Data Analysis When conducting data analysis, ask yourself: Does the data look real?  It is important to validate that the data that you are analyzing is reliable.  Can you identify any inaccuracies in your sample? Do the outcomes meet your expectations?  Compare your outcomes to your goals and industry benchmarks.  How do you stack up? What impact would change make?  Would there be a positive impact on your patient care services if you improved your performance in this area?

5. Data Analysis Selecting Indicators:  Review outcomes  Determine what is below benchmark  Figure out what is meaningful to your facility  Determine what is attainable for your facility

6. Gathering Data Using FIM  Functional Independence Measure: An eighteen item instrument designed to gather functional status at admission and discharge. Scores are assigned 1-7 with one being the lowest level of patient function and seven being the most independent. Basis for the IRF-PAI used in inpatient rehabilitation settings. Allows a SNF to provide evidence based data that the IRF providers are already using. Useful for facilities competing for joint replacement patients and other traditional rehab patients.

7. Looking at Functional Gain Functional Gain:  The functional change between admission and discharge measures the degree of improvement demonstrated by patients.  Goal: Ensuring patients obtain sufficient gain to be able to return to their prior level of function. What are the problems?  Outcomes are too high  Outcomes are too low  Discrepancy between the scoring of items within the same category

8. Looking at Functional Gain Why would outcomes that are too high be a problem?  Admission FIM scores were too low during the assessment period.  Failure to assess areas of the FIM (i.e., bathing, stairs) can lead to gains above the benchmark.

9. Looking at Functional Gain Tip: Focus on Gain Above Benchmark Look at the number of 0’s on particular FIM items  Remember 0 is not a score and there are only three reasons that justify the use of 0.  1. The clinician determines it is not safe.  2. Medical condition or treatment  3. Patient refusal Look at reliability of the scoring for items that exceed benchmark. Look at facilitators within the environment that enable gains to exceed benchmarks to explain the outcomes.

10. Looking at Functional Gain Action Plan Suggestions:  Evaluate length of stay for opportunities to reduce as appropriate  Evaluate initial FIM scores for proper scoring Be sure that the lowest score is taken from the documentation Be sure that a full set of scores is captured regularly Set the stage for accuracy through communication among team members  FIM training for all staff

11. Looking at Functional Gain Why don’t we want gains that are too low?  Why gains are less than the benchmark: Patients are not admitted from acute in a timely manner Therapy protocols or techniques need to be examined Lengths of stay are not sufficient FIM scoring during the admission process may be delayed

12. Looking at Functional Gain Tip: Focus on Gain Below Benchmark Look at the average length of stay Look at interdisciplinary treatment processes Look at patient mix Look at volume

13. Looking at Functional Gain Look at admission scores for individual FIM items Look at point at which FIM scores are collected (early within 3 day look back or on day 3) Look at LOS on acute

14. Looking at Functional Gains Look at returns to acute Look at discharges to settings other than home

15. Looking at Functional Outcomes Action Plan Suggestions:  Evaluate the consistency of scoring within the FIM items  Evaluate and adjust length of stay as appropriate  Evaluate and improve team communication through daily stand-up meetings, functional communication boards, etc.  Educate all staff on admission and discharge scoring rules.

16. Looking at Functional Outcomes Action Plan Suggestions:  Evaluate team skills for treating current patient mix  Evaluate screening and admission process to determine if patients are being admitted at the right time in their recovery  Start an ADL program, ambulation group, cognitive group, etc to focus on enrichment of skills learned in 1:1 sessions

17. Measuring Goal Attainment Goal setting is important!  Look at the team's practice of setting goals. Are the goals set too high? Were realistic goals set at admission?

18. Measuring Goal Attainment Goal setting is important!  Did something change in the patient’s performance?  Were goals modified when that patient’s status changed?  Is the room arranged so that the patient can access clothing so he/she can dress without the assistance of another person?  Is nursing included as a facilitator in upgrading the patient’s independence?

19. Measuring Goal Attainment Goal setting is important!  When the unit consistently exceeds the benchmark, that can indicate a problem too. Is the team setting goals that are too low? When goals are attained is the patient re-assessed for the ability to reach a higher level of performance? If this happens, where is it recorded?

20. Measuring Goal Attainment Action Plan Suggestions for low goal attainment:  Conduct an inservice on goal setting to include proper goal setting and progression of treatment through incremental goal achievement.  Educate on setting goals that mirror the typical course of therapy.  Begin reviewing long term goals in the weekly team conference. Emphasize goal revision on the plan of care.  Determine a method to communicate current status and goals regularly through a functional status board, stand-up meetings, and/or team conference.

21. Measuring Goal Attainment Action Plan Suggestions for high goal attainment:  Conduct an inservice on goal setting to include proper goal setting and progression of treatment through incremental goal achievement.  Educate on setting goals that mirror the typical course of therapy.  Begin reviewing long term goals in the weekly team conference. Emphasize goal revision on treatment plan.

22. Case Mix Are we getting paid for the work that we do?  Does it seem like your average expected reimbursement is lower than your burden of care? Capturing the proper RUG score is essential to enable you to staff appropriately. Since many of us predict staffing ratios based on patient acuity as realized through the average RUG, it is important to capture what most closely reflects the care being rendered on the unit.

23. Case Mix Review RUG levels against expected reimbursement:  Look for patterns in RUG level assignment by Medicare assessment periods.  Review therapy utilization by RUG.  How many assessments fell short of the next RUG by a small percentage?  How many were over the assigned RUG by a large percentage?  By how many minutes?

24. Case Mix Analyze your facility admission type  Gather and trend data on the impairment groups and diagnosis groups Review for counts and percentages in each group Comparison data will help you determine other avenues for marketing

25. Case Mix

26. Analyze your facility admission types In eSNFdata, you can pull reports to show your case mix group breakdown Are you missing high acuity patients, low acuity patients?

27. Case Mix Action Plan Suggestions:  Start looking at the data to show what types of patients you are taking. Benchmark to the region and nation.  Evaluate your RUG distribution, case mix groups, or diagnostic groups to see if you are capturing the patients in the market that will enhance your revenue.  Analyze your documentation for capture of the ADL score. Benchmark your acuity scores with others.  Evaluate physician documentation. Does the H&P capture all of the reasons for admission and diagnoses being managed. Are they correct?

28. Conducting a Non-Admission Review Non-admission review:  The review of all patients that have not been admitted to rehab unit.  Access to Care- Common Reasons:  Too impaired  Too functional  No bed available  Physician did not agree  Patient or family refused  Insurance did not authorize

29. Conducting a Non-Admission Review What can we do about the too impaired category?  Determine if the admission denial was based on objective criteria.  Identify if the denial was based on staff’s lack of competency.  Clarify with Medical Director his/her comfort level with the staff managing a patient with that diagnosis or at that level of acuity.

30. Conducting a Non-Admission Review What can we do about patient/family refusals?  If you are experiencing non-admissions secondary to patients/families who choose another facility, use outcomes information to show them the quality of your services.  Show length of stay and discharge destination trends for your facility.  Use marketing materials that share your successes.

31. Conducting a Non-Admission Review Action Plan Suggestions:  Identify staff educational needs for diagnoses that are being denied  Ask Medical Director to provide in-services if appropriate  Provide educational in-services that enhance staff’s skill set to care for more complex patients  Use trend reports in marketing

32. Conducting a Non-Admission Review Action Plan Suggestions:  In-service to case managers regarding the facility’s outcomes and appropriate referral time frames.  Shorten the time frame between referral and actual screen.

33. Return to Independence Success in rehab is often measured by the percent of patients who return to home after discharge from the rehabilitation program.  If the return home percentage is low, the unit can look at: Family preparedness to return home – including family training, home evaluation, and accommodation Utilization of social supports Returns to acute care due to medical complications Length of stay to determine if keeping the patient on case load longer would have allowed the patient to return home Preadmission screening process to properly identify patients who can go home Identify the origins of the patients (did they come from home?)

34. Return to Independence Action Plan Suggestions:  Evaluate the pre-admission screening process to determine if patients and families are well educated on the stay, have reasonable expectations, and express the anticipated discharge disposition.  Set time lines for starting family training sessions early so all parties are prepared for discharge.  Evaluate the length of stay for indicator that there is adequate time in the stay for discharge planning and family teaching.

35. Return to Independence Action Plan Suggestions:  Use your outcomes reports to determine what types of patients are not returning home.  If you identify a skill set issue with a certain diagnostic group, seek clinical training in that area.

36. Transfers to Acute Since the industry is taking more acutely ill patients, it is important that we have the skills to care for them in rehab.  Minimizing the number of patients transferred to an institutional setting is important.

37. Transfer Payments Tips:  Evaluate your pre-admission screening decision making.  Evaluate how you deliver therapy sessions to get to the optimal RUG level.  Determine if the staff has the appropriate skill sets for treating the most commonly treated patient types.

