Posts Tagged ‘Home Health’

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Home Health Consumer Assessment of Healthcare Providers and Systems Survey aka HHCAHPS

Thursday, October 27th, 2011

The first letters of non- compliance notification have begun arriving to over 1300 agencies. Many agencies are complaining they had complied. What has occurred? What should an agency leader do after receipt of such a letter? Why is there such focus on this survey?

What is the CAHPS Program?

The Consumer Assessment of Healthcare Providers and Systems is designed to develop and support the use of comprehensive standardized surveys that ask customers and beneficiaries to report on and evaluate the care they received. The program is funded by and administered by the US Agency for Healthcare Research and Quality (AHRQ). For over a decade CAHPS has established principles that include identifying and supporting consumer information, adherence to scientific testing principles, comparability of data, as well as maintaining products in the public domain. (CMS, AHRQ, CAHPS).

CAHPS surveys are standardized per AHRQ in the following manner:

The Instrument is standardized in such a fashion that anyone administering the survey can ask the questions in the same way.

The protocol is standardized in that it adopts the same approach to “drawing the sample, communicating with potential respondents, and collecting the data.”

The analysis is developed in a way to minimize variations in how vendors process and interpret survey results.

The reporting uses a well-tested approach that reflects best practices in reporting.

How is CAHPS Data Utilized?

Health care monitoring agencies, such as State regulatory agencies and Quality Improvement Agencies (QIOs) use CAHPS data coupled with quality measure data to evaluate agency performance. Since 1999, the National Center for Quality Assurance (NCQA) has required CAHPS data from health plans that are seeking accreditation or when they submit data as part of the Health Plan-Employer Data and Information Set (HEDIS). Behavioral health organizations must use CAHPS data along with their ECHO survey when they are seeking accreditation. PPOs must have CAHPS survey findings completed routinely as part of their accreditation process through URAC.

The CAHPS standardized surveys are expanding into new areas of healthcare but CAHPS is not new to the business of surveys. CAHPS Health Plan Surveys are designed to be heterogeneous in population coverage.

Per CMS, CAHPS Emphasis is on Consumers and Patients

CMS believes that “consumers and patients are the best and/or only source regarding care.” They also state that CAHPS surveys do not attempt to collect information that can be gathered more effectively through other means. This overall program has been a successful collaboration of public and private research organizations that includes RAND, Yale School of Public Health, and the American Institute for Research. Together, the private and public groups are known as the CAHPS Consortium. Together, they have been instrumental in developing and testing ways organizations can use CAHPS data for quality improvement.

Can an Agency Improve their Scores Through Better Practice?

Yes, an agency not only can influence later scores, they should be aggressive in doing so. Reward clinicians when a positive comment is known. In the same regard, keep track of negative comments. Help the clinician who is perceived as lacking in customer service attributes. Review facts such as sitting with a patient for 1-2 minutes creates an image of spending time and not being in a hurry. Taking time to ask about a grandchild or a pet conveys sensitivity and caring. Sometimes, a busy very qualified clinician can have behaviors misunderstood.

Be certain that clinicians understand that research supports the fact that patients want at least a day’s notice of a visit. Timely notification scores decline if the clinician does not establish or remind the patient of the visit at least one day in advance.

Find creative ways to help patients remember their education. When I once visited a home to survey care, the patient showed the picture of the blue ribbon she had received for correctly learning how to properly administer her meds. She and her nurse had  a fun time discussing the fact that she had always wanted a blue ribbon. “Now, I have one,” she stated.” And later she challenged me. “Ask me anything about those meds,”

Patients who are visual learners may appreciate a journal to take notes or may appreciate printed information they can underline with colored markers. The important point is learning how they have learned in the past.

Return phone calls promptly (within 10-15 minutes) to obtain high scores on timeliness of response to questions.

The First HHCAHPS Letters of Non-Compliance have been Received

Over 1300 agencies have received letters notifying them that they have not satisfied the requirement for participation in HHCAHPS. As a result, these agencies are slated to have a 2% market-basket reduction in 2012. That 2% will be in addition to the 3.5% payment cut proposed by CMS for that year. In a time of fragile bottom lines, a 5.5% reduction can be onerous.

