Select Data

HHCAHPS Frequently Asked Questions

jeffbrittain — Mon, 19 Jul 2010 22:59:29 +0000

Besides PECOS, RACs, MICs, MACs, and Z-PICs, the home health industry has been actively involved with CAHPs. Final rules were posted November 10, 2009.
The CAHPs survey was designed to essentially determine the performance and care quality delivered to a home health patient/client as identified by that patient/client. The industry is generally knowledgeable about CAHPS but, below are some of the most frequently asked questions to Select Data personnel.

Question 1: Which home health patients should have a HHCAHPs survey?
Answer 1: Patients whose care is paid by Medicare and Medicaid are eligible for inclusion in the HHCAHPS survey. Agencies must contract with a CMS approved vendor, who will conduct the surveys. Patients/clients have the right to state they do not wish to participate. The agency is not expected to ask the patient/client if they wish to participate. They are encouraged to leave that responsibility to the surveying vendor. For general information, visit the CAHPs website at www.homehealthcahps.org

Question 2: I know we are to include Medicare and Medicaid patients/clients but are there any guidelines?
Answer 2: Yes, for detailed guidance refer to the above website. In general be aware that the survey will consider current and discharged patients who have had at least one skilled visit during a sample month, who are at least 18 years of age, who have had at least two skilled visits from the agency during a 60 day look back period, who are not receiving hospice care, and who are not maternity clients.

Question 3: How many patient/clients should be surveyed?
Answer -3: Agencies are expected to survey 300 patients/clients annually with larger agencies using a sampling method and smaller agencies potentially surveying all clients. Agencies serving less than 60 HHCAHPs eligible patients/clients from 3rd quarter 2010 though 2nd quarter 2011 will be exempt from the HHCAHPs survey requirement. Going forward, the unduplicated patient count from 10/1 through 9/30 will be used to determine HHCAHPs.

Question 4: We are a relatively new agency and don’t have 60 patients. Do we just ignore HHCAHPs?
Answer 4: New agencies (with provider numbers) serving less than 60 patients had to notify CMS by June 16, 2010, with a patient count for the period from 4/1/2009-3/31/2010. The form used for such a count was/is available at www.homehealthcahps.org

Question 5: Can an agency decide not to participate in the HHCAHPs process and use their own survey instead?
Answer 5: HHCAHPs had been identified as a voluntary survey process, however, the final rule makes it clear that non participating agencies will be subject to a two percentage point reduction in the market basket update in 2012.

Question 6: We do not want to have two surveys going to our patients/clients. Can we work with a vendor to develop our own individualized survey tool?
Answer 6: Yes. The HHCAHPs survey consists of 34 survey questions addressing care as it relates to safety, medication, pain management, along with communication and interpersonal interactions. The patients will also be rating the agency overall and the likelihood of referring the agency to another individual. The surveys will also collect data regarding the types of services received as well as ratings regarding the patient’s view of their own overall health. The CAHPs questions are required and cannot be changed or deleted, but agencies may add questions to the survey.

Question 7: If the patient is confused, can the agency answer the questions for them?
Answer 7: No. The patient/client’s family/friends may answer the questions as a proxy, but the agency personnel may NOT answer the CAHPs survey.

Question 8: Can we send the patient lists to our CAHPs vendor quarterly?
Answer 8: CMS expects the data to be sent to the vendor within 21 days after the close of the month.

Top 5 Questions asked regarding PECOS

jeffbrittain — Fri, 09 Jul 2010 16:12:53 +0000

At Select Data, PECOS is a “hot” topic. Here are the 5 Top Questions asked of Select Data re PECOS….
Over the past three weeks, the home health industry has been focused on PECOS (Provider Enrollment, Chain, and Ownership System). The final interim rule was published in the Federal Register May 5, 2010, mandating physicians who certify DME and home health services be enrolled in PECOS by July 6, 2010. The situation heated up in June because many physicians thought they had until January 1, 2011. That mistaken information was stated in an April CMS transmittal and has caused confusion and angst within the industry. In addition many physicians, per our clients, thought that being a Medicare provider for years automatically meant they were enrolled in PECOS.

Question 1- An agency asked, can we hold off and see if CMS extends the deadline?
Answer 1- Agencies need to continue to verify that physicians are enrolled in PECOS. Physicians need to verify they are enrolled and active. Some physicians are finding that, though they have been enrolled in Medicare for many years, their information is not appearing in PECOS. If those physicians have not reported any changes to CMS within the past 5 years, they may not have any enrollment records in PECOS. They need to submit a PECOS application.
Question 2- Can a physician submit an application online?
Answer 2 -The PECOS enrollment process has progressed from paper (CMS-855) to an internet-based application process for physicians, non-physician practitioners, providers, and DME supplier organizations to not only enroll but, update their Medicare enrollment information and to verify status of the application process. For further information, go to: www.cms.gov/MedicareProviderSupEnroll/01_Overview.asp
Question 3 - How can a physician tell if (s)he has an enrollment record in the Provider Enrollment, Chain and Ownership System (PECOS)?
Answer 3 – Per CMS: There are three ways to verify that you have an enrollment record in PECOS:
1. Check the Ordering Referring Report on the CMS website. If you are on that report, you have a current enrollment record in PECOS. Go to http://www.cms.gov/MedicareProviderSupEnroll, click on “Ordering Referring Report” on the left.
2. Use Internet-based PECOS to look for your PECOS enrollment record. If no record is displayed, you do not have an enrollment record in PECOS. Go to http://www.cms.gov/MedicareProviderSupEnroll , click on “Internet-based PECOS” on the left.
3. Contact your designated Medicare enrollment contractor and ask if you have an enrollment record in PECOS. Go to http://www.cms.gov/MedicareProviderSupEnroll , click on “Medicare Fee-For-Service Contact Information” under “Downloads.”
Note: If you have submitted an enrollment application within the last 90 days, and your enrollment application has been accepted for processing by the carrier or A/B MAC, you need not take any additional actions based on this listserv message. Per CMS
Question 4 – Can I get some online help with enrollment?
Answer 4- Certainly. Tips on how to enroll in PECOS can be found at: www.cms.hhs.gov/MedicareProviderSupEnroll on the CMS website
Question 5 – How will the PECOS system work (once they get physicians enrolled)?
Answer 5 – Refer to the CMS MLN (Medicare Learning Network and reference article MM6856 and the CR 6856 Change Request which requires the NPI for the attending physician on the claim to be valid and enrolled in Medicare.
The FISS (Fiscal Intermediary Shared System will reconcile the physician claim data to the PECOS. To reconcile, the physician (an MD, DO, or DPM) must be enrolled in the Medicare system and be registered in the PECOS system (unless they have opt out status).
The FISS system, using the PECOS system will verify physician validity by matching the NPI number, the first letter of the first name, the first four letters of the last name to the claim information.
The FISS system requires physician enrollment for a valid claim and validity is tied to payment. CMS official instruction is available at www.cms.gov/Transmittals/downloads/R677OTN.pdf
Please be aware that on 6/30/2010 CMS posted the following:
“The Centers for Medicare and Medicaid Services (CMS) is working with providers to address concerns about enrollment in the Provider Enrollment, Chain, and Ownership System (PECOS) to ensure that Medicare beneficiaries continue to receive the health care services and items they need. PECOS is the electronic system used to enroll physicians and eligible professionals into the Medicare program.
As part of those efforts, CMS will, for the time being, not implement changes that would automatically reject claims based on orders, certifications, and referrals, made by providers that have not yet had their applications approved by July 6, 2010. While more than 800,000 physicians and other health professionals have enrolled and have approved applications in the PECOS System, some providers have encountered problems. CMS is continuing to update and streamline the process, and more providers have been enrolled in the past few days.”

Evidenced Based Practice

jeffbrittain — Mon, 19 Apr 2010 23:20:47 +0000

CMS, through OASIS C, is guiding the home health industry toward evidenced-based practices. These practices require the identification of a solid literature review with established clinical integrated expertise that includes the patient’s cultural, socioeconomic, and educational background.

An organized plan with expected outcomes is being mandated in this contemporary health industry. There is a need for information directed toward diagnosis, prognosis and disease prevention. Traditional sources; such as textbooks no longer meet the fast paced knowledge accumulation of today. Time treating patients has become expensive and limited. Current up to date, tested knowledge is vital to maintain diagnostic/practitioner skills and quality outcomes.

There are specific steps recommended to achieve evidenced-based practices:
1. Select a topic or a clinical question is asked:
Problem-focused such as identified through Quality improvement, benchmarking, and recurrent data
Knowledge-focused, based on research from conferences or journals
2. Form a Team
3. Have a well defined process for evidence retrieval . A common paradigm used today is PICO; a) who is the Population, b) what is the intended Intervention, c) is there a Comparison intervention or Control group, d) what is the desired outcome.
4. Classify the literature as either conceptual (theory and clinical articles) or data driven (systemic research reviews). The data is derived from clinical trials, meta analysis, and national rated articles.
5. The information should then be interpreted and critically evaluated as to application, validity, and expected outcome. Apply the evidence.
6. The decision to change practice considers the relevance of the evidence and the consistency in research findings, looking for ways to improve or modify the application. Qualitative research is being used more frequently in this regard.

To further encourage evidence based practice in home health care, CMS is seeking standardized tools to be used in the OASIS C Integrated Assessment. These tools, such as the Braden and Norton used for skin integrity assessment are readily recognizable, not only in home health but, in other levels of care in health care. Thus, if the patient is transferred to another care level, a reliability of skin assessment can be maintained because the tool is a recognizable standardized instrument.

Evidenced-based processes are also being encouraged because the patient population is requiring more from their health care practitioners, having increased knowledge, empowerment, and access to information, and expecting predictable outcomes from care.

Evidenced – based practice is not a new concept. It is documented in Daniel 1:6 in the Bible where “controlled trials” were used in comparing dietary benefits for families. In the 1700s, James Lind used randomized trials to show that scurvy could be prevented by citrus fruit. In the 1800s, Semmelweis studied the transmittal of puerperal fever, an infection occurring in females post partum. Semmelweis was able to document that physicians and medical students would perform aurtopsies, and in the same clothing (dirty aprons and all), frequently, merely wiping their bloody hands on their aprons, then perform gynecologic examinations on the new mothers. By instituting hand washing with chloride of lime prior to examining the females, the infection rate dropped over 80%. Evidence-based practice is soundly grounded in research.

The Agency for Healthcare Research and Quality, the National Guideline Clearinghouse, and the Evidence-based Medicine Resource Center are just a few organizations involved with the practices of EBP. Discipline specific associations impacting medicine, nursing, and the rehabilitation oriented therapies are also actively involved in research.

Evidence-based practice in nursing is seen with a new model called Guided Care Nursing (GON) being researched in Maryland, to examine seven chronic care interventions, including disease management, patient self management, case management, lifestyle modification and geriatric management. The nurses involved in the program have completed a specific educational program that looked to enhance their skills in these areas. Predictive modeling software was used to identify patients for the study. The study has been so positive further clinical trials have been funded..

Researchers at the University of California San Francisco Medical Center have undertaken a prospective study to look at incongruencies in practice standards across specific disease lines.

Evidence Based Practice is now being applied in the health care education and training setting. Data has been evaluated on over 109 medical schools in the country.

Government has a strong belief that evidence based practice will positively impact both on the quality and financial outcomes in health care. It is an exciting time in health care. It is truly the time for strong data driven practice.

Susan Carmichael
MS, RN, CHCQM, COS-C
Fellow of the American Institute for Healthcare Quality

Evidenced Based Outcome Improvement

jeffbrittain — Wed, 24 Mar 2010 22:14:40 +0000

Outcome improvement and safety in Home Care is a focus of CMS. All levels of health care are being encouraged to find evidenced- based ways to improve patient safety, prevent adverse events, and achieve optimal outcomes. OASIS C has been designed to measure improvement in processes. Data collected from the OASIS C assessment, plan of treatment, and evidenced practices will be utilized in publicly reported measures, OBQI/OBQM quality reports regarding care improvement guidance, and development of a Pay for Performance system.

In 1999, the Institute of Medicine (IOM) recommended adverse event reporting, first in the acute care setting and then to other health care delivery systems. An adverse event is defined as “an injury caused by medical management rather than by the underlying disease or condition of the patient” (IOM, November, 1999). Systems failure remains the number one reason for medical error. Types of errors include medication, accidents/falls, and pressure wounds. Causes of error and adverse events include complex patients with complex problems (multiple diagnoses and co-morbidities, multiple medications), complex information management, and the complexities of being human (emotions, support systems, and resistance to change). The IOM encouraged improved data collection and analysis and improved systems.

By 2005, various studies reflected that the IOM goals had not been met (Leape and Berwick, JAMA, 2005). This fact encouraged various organizations, including the Joint Commission to revise and update performance standards including National Patient Safety Goals to more aggressively encourage safety and prevent adverse events. CHAP encouraged improved infection control processes by clinicians in the home. In 2010, CMS, through OASIS C, is driving evidenced-based processes. Home Health Agencies are charged to screen patients for risk in skin condition, depression, pain, falls. SOB, depression, and anxiety are considered very strong risk predictors for outcomes. In the near future, outcomes are expected to be tied to referral potential and payment reality.

Evidenced-based processes are advanced by standardized assessment tools. These measureable assessment tools are enhanced when used in conjunction with well captured patient data. That means completing an OASIS data set thoroughly and accurately. Changes in OASIS coupled with impending RAC audits should be an impetus to agency leadership to effect powerful change and/or review in their organization. Clinical accountability for timely documentation, attending educational sessions, and case conferences are essential to maintaining skill sets and excelling to achieve improved patient outcomes. Streamlining processes becomes vital.

Clinicians require a thorough knowledge of how to answer each of the OASIS M question. As adult learners, they will naturally want a better understanding of the big picture conceptual changes and how the new evidence tools will drive care quality. They may ask for more education as to how to assign risk. This is where algorithms and protocols play a part in quality care. Agencies need to establish “next steps” in care; a falls risk score of 10 may trigger a physical therapy referral or weekend hospital discharges may mean an admission to home care is completed that same day instead of the agency routine policy of “within 24 hours”.

OASIS C has the potential to measurably improve clinical excellence and increase consumer value but, assisting clinicians to embrace the change can still be challenging. One facet to review regarding clinician efficiency and accuracy is having the right tools. Having a tool designed by home care clinicians that flows through a head to toe assessment, that triggers clinician care planning, that allows for additional screening tools to be available is essential. Also, consider providing coding support for the clinician. We all know that for the average home health agency, the home health nurse is an excellent clinical generalist, not having the luxury to specialize in one diagnostic area. (And many nurses state that is one reason they enjoy homehealth). But in the area of coding, providing coding expertise is an essential part of risk management.

OASIS C may be the impetus for transformational change for the industry. It has morphed from a mere data collection tool to a process oriented tool that requires the clinician to create a highly comprehensive client/patient-centered plan of care with a diagnosis code table of contents and evidenced –based care with expected outcomes. In the very near future, those outcomes are expected to be linked to patient/client satisfaction ratings and agency reimbursement. CMS is well on its way to expanding processes that have publicly reported measures solidly supported with evidenced – based practices. Those practices begin with tools to aid the clinician in gathering accurate data…efficiently.

Susan Carmichael
MS, RN, CHCQM, COS-C
Fellow of the American Institute for Healthcare Quality

Medicare Outlier Caps Change for 2010

jeffbrittain — Fri, 12 Mar 2010 00:16:26 +0000

In this months E-zine article, we discussed the changes that were made to outlier payments which became effective Jan 1, 2010. One of the interesting points that was brought up is how outliers were calculated prior to the changes. What was clear when writing the article was that outliers, while valuable to bridge the gap on high utilization on episodes, it never completely covered the cost in providing care. Some agencies have heard that many organizations have been using outlier payments to help increase their overall revenue intentionally. However, many times they are a cost of doing business. This is why there is additional reimbursement available to help accommodate for those situations.

The problem is that you only receive 80% of the difference of the additional cost associated for those services. If you would like examples of these calculations and definitions, please read our latest E-Zine article here. This is why it is important to always diligently assess the patient but at the same time, make sure you are addressing the correct utilization for the patient.

With Medicare now only allowing outlier payments to be made for those that equal 10% of the total PPS payments year to date of that claim, it will be wise to monitor and closely manage this practice. So remember, outliers should be exceptions to the rule and not the rule.

Jeff Brittain
CTO, Executive Vice President
Select Data

Patient Teaching

jeffbrittain — Wed, 17 Feb 2010 23:24:23 +0000

Home Health agencies should begin now to review processes and be certain that care delivered is “reasonable and necessary” and that each and every visit can withstand scrutiny by auditors/RAC or MAC auditors. Of course, so much of care delivered involves patient teaching. Recently, several colleagues (who are involved in QI) and I were discussing the least supported documented visits we see in home health. We unanimously agreed that visits involving patient teaching seem to be the weakest in documentation. We also realize that if we have noticed this weakness, it is only a matter of time before the MACs and RACs see this also (if they haven’t noticed already).

Visits that are essentially patient teaching oriented must involve teaching that requires the skills of a nurse or therapist. The clinician may also teach the patient about an essentially unskilled service however, it must relate to their illness. Issues can arise if the clinician does not adequately document the connection between the patient’s skill deficit and the patient’s learning need. Additionally, how the clinician addressed the need and the patient’s response is essential.

In the 1980s, Malcolm Knowles (called the father of adult education) identified that successful adult learning involves understanding that:

Adults want to participate in identifying their needs for learning.
Adults appreciate a sequence or clear outline of experiences/teachings needed to achieve the desired result.
Adults learn better in a reduced stress environment with a supportive teacher/facilitator/educator.
Adults learn better with appropriate learning techniques and instructional methods.
Adults have improved learning experiences when they have the most appropriate material and resources necessary to produced the planned learning.
Adults have greater learning success when they are motivated toward measureable desired outcomes.

So, just handing a patient a flyer about medications or diet isn’t necessarily teaching and it frequently doesn’t result in learning. So, in future blogs, let’s look at proven techniques for successful teaching, because reimbursement should be retained for the valuable skill of teaching.

Susan Carmichael
MS, RN, CHCQM, COS-C
Fellow of the American Institute for Healthcare Quality

OASIS-C

admin — Thu, 11 Feb 2010 13:47:15 +0000

OASIS-C is making agencies more aware of the needs of the depressed patient. Recently, I was speaking with an agency that wants to expand their psych team. We discussed adding an Occupational Therapist to the predominately RN team.

So much of successful therapy requires healthy displacement of internalized anger. The RN therapist frequently uses words, supportive counseling, or cognitive restructuring action plans. The OT leans toward activities. Adults enjoy activities, especially when they build ego strength or divert or displace hostility in a more acceptable manner. Plus, did you ever notice that it is sometimes easier (and sometimes safer) to talk when active? OTs can assist with stress management, anger/conflict management, basic living skills, relaxation strategies, and grief counseling. They are usually comfortable using the mini-mental status exam and the geriatric mood assessment. Of course, the team must agree on which tools will be used and be certain all members are proficient in their use to reduce inter-rater reliability issues and promote optimal effectiveness. Both RNs and OTs model relationship skills with patients and families to promote patient goal achievement. Both disciplines model interpersonal and communication skills and respond effectively to conflict and complex issues in coordinating services. So, when you are considering your home health psych team, consider OT. They add another dynamic dimension.

Susan Carmichael
MS, RN, CHCQM, COS-C
Fellow of the American Institute for Healthcare Quality