38. Transfer Payments Action Plan Suggestions:  Look at your patient selection process to be sure that you are taking the right patients.  Be creative with scheduling therapy times in order to help the patient build endurance to capture the most optimal RUG.  Develop nursing skills for acute care delivery. Make sure that your medical director is willing to take care of conditions that may require consultations or closer monitoring.  Keep your eye on the discharge plan. Are you using length of stay measures appropriately?

39. Utilizing Patient Feedback Patient Satisfaction  Feedback from Stakeholders: Collect information through a formal patient satisfaction measure and also through patient complaints and grievances. All data should be tracked and trended.

40. Utilizing Patient Feedback Tips:  Multiple survey tools may decrease the number of questionnaires returned. Questionnaire responses go up when those who fill them out feel: 1.They have something to say 2.Have a relationship with the program 3.Think it will make a difference

41. Utilizing Patient Feedback Why Am I Getting an Insufficient Number of Return?  Ways to improve return rate: Leave the questionnaire at bedside the day before discharge and ask for it to be filled out Make the questions meaningful to the patient Interview the patient before discharge Keep the number of questions small

42. Utilizing Patient Feedback Poor satisfaction outcomes may occur when expectations are not met.  A good way to review poor outcomes is by evaluating: Patient goals versus what was provided and attained. Example: Dissatisfaction with nursing care because the patient "only wanted to walk again"  Patient and family expectations versus what was provided.

43. Utilizing Patient Feedback Action Plan Suggestions:  Offer assistance or conduct the interview with the patient and a family member present.  Provide explanation of what you are measuring with this survey.  Ask for suggestion, rather than asking yes/no questions.  Ask selected past patients for suggestions.  If there are trends in dissatisfaction results, construct a task force to analyze the current process. Plan, Do, Check, Act

44. Utilizing Patient Feedback When a patient makes a suggestion, take action on it.  Remember that satisfaction is tied closely to outcome.  The patient who expects one thing and gets another is usually dissatisfied.  Team communication and clarity with the patient is the main element to keeping the patient satisfied even when outcome is not to the level of expectation.  Take all suggestions to the team because they need to hear what all patients say.  Post satisfaction surveys in an area where the team can see them. Consider posting them where families can see them, too. Could be a component of a tour of the unit.

45. Putting it All Together Case Study  Problem: Toilet Transfer goals not being met. The program was at a 64.1% for the most recent quarter's outcomes.  Target: 80% of the patients who are not independent upon admission will meet or beat the goal target as set by the team.  Tactic for interpretation: Review what goal outcome the team expects by thinking how much gain the patient has to achieve to make the goal the team has set. Then compare it to the target. TargetUnit Outcome Unit Expectation Actual Gain Toilet Transfer 80% Goal attainment 64.1% Goal attainment 2.2 FIM gain per day 1.44 FIM gain per day

46. Putting It All Together Analyzing the Problem:  The first step is to assess team goal settings.  Evaluate the team’s philosophy. Some team members set goals at the level of independence because they feel that is the only acceptable target. Most patients in rehab programs are attaining a range of a 4 or 5 in mobility and self care areas and 5 or 6 in the language and cognitive areas prior to discharge. If that is the pattern in your unit, goals should be set with the discharge plan in mind.

47. Putting It All Together Analyzing the Problem:  Evaluate method of gathering FIM scores. Are you getting the best picture of what the patient is able to do?  Look at discharge destination. Did you have a higher than normal return to acute in that time frame, which would result in lower discharge FIM scores?

48. Putting it All Together Action Steps:  Conduct inservices on goal setting for nurses and therapists.  Begin reviewing goals during patient rounds. Modify the goals as it is clinically appropriate.  Initiate discharge stand-up meetings to be sure that everyone is encouraging the patient’s independence by providing the proper amount of support.

49. Putting It All Together Action Steps:  Begin discharge planning as soon as the plan of care has been established.  Work with hospital administration to ensure that the unit has physician support for consults in order to provide appropriate medical treatment on the unit rather than transferring the patient to an acute bed.

50. Putting It All Together When the data shows you that you have a performance area that needs further analysis, your next step is to go to the record.  What is your plan for medical record review?  What do you do with the findings?  What impact does this have on your facility’s operations and reimbursement?  How do you report it?

51. Putting It All Together Best Practices in Performance Improvement –  Communicate  Inservice  Peer Auditing  Use Case Studies to facilitate learning  Select a manageable number for performance indicators to work on  Report change and what worked to facilitate change  Don’t fear it!

52. Questions? Contact: Lbazemore@esnfdata.com 202-588-1766