Archive for November, 2011

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Speech and Language Pathology, the “OTHER” Therapy

Friday, November 25th, 2011

While there is much focus on PT and OT, know that documentation will be scrutinized regarding Speech/Language Pathology also. Most clinicians have a good understanding of how PT and OT intervenes with the clients but many clinicians may admit, that other than help with dysphagia, they are uncertain what other care the S/LP can provide?

S/LPs are subject to the same documentation goals under the CoPs:

¡  Provide evidence that the care given meets clinical standards

¡  Justify reimbursement for the payor

¡  Provide protection from liability

¡  Means of communication among individuals providing services

Provide accurate data regarding care for specific patient and diagnostic populations.

S/LPs must meet the same legal requirement to communicate:

¡  Record must be accurate in all respects

¡  Content of the record should contain measurable and objective data

¡  Interventions must be specifically documented and be relational to the POC

¡  Document what was taught and to whom

¡  Document what was learned and by whom

¡  Legal signature includes: Full Name, Full credentials and be legible

S/LPs must have the patient meet the Home Health eligibility per the CoPs:

¡  Homebound Status

CMS expects that the patient’s physical condition and/or physical limitations are such that it would be a considerable and taxing effort for the patient to leave home.

NOTE: Refer to CMS Benefit Policy Manual, (Pub 100-02), Chapter 7, 30.1

¡  Under the Care of MD, DO, DPM

“A medical treatment plan of care or the optional Form 485, must be established by the attending physician, or, where appropriate, in conjunction with a home health agency nurse, regarding nursing and home health services, and/or by skilled therapists regarding specific therapy treatments”

See 42 CFR Part484, Conditions of Participation, Subpart A General Provisions and 484.18 Plan of Care.

¡  Medical Necessity and Skilled Need

CMS states that medical necessity is defined as a “reasonable and necessary need for the diagnosis or treatment of an illness or injury, or to improve the functioning of a malformed body member.”

S/LPs must document specific care to justify Medical Necessity

¡  Is there a feeding and swallowing problem?

The S/LP will routinely perform an oral/motor examination. They will evaluate swallowing, coughing, and the size of bolus.

The S/LP can develop a plan to mitigate risk of aspiration such as bolus control.

The S/LP can assist with the plan to maintain adequate hydration and nutrition through body positioning and maneuvers to improve safety.

They will assist in evaluating the independence factors in compliance with the overall plan.

¡  Is there a problem with language  (verbal expression, comprehension, reading)

The S/LP can assist to minimize safety risks by finding tools and devices to aid in communication of safety needs to family and other caregivers.

¡  Is there a cognition issue?

The S/LP can assist with strategies to improve attention and attending cues, as well as memory cues.

The S/LP can identify strategies and tactics that can aid problem solving skills. This too can impact safety and independence.

¡  Does the patient require intervention with Voice?

The S/LP can identify strategies to impact on verbal expression, relieving vocal symptoms and, improving their functional voice. The S/LP will identify ways to increase voice loudness and decrease hypernasality.

The clinician should assess this need for S/LP under the Safety evaluation.

¡  Is the patient struggling with fluency and difficult sound production? Do they have an impairment of the tongue? Do they have a lower neuron disease or cerebellar lesion? Does the patient suffer from TBI or had a stroke, or MS?

The S/LP can provide assessment of and interventions for the patients suffering from receptive language deficits; the need to improve understanding of spoken language and can assist with expressive language needs also. It can be frustrating to a patient who cannot state needs or answer questions. Acting out behavior is frequently found to be due to fear, sadness, and frustration.

Depending upon the condition teaching and reteaching occurs.

¡  Three Types of Teaching:

¡  Initial Teaching of a patient requires instruction on a new order, new medication, new diagnosis

¡  Reinforced Teaching requires teaching/instruction on something the patient and/or caregiver may be knowledgeable of, but needs additional teaching

¡  Re-teaching involves evaluation and reinstruction on a medication, diagnosis, treatment, etc that the patient has had prior instruction

The S/LP has expertise in learning principles and teaching techniques.

Using Descriptive Verbiage in Documentation

Expect to see documentation descriptors that create a visual image in the mind of the reader. They should demonstrate the skill of the therapist, the value of the care as well as progress of the patient toward their goals:

Accessed                    Assessed                          Assisted               Adaptive

Altered                     Accurate                   Automatic             Applied

Analyze                    Appraise

Cues/Cued                Compromise              Corrected             Customize

Calculate                  Compare                   Contrast               Construct

Compose                  Choose                      Categorize            Collect

Directed                   Develop                      Distinguish          Define

Demonstrate                      Dramatize                  Diagram

Evaluate                   Exercised                            Elevate                Express

Explain                     Examine

Facilitate

Illustrate                   Identify                     Interact                Instruct

Modify                 Measure

Progressed           Practiced                   Proposed

Revised

Stimulated            Scheduled

Updated

The S/LP should document prior functioning in comparison to current. They should clearly document care coordination.

Choosing the Assessment Instruments and Tools

The home health agency, in conjunction with the therapist, should determine what tests will be approved by the agency, so there is continuity among all therapists. Be certain each therapist is knowledgeable with the tools chosen so inter-rater reliability issues are minimized. Also, much like PT consistency; will a TUG or Tinetti be used, S/LP must consider test and re-test reliability.

Consider time for the administration of the assessment. Nurses have seen assessment tools come and go. I can recall a fabulously thorough clinical assessment tool to be used on an inpatient unit. It soon lost favor when its lack of practicality surfaced. Are you seeking comprehensive tools? Be certain they are standardized so that reliability and validity issues do not surface.

Look at the OASIS functional items and look to well thought of commercially acceptable outcome measurements such as the NOMS. The National Outcome Measurement System can be used as an objective measurement tool for the CMS 13th and 19th visit per the American Speech-Language-Hearing Association.

Eight of the fifteen Functional Communication Measures (FCM) from the Adult NOMs were submitted to the National Quality Forum (NQF) for review and were endorsed and became a part of the public domain.  The FCM is but one component of the overall NOMS, the national data base of treatment outcomes and customized data reports.

Other Common Tools Used by the S/LP

The Aphasia Language Performance Scale (ALPS)

The EFA-3, Examining for Aphasia

Boston Diagnostic Aphasia Exam

Cognitive Linguistic Quick Test (CLQT)

CADL, Communication of Activities of Daily Living

For a more complete list of Standardized Assessment Instruments, go to:

http://www.asha.org/assessments.aspx

¡  Documentation to substantiate coding and care have become critical to agency providers.

¡  Documentation has become the key communication tool for care.

¡  Documentation has become the first and last line of defense with the scrutiny of the industry auditors.

Documentation provides the demonstration of the skills of the clinician and justifies the retention of the agency payment received.

Quick tip: Recently, a colleague shared with me that on their psych team, besides the psych nurse and the occupational therapist, they have added a S/LP in certain circumstances, especially with patients with challenged cognition. With patients who are acting out and have recently suffered a stroke or have exacerbated MS, the S/LP has much to add to the Home Health Team in assisting to decrease frustration and anxiety. Speech and Language Pathologists (therapist) add depth to the total team.

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Posted in CMS, Compliance, CoPs, Home Health, Therapy | No Comments »

Compliance Q&A: Survey protocols, CoPs, HIPAA, ACOs, and Transitions of Care

Saturday, November 19th, 2011

Questions regarding 2011 Survey protocols

Q. We have several questions re the new survey protocols. What are some of the key differences? What does the pre-survey preparation include?

A. The new survey protocols focus on specific standards within identified conditions that are related to quality care. To identify the care delivered and its relationship to the assessment and plan of care designed, besides reviewing the clinical record, the surveyor will also rely on personnel interviews as well as home visits. The survey is data-driven, patient-focused, and outcome-oriented.

The surveyor is expected to collect data and review State file data, prior survey results, OASIS reports, and agency specific characteristics. (S)he will review outcomes, potentially avoidable events of both active and discharged patients, and make visits for higher risk patents. The new protocols provide specific guidance on citing standard and condition-level deficiencies.

Q. Can you explain the survey levels? How is a standard survey extended?

A. A Standard Survey focuses on Level 1 standards (9 of 15 CoPs) which focus on the delivery of high quality patient care using not only clinical records but inclusive of interviews. If the home health agency is in compliance with all Level 1 standards and there are no identified concerns requiring investigation, the survey will be concluded and form CMS 2567 is issued.

Partial Extended Survey begins/expands when expected outcomes are not met for one or more Level 1 Standards. It requires a review of Level 2 standards. It should be expected that related information would be sought for areas of concern such as agency policies and procedures, personnel competency evaluations, and inservice training

Condition-Level Deficiencies can occur with serious findings related to or not related to Level 1 and 2 standards. Immediate patient jeopardy is always cited at the condition level. All conditions are reviewed.  Refer to the State Operations Manual, Appendix B Guidelines.

Questions re CoPs

Q. What are the required leadership positions stated in the CoPs?

A. The Conditions of Participation cite three administrative positions:  a governing body, an administrator, and a supervising physician or RN.  You may title these three positions whatever  your agency prefers, however the positions must exist and the individuals appointed must perform the duties identified in the CoPs. Be certain job descriptions, policies and procedures, and other necessary documentation clearly define that the positions perform all required designated responsibilities.

Do not forget the delegates required. Be certain that agency policy identifies who will function as the administrative delegate. The agency must also be in compliance with state requirements, which frequently are more stringent. Compare both State and Federal requirements so the agency is in compliance.

Q. Is it true that we must have a realistic end point for intermittent services for a patient who has a chronic diagnosis, such as Alzheimer’s disease?
A.The CMS Publication 100-2, Chapter 7, § 40.1.1,  states  services can be provided “without regard to whether the illness or injury is acute, chronic, terminal, or expected to extend over a long period of time.”

According to the publication, if the patient with a chronic disease is homebound and needs skilled, reasonable, and necessary services that meet the part-time or intermittent requirements, then the agency can provide care.  That documentation must carefully be documented, The agency must be certain there exists an intensive assessment of the patient and their support services with interventions and goals clearly stated.  Carefully delineate the SKILLED need for each visit made. If the patient with Alzheimer’s disease qualifies for Medicare coverage through a need for monthly catheter changes and receives home health aide services 1x per mon, be certain each visit shows progress and document pt/cg response to care.

Up to a maximum of 28 hours per week of skilled nursing care and home health aide services combined completed in less than 8 hours per day or up to 35 hours per week of skilled nursing and home health aide services and subject to review by the fiscal intermediary. Medicare requires supporting evidence of the continued skilled care need. The agency must reflect the need for compliant skilled care through clear documentation.

Questions about ACOs and New Payment Methods

Q. I am hearing about bundled services. Should I be concerned?

A. Home Health Agencies should be aware of potential ACO formation in their respective markets.  Does your agency have a specialty you should be marketing to local hospitals? Some hospitals are looking at the bundled payment options as well as ACOs. Read more at the CMS website but know that the proposed pilot gives participants the opportunities to make choices regarding patients to include, length of episodes of care, whether acute inpatient care should be included, and the target payment to be established. There are a variety of proposed models. Go to www.CMS.hhs.gov to learn more.

Q. I have heard there will be new payment methods. What are they?

A. Select Data will be providing ezine articles in late November and December regarding some of the proposed payment and treatment methods being considered and presently being evaluated. Those may include:

Accountable Care Organizations (ACOs) with Bundled Payments or Shared Savings Programs where the ACO shares risk. There will be various types of risk sharing programs. There may be Value- based Payment plans. Expect to see ACOs lead by hospitals or physician groups. Home Health Agencies will need to show value to become a part of such collaborative formalized groups.  Expect CMS to utilize comparative-effectiveness techniques of evidenced-based practices. Become familiar with the following terms:

ACOs: Integration of providers to assume responsibility for the quality, costs, and outcomes of care.

Total Costs of Care: A reimbursable methodology that is being designed to reduce cost by person by episode.

Predictive Modeling: A methodology to estimate how clients may use services and the related costs based upon variables, prior behavior, and attributes assigned.

Transition of Care: The movement of patients from one health care practitioner or setting to another as the condition and care needs change. Under this model, there will be NO discharge summary. Instead expect a “Transition Summary”. See the next Select Data article: CMS and Transitions of Care.

Questions re Face to Face

Q. Is anyone working to get some help for home health agencies regarding the face-to-face rule?

A. Yes, several state associations as well as NAHC are working to obtain some legislative relief. NAHC has called for 1) exemptions in specific hardship circumstances, 2) a reduction in documentation required, 3) expanded use of telehealth to meet the face to face requirement, 4) protection of home health agencies from denials without fault, 4) allow one physician/NPP to complete the Face to Face and another to certify (CMS has proposed this but is limiting it only to an inpatient physician).

Q. Could you give a summary of key points of the proposed 2012 Home Health PPS Rate Rule?

A. Agencies will need to be efficient as there is a proposed 2.5% inflation update, a 5.06% case mix creep adjustment, and a 3.56% rate reduction for 2012. In addition there is a recalculation of case mix weights proposed that includes elimination of two hypertension codes (401.1 Benign essential hypertension and 401.9 Unspecific essential hypertension). Also, there would be lower therapy episode coding weights. This would include a deceleration of a higher number of visits with a removal of the therapy visit step indicators. There will also be a recalculation of points to clinical and functional scores. Additionally, if an agency failed to complete a successful dry run  in Q3 of 2010 for HHCAHPs, they risk a 2% reduction in payment. (See October, 2011 Select Data ezine for more regarding HHCAHPs).

A few questions regarding HIPAA

Q. Could you give a brief summary of HIPAA HITECH? Can you discuss breach? Can you discuss best practices needed?

A. The American Recovery and Reinvestment Act (ARRA) of 2009 brought changes to HIPAA regulations in three broad areas: breach notifications, business associations, and penalties. It increases enforcement of HIPAA and allocates billions of dollars to invest in the implementation and exchange of health information technology such as the EMR.

Under HITECH, if a breach compromises the privacy and security of the patient’s information and poses a significant risk of financial, reputational, or other harm, patient notification is required.

Five new definitions have been added:

  • Breach Electronic
  • Health Record (HER)
  • National Coordinator
  • Personal Health Record (PHR)
  • Vendor Of PHI

HITECH strengthens the specifics of privacy, significantly increasing penalties, establishing a heightened enforcement scheme and giving state attorney general enforcement authority. Individuals may now be held accountable for wrongful disclosure (HITECH Act section 13409).

If a breach involves 500 or more individuals, the department of HHS should be immediately notified. DHHS began posting names on March 1, 2010. Breaches below 500 must be logged and annually sent to DHHS.

For Business Associates, the Covered Entity must ensure that BAs have implemented the administrative, physical, and technical safeguards of HIPAA security. The CE must also specify that the BA must comply with use and disclosure rules in the HIPPA Privacy Rule. The BA should demonstrate how they will negotiate security/data breach coordination. There should also be an agreement on reporting and dispute resolution.

If the health care organization suspects or knows that a BA has committed a material breach or violation of the agreement, “the health care organization is in violation of the business associate rules unless it takes reasonable steps to cure the breach or end the violation {45CFR 164.504 (e)(1)(ii)” (Decision Health, HIPAA, 2010).

Penalties include a Tiered System for assessing both the level and penalty for each violation. There is a cap of $50,000 per violation and 1.5 million for the calendar year for the same type of violation.

Health care organizations should have in place policies that address various levels of violation, such as failing to sign off a computer terminal when not attended, sharing passwords, assessing a patient record without legitimate reason, releasing data for personal gain, and intentionally destroying or altering data.

Use Best Practices for:

Authentication: pre-boot and intricate passwords

Access: Need to know basis on approved devices

Retention: Destroy if not needed

Encryption: Laptops, notebooks, desktops, email, and social networks

For some peace of mind, have a written information security program, an active HIPAA privacy program, and a living Corporate Compliance Program.

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Posted in ACO, Best Practice Intervention Practice, CMS, CMS Guidelines, Compliance, Face to Face Encounters, HIPAA, HIPPA HITECH, Home Health, Medicare, Patient Survey, Surveys | No Comments »

CMS released the final regulation which implement a new form of healthcare organization, the Accountable Care Organization (ACO)

Saturday, November 5th, 2011

On October 20, 2011the US Department of Health and Human Services released the final rule implementing the ACO Shared Savings Program and the complementary regulations and guidance from CMS/OIG as well as the DOJ/FTC. It should be noted that the final rules are materially different from the proposed rules of March, 2010.

ACOs were created by the Affordable Care Act (ACA) signed into law March 2010. The dual purpose, of this network provider model, is to reduce the increasing cost of healthcare and to include incentives to create this new way of providing care for individuals. Coupled with the ACO rules, CMS had unveiled the Shared Savings Program (SSP), a program created by Congress to allow the ACOs to share in the savings and potentially share the costs of care to Medicare beneficiaries.

The final regulations were released. The proposed rules did not stimulate the interest expected. CMS has since changed the final rule to focus on the themes of flexibility, accountability, and innovation. It also provides clear guidance aimed at encouraging the development of the ACO participation in the Shared Savings Program. The purpose of ACOs is to realize savings and quality care through the coordination of services among the various providers, including hospitals, individual physicians, group practices, hospitals, home health agencies, and community health centers, or any combination of the above. Applications for the implementation of ACOs are currently being accepted through January 1, 2012, and the first ACOs will begin April, 2012.

The three goals of the ACOs stressed under the Shared Savings program will be to promote: 1) effective, patient-centered care for individuals; 2) preventive oriented and education oriented care for specific populations; and 3) cost savings (and profit) for the ACOs and CMS in general as well as decreasing waste in the system.

To be eligible to participate in the Shared Savings Program, ACOs must be accountable for at least 5000 beneficiaries a year for each of the three years of the agreement. To be eligible to share the savings, ACOs will be required to report on four quality measure domains.

It is apparent that this new healthcare model will be very patient-centered, not only addressing the medical needs of its participants, but also the social, nutritional and community needs as well. The cost sharing for the ACOs is determined by not-yet established benchmarks for 33 quality measures (QMs) broken down into the four domains:

  • Care Coordination/Patient Safety (6 measures)
  • Preventive Health (8 measures)
  • At-Risk Populations/frail elderly health (12 measures)
  • Patient/Caregiver Quality Standards (7 measures).

The QMs include population focused areas that are approached in a patient-centered manner. These indicators include timeliness of physician appointments, effective communication, tobacco use, diabetes and other comorbidity control, as well as preventive screenings. Depending on the success of the outcome-driven education and approach to the care as well as patient ratings and surveys, specific provider scores could garner up to 60% of the savings realized by the organization. It is anticipated that the new system will save over $960 million over the next three years for the Medicare program, per CMS.

This new form of healthcare organization will utilize technology to link providers. “An ACO will be rewarded for providing better care and investing in the health and lives of patients,” said Donald M. Berwick, M.D., CMS Administrator. “ACOs are not just a new way to pay for care but a new model for the organization and delivery of care.”

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Posted in ACO, Affordable Care Act (ACA), CMS, CMS Guidelines, Compliance, Home Health, Legislation, Medicare, OASIS-C, OIG | No Comments »

Educational Videos: CY2011 Changes Part III of III

Saturday, November 5th, 2011

Home Health Consumer Assessment of Healthcare Providers and Systems (HHCAHPS)

This survey is meant for patients and people to identify their experiences with Home Health providers.  This gives the patients and their families the opportunity to voice their opinions of the care that they recieved.  In another sense, the Healthcare providers are receiving a form of audit done by their patients.  Those agencies not participating in this survey are at risk of -2.0% reduction for the market basket index rate.

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Educational Videos: CY2011 Changes Part II of III

Saturday, November 5th, 2011

Therapy Changes Will Impact Home Health Agencies

With the changes in CMS release auditors such as RACs, MACs, Z-PICs, and Heat, Therapist are now the center of focus.  CMS has asked for this CY2011 is more visits by the qualified Therapist, more supervision.  Their belief is that the qualified therapist, identified as the physical therapist, occupational therapist, speech language therapist, should be making supervisory visits every 30 days and should be making the actual visit to the client on the 13th and 19th visit.

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