So, what should the agencies do if they receive the letter of non-compliance and they believe it was sent in error? Consider appeal! Be prompt. The letter of non-compliance has a 30 day life span for appeal. Do not miss it. Verify with your vendor that the required data was submitted timely. Ask for proof of transmission.

Many agencies that received the letters reported to NAHC that submission of data occurred. Obtain proof from your vendor of the dry run and the ongoing data submissions. Data submission guidance can be found at https://homehealthcahps.org/HHAGuidanceforDataSubRept.pdf

Some agencies believe CMS may have a glitch in the reporting system. Take no chances. Obtain proof from your vendor of submission and preserve your rights by filing the timely appeal. Be proactive. The old adage, “not to decide is to decide… is true” Decide and Act.

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Posted in CMS, Compliance, HHCAHPS, Home Health | No Comments »

OBQM/Chart Audits and the New Survey Protocols: Tweaking and Streamlining Process for Real Improvement

Tuesday, October 25th, 2011

From Outcome-Based Quality Improvement (OBQI) refresher training to Total Quality Management Agency Programs, the home health agency of today needs to define the level of programs needed to operationally and financially drive  success. The home health agency needs OASIS stop, logic, and congruence edits to prompt clinicians and flag incongruence between M questions. But, that is just the start. The OASIS integrated assessment sets the stage for the plan of care created. From the plan comes the visits and they must support that plan and drive to expected outcomes.

Perhaps your firm would benefit from a third party quality clinical chart audit. Your Professional Advisory Committee, Board of Directors, and you may well see the merit of an independent view of clinical processes and care. Noting strengths and determining opportunities for improvement before a survey makes sense. Are you spending too much time and money internally for chart reviews? What does happen after those reviews? Do you educate personnel? How do you know if that education was successful?

Clinical chart audits can assist you to remedy issues, provide education and training, and improve efficiencies. Clinical audits can assist to streamline processes, determine areas of risk, and assist to improve the bottom line.  Clinical audits can assist to identify quality customer service and improve patient care.

“Identifying ways that an outcome-based corporate culture fully extends to both internal and external customers is the responsibility of leadership. Developing and using simple tools can aid in the process. Once systems are implemented, maintaining a true commitment to TQM becomes a powerful challenge. But, to the persevering leader, the rewards of quality customer service can go hand in hand with a positive bottom line” (Carmichael, 2005)*

The new survey protocols mandate an outcome–oriented survey process, therefore, know that the surveyor will continue evaluating, per CMS, “the quality of care and services furnished by the agency as measured by indicators of medical, nursing, and rehabilitative care.” In addition, the new process will emphasize the clinical record of assessment and care, agency personnel interviews, and home visits. The new regulations provide clear guidance for expanding the survey, if needed.

Besides Process and Chart reviews, agencies should routinely use the Surveyor Worksheets to review agency data filed with the state, look at diagnoses and expected outcomes, monitor potentially avoidable event outcomes, and be certain there is adequate documentation for case mix indicators.

An evaluation of Level 1 indicators (see Select Data University April, 2011 article on New Survey Protocols, Survey Protocol Worksheets) includes standards under skilled nursing and therapies. If the agency is in compliance with Level 1 standards and no additional issues or concerns are identified, the survey is completed. If the expected outcomes are not met for one or more Level 1 standards, then the survey expands to become a partially extended survey.

At the very minimum, compliance with Level 2 standards is evaluated if deficiencies were identified with Level 1 standards. This is the partially extended survey. Be aware that surveyors may review additional non Level 1 or 2 standards under the same conditions during the partially extended survey at their discretion. (State Operations Manual, SOM, Appendix B). In an extended survey, all conditions will be reviewed. Appendix B and Survey Protocols provide specific recommendations for: citing condition-level deficiencies, extending the survey, and related conditions for further survey.

Now, more than ever, a thorough assessment must drive discipline specific care plans that drive the overall POC with every visit skilled and enhancing the process toward expected outcomes. Clinical record reviews, clinical interviews, and home visits drive the survey process. Documentation is essential. Good documentation starts with a thorough assessment. That assessment should be specific. Does your assessment tool set the stage for success? Is it detailed enough to gather data to allow the highest level of coding specificity? Does it cue the clinician with requests for detail to support a case mix diagnosis that may be assigned?

It is simple in the guidelines; a good POC starts with a solid clinically integrated OASIS assessment. That assessment drives the discipline specific care plan and those plans contribute to the overall POC. That POC has diagnoses present that require substantiation in the clinical record and the expertise of master coders. That very record supports the diagnoses sequences chosen. The visits can stand alone as to skill but reflect that they are a part of an individualized skilled plan of care.

Documentation takes time and thought. Clinicians are busy and require assistance and support. Consider a third party coding entity. Also consider an OASIS data collection service that was created by clinicians.  The system should be reflective of what you expect and of what your clinicians need.

The new survey protocols are data driven. Agency leaders need real data daily, weekly, monthly to monitor clinical performance and patient care outcomes.

The Surveyors have the data when they arrive. Do you?

*Carmichael, S (2005). Total quality management and outcomes based quality improvement: revisiting the basics. In Home Health Care Management and Practice (17)(2),119-124

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Posted in Best Practice Intervention Practice, CMS Guidelines, Compliance, Home Health, ICD9-CM Coding, Legislation, OASIS-C, OBQI, Patient Survey, Surveys | No Comments »

Medicare Home Health Agencies and Medical Social Services (MSS)

Wednesday, September 28th, 2011

Let’s talk about the role of the medical social worker in the home health setting. In these tougher economic times, are agencies seeing a growing need for MSS? Have social and emotional factors risen? What MSS skills are necessary to best serve the patient? How can the MSS best assist your agency?

The patient Plan of Care must identify the skilled services needed that will be provided by MSS. Under the Medicare Home Health Benefit 42 CFR 409.45(c), Medicare Benefit Policy Manual Chapter 7, Section 50.3, and Medicare Conditions of Participation 42 CFR 484.34 Publication 100-07, Appendix B, Medical Social Services is described as a dependent service that is only covered in a certified home health agency when the patient is already ordered and receiving skilled nursing, physical therapy, occupational services, or speech/language therapy. Think of Medical Social Worker as providing services that will provide intervention or resolution of emotional or social issues that might impact unfavorably on the patient’s recovery. Agencies are citing increasing patient challenges in a struggling economy especially with the housing challenges that are so prevalent. If you believe those issues could impede progress in care outcomes, then MSS should be considered.

The frequency and duration of the services are necessary to be quantified just as with other skilled services and the delineated services must be provided by a Masters or Bachelors prepared social worker. The MSW is also required to have one year of social work experience in a health care setting prior to working in home health care. The Social Work Assistant must have a bachelor degree in social work, psychology, or sociology. The bachelor prepared assistant works under supervision of the MSW in accordance with the patient Plan of Care.

The Assessment and MSS

The MSS assessment of the patient is completed by the Masters prepared social worker (MSW). Medical Social Services works with the patient and family to use community resources, provides short-term intervention skills, assists to design a plan of care to deal with chronic conditions such as Alzheimer’s disease. Additionally, as with other skilled services, medical social services are supported by OASIS answers:

  • M1018 identifies medical condition change

Are the patient and caregiver coping with the change of condition?

  • M1022-24 sequences diagnoses
  • M1032 states risk for hospitalization

Is there emotional, social, or financial risks that necessitate MSS intervention?

  • M1034  cites overall status
  • Look at reduced functional status
  • Identify any medication issues
  • M1100 looks at patient living situation

Is the living situation impeding patient progress?

  • Look at the safety evaluation

Is the patient at risk for abuse? Is there risk for emotional issue exacerbation?

  • M2100 sources and types of assistance

Medical Social Services and the Challenges in Home Health

Involving MSS can assist to reduce the hospital readmission and assist the patient with a positive adjustment to the home health experience. Medical Social Services can provide family and caregiver support services. The MSS can facilitate access to needed medications, supplies, and DME, as well as aiding in removing barriers to transportation access.

The MSS can assist with case coordination with all disciplines addressing social and environmental factors while skilled nursing addresses the medical and nursing factors. The MSS can document patient and family challenges so the physician has a better “view” of how the patient interacts with their home environment.

The social worker can assist the family with referral services and act as a liaison for that care. The MSS can provide patient counseling. Brief Counseling or Cognitive Restructuring Therapy may be needed for the depressed patient. The MSS can liaison at both the macro and micro patient care level; addressing patient specific needs.  Medical Social Services can add value and positive customer satisfaction. Think patient satisfaction calls. A strong social work program can aid in reducing the number of clinical visits needed, improve customer relations, support team members, and increase referrals to your agency. This is usually an under-utilized valuable service benefiting patients, employees, and the agency.

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Posted in CMS, CMS Guidelines, Compliance, Home Health, Medicare, OASIS-C | No Comments »

The Affordable Care Act and Bundling Payments

Tuesday, September 27th, 2011

The Patient Protection and Affordable Care Act has caused much change in health care and another change is being encouraged: a Bundling Payments initiative. The Department of Health and Human Services recently announced a new initiative designed to help patients receive improved acute and post care. Physicians, acute care facilities, and other health care providers can now apply to participate in the Bundled Payments for Care Improvement Initiative. CMS is seeking assistance to test and develop four different models of payment bundling. Through this initiative, providers could select conditions to bundle and determine how payments would be distributed among providers.

The belief is that “bundled payments can help align incentives for providers to partner and work closely together across specialties and settings…” (CMS, 8/23/2011).

The CMS Innovation Center http://www.innovations.cms.gov has made available the Request for Application (RFA) for three retrospective models. The application is due November 4, 2011. To apply: http://www.innovations.cms.gov/areas-of-focus/patient-care-models/bundled-payments-for-care-improvement.html

Specific questions can be directed to BundledPayments@cms.hhs.gov

Per CMS, research and prior demonstration projects have shown that using a bundled payment initiative for patients with coronary artery bypass graph surgery saved CMS $42.5 million, roughly 10% of expected costs. The research was conducted at hospitals in Atlanta, Columbus, Ann Arbor, and Boston.

Bundled payments are just one part of a wide-ranging effort to improve healthcare yet reduce the cost of that care. The Accountable Care Organizations are another strategy being encouraged.

These strategies are not new. Many organizations have recognized the fragmentation that occurs in healthcare delivery. Recently, the National Quality Strategy launched a Partnership for Patients uniting physicians, nurses, other healthcare professionals as well as unions, the State and the Federal Government to offer ways to prevent hospital readmissions and improve transition between levels of care. CMS announced an investment intended over $1 billion to help drive these changes. CMS also announced their intent to invest over $50 billion over 10 years in like projects.

It appears that innovative projects to decrease fragmentation in care could be rewarded. If you have ideas, why not apply for the RFA?

To read the Affordable Care Act, go to www.HealthCare.gov/news/factsheets/deliverysystem07272011a.html

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Posted in Affordable Care Act (ACA), CMS, Compliance, Home Health, Medicare, Resources | No Comments »

Education Videos: Coding Compliance Diabetic Complications – CVA Part I of II

Saturday, September 24th, 2011

Coding Compliance Diabetic Complications – CVA Part I of II

Coding Compliance Diabetic Complication – Late Effects of a CVA Part I

Many times we see a diagnosis of diabetes and throughout the assessment we will see PVD, Neuropathy, Chronic Kidney Disease, Ulcers, and other diagnoses.  We cannot code any of these complications unless they are documented as such.  If you are using the SmartScribe documentation there is a special section marked endocrine status which will list all of the complication.  So, please use this as it will make it very clear to us that these need to be coded as diabetic complications.  If you are using your own agencies documentation please include in the narrative that these diagnoses are diabetic complications.

Also, if there an ophthalmic complication of diabetes, please note what type of complication it is so that your coding is not help up while we determine what it is.

Finally, please make sure that the codes used in M1020 and M1022 match the information shown in the endocrine status.  Many times we see diabetes as a diagnoses, while in the endocrine status it will show diabetes type I or even uncontrolled diabetes.  So, please make sure to document the correct type as well as all diabetic complications which must be verified by a physician.

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Posted in CMS, CVA, Compliance, Educational Videos, ICD9-CM Coding, Medicare, Teaching/Education | 1 Comment »

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