Managing Outcomes

Learning Objective As a result of this session, the participant will:  Identify areas of clinical performance that relate to positive patient outcomes.  Have strategies for drilling down to uncover performance issues.

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.

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

Facility Report Case Mix Index:  Benchmark against the nation and the region.  Investigate the components- Rehabilitation Impairment Classification Motor FIM Subscale Weighted Score at Admission Age Tier Assigning Co-morbid Conditions  Investigate the distribution of impairment groups, CMG, or RIC.  Investigate the components for the most common groups.

Facility Report Average Medicare Expected Reimbursement:  Based on Medicare reimbursement  Adjusted for your facility pricer as updated through eRehabData  Includes calculations for transfer payments and short stay reductions

Facility Report Transfer Patients:  Percentage of patients that are discharged to another Medicare bed Acute care SNF LTACH Another IRF Discharge Destination:  Breakdown of discharge locations for the patient’s served  Skilled nursing and subacute designation errors

Facility Report Averages:  Two benchmarks: Weighted and unweighted  Onset days: Different instructions by RIC  Length of stay considerations  FIM scoring data- Admission Totals Discharge Totals FIM Change Motor subscale at admission

Facility Report Individual FIM Items:  Admission, discharge, change, and follow-up  Explains difference between facility totals and benchmark totals  First glance at isolating FIM scoring errors

Drill-Down Case Mix Index:  Capturing Tiering Co-Morbidities Considerations-  Which tier level?  Which RIC, IGC, CMG?  Which codes?  Capturing the burden of care Considerations-  Weighted and unweighted FIM motor subscale comparisons at admission  Which RIC, IGC, CMG?  Which items?  Assessment warnings?

Drill-Down  Assigning the proper IGC and etiologic diagnosis Considerations-  Which warnings?  How often?

Strategies Performance Improvement Strategies:  Evaluation the documentation for areas that need improvement. Is IGC stated? Are all conditions being treated diagnosed in the physician assessments, consults, or progress notes?  Ensure that the coders are on top of the rehab coding process.  Communicate with the coders.  Inservice staff on FIM scoring regularly.  Use data to direct staff education for accurate FIM scoring.

Drill-Down Reimbursement:  Determine which populations have the greatest transfer payment percentages.  Evaluate length of stay by RIC, IGC, CMG.  Review discharge destinations by group.  Use the patient report to identify outliers.

Strategies Transfer Patients and Discharge Destination:  Evaluate the patient selection process to be certain you are taking the right patients.  Be creative with scheduling therapy times in order to help the patient build endurance to meet the 3-hour rule.  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 Metrics reports appropriately?  Remember that before transferring a patient to a skilled or long-term care bed, the patient should be performing at their best while meeting the conditions of participation for the IRF level of care.

Drill-Down Averages:  Onset days should be evaluated on a RIC basis to ensure you are hitting your targets given the definition stated in the IRF- PAI Training Manual. RIC Report Referral date to admission date  Length of Stay should be evaluated to ensure you are hitting your targets. RIC, IGC, CMG, Patient Report

Drill-Down Averages:  FIM Scores Total Admission FIM shows patient’s overall burden of care and potentially indicates barriers to progress or expected rate of progress. Total Discharge FIM shows patient’s achieved performance. Scores are gathered across the last 3-days of the stay. Facility identifies patient’s best performing 24-hour period and the lowest scores from that day are reported on the IRF-PAI. FIM Change is the amount of gain from admission to discharge and is also reported on a per day gain basis.  Considerations:  Totals reviewed for total population  Totals reviewed by RIC, IGC, CMG  Items reviewed in for total population  Items reviewed by RIC, IGC, CMG  FIM Scoring Comparison Graph  Time-Series Graph  Metrics

Strategies Averages:  Evaluate screening and admission process to determine if patients are being admitted at the right time in their recovery.  Evaluate initial IRF-PAI 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 daily Set the stage for accuracy through communication among team members  Evaluate the effect of the volume factor.  Start an ADL program, ambulation group, cognitive group, etc to focus on enrichment of skills learned in 1:1 sessions.

Measuring Goal Attainment Goal setting is important!  Patient metrics page reports admit, discharge, goal, and gain.  Review again goal at team and following discharge for success with goal attainment.

Strategies Goal Attainment:  Emphasize goal revision on the plan of care.  Inservice on goal setting to include proper goal setting and progression of treatment through incremental goal achievement.  Begin reviewing long term goals in the weekly team conference.  Determine a method to communicate current status and goals regularly through a functional status board, stand-up meetings, and/or team conference.

Other Views Time Series Graphs:  Look at performance over time  Multiple indicators can be viewed simultaneously  Data tables are useful tools for report preparation

Other Views FIM Scoring Comparison Graph:  Graphs admission, discharge, and change scores for the facility and region/nation  Review weighted and unweighted comparisons  Helps identify items that may require special attention in order to accurately represent the burden of care

Other Views 75% Rule Report:  Know how you will report your compliance to the FI: admissions or discharge  Know your cost report year and look back periods  Manage conditionally compliance closely

Other Views 75% Rule Report:  Confirm the final IRF-PAI with the patient’s status on the compliance report Presumptive or conditional? In order to appear on this report correctly, you will answer questions on the eRD tab to determine if the patient is 75% compliant or not. Review the detailed assessment to determine what makes the patient compliant.

Other Views 75% Rule Compliance Threshold:  Provided that each patient is properly identified on your 75% report, the compliance threshold established for your current reporting period is adequate.  Every patient that meets the criteria for inpatient rehabilitation deserves to receive that level of care. Therefore, operating at a higher compliance while beds are empty is essentially denying a patient an opportunity to regain independence.  The key is to be sure that you capture the 75% status of each patient correctly.

Other Views Dashboard:  Great tool for daily census update  Offers a 14-day projection of census decline for current case mix  Provides 30-day analysis of several indicators: CMI, 75% rule compliance, RIC distribution, and payor source breakdown  In order to provide data, your bed configuration and pricer need to be up to date

Other Views Referrals Outcomes:  Designed to trend referral sources, referring physicians, and conversion rates.  Offers information on reasons for denied admission.  You can filter the information to drill down on physician, referral source, internal vs. external fill, and reason for denied admission.

Other Views Referrals Outcomes:  Use information to determine referral trends by- Referral source Referring physician Internal versus external fill Zip code breakdown Payor source breakdown Conversion rates Reasons for denial  Drill down by RIC, CMG, and Patient Patient reports list patients denied

Optional Items Patient Satisfaction Instrument:  3-Step Satisfaction Tools specific to rehab Service Recovery Discharge Follow-Up  Feedback from Stakeholders: Reported with demographics Item by item averages of responses for each item Same drill-down capabilities as facility reports

Optional Items Patient Satisfaction Instrument:  Graphs responses to questions from each survey type for selected time period  Graphs historical trends for each question asked on the surveys  Time Series Graphs available to drill-down by patient type or demographic profile  Stores and reports narrative comments provided by patients

Optional Items Utilizing Feedback  Collect information through a formal patient satisfaction measure and also through patient complaints and grievances.  All data should be tracked and trended.  Ask the community advisory board or selected past patients for suggestions.  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.

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!

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