Nightingale and Aspire                                                           Nightingale and Aspire Home Healthcare QUALITY CARE & DOCUMENTATION 2011-2012

Home Health Services Covered under the Part A Medicare benefit. Are part-time, medically necessary skilled care (Nursing, PT, OT, ST) ordered by a physician.

Reporting Home Health Quality uses OASIS Beginning January 2010, agencies have been required to collect OASIS-C data. CMS anticipates that OASIS C will promote the use of evidence based practices in the home health industry.

Need for Home Health is Increasing 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: 5-10% 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 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 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. 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.

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: Higher values are preferable for end result outcomes. Lower values are preferable for utilization outcomes. 

Outcome Measures 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.

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.

Medicare.gov

2012 Agency Focus Areas 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)

Quality Assurance & Performance Improvement (QAPI) 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 Replace acute needs of people who would otherwise have to remain in, or enter, acute care facilities; AND… Assess & address patient needs with self-management 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 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? 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? 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 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 2. Use open ended questions & probe. Some examples: 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

Wound Care 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

COMPREHENSIVE ASSESSMENT 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 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

VISIT NOTE = Discipline Care Plan FORM 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. long-term 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” 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

Home Health Aide Supervision Supervision of the Aide & review of Aide Care Plan is done by the Case Manager. Example in Visit Note: 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

REQUIRED Skilled Supervision: LPN/LVN, PTA, & COTA 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 “Agency professional staff must promptly alert the physician to any changes that suggest a need to alter the plan of care” 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 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  

PHYSICIAN ORDERS: WRITe CORRECT Visit FrequencY ORDERS 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

Adherence to the Plan of care: Follow CARE PLAN ORDERS § 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 Read your patient’s Care Plan prior to each visit , check e-mail regularly If Evals are ordered but delayed or not completed, the physician must be contacted for new orders to reschedule or cancel the evaluation Directions on the plan of care are obtained from the physician Never leave patient/caregiver to coordinate care alone. That is our responsibility.

Required recertification Documentation: The 60 Day Summary 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! 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: Reinforce on a continual basis OR every visit: Home Safety D/C Planning Medications Satisfaction with Care Show Respect: Do not burden patients with personal or company business No text messaging OR non-care related phone calls during visits 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 Thank you for investing in this training time today. Brenda Tea 866.334.7777, 1232 btea@HomeCareForYou.com