Achieving Optimal Clinical
Management and Financial
Balance
Pat Laff, CPA, Managing Principal
Lynda Laff, RN, BSN, COS-C, Principal
OASIS-C…Fast Track to P$P
• Federal Register/Vol. 74, No. 44, Monday, March 9, 2009
– CMS ultimately plans to create a standard patient assessment that
can be used across all post-acute care settings.
• New Process Measures • OASIS – C was not intended to impact payment policy and OASIS items
used in the payment algorithm were assessed to make sure they were not
changed in a way that would affect the payment algorithm. Once OASIS
data are collected it will be possible to assess whether they could be
useful for refinements to the case mix adjustor.
• All information in OASIS –C will be considered for use in the updated riskadjusted models that will be applied to OASIS – C based outcome
measures in Home Health Compare, OBQI and OBQM measures.
OASIS –C: Public comments & Responses
Clinical Episode Management Goal
• “Provide the right amount of care
efficiently and effectively to achieve
anticipated or desired patient & financial
outcomes”
Human Resources…
• Make sure you have the right people in the right
positions
• All registered nurses are NOT case management
material
– A warm body doesn’t cut it!
• All PTs are NOT team players….
• An experienced nurse is not always a qualified coder
or quality review nurse…
• An excellent field clinician is not always an excellent
manager
• A scheduler is NOT a manager of patient care
Components of
Clinical Episode Management
• Clinical Management Information
– Key Indicators
– Routine Reports
• Education
– Clinical assessment
– OASIS Accuracy
• Supervision & Oversight - Vigilance
– Documentation Timeliness
– Care Plan Development
• Continuity
– Case management
– Clinical model
• Accountability/ Responsibility
– Reward / incentive
– Corrective Action
Key Management Indicators
•
•
•
•
•
•
•
•
•
•
Case Weight
Timeliness of RAP Submission
OASIS Errors by Clinician
OASIS Corrections Completed
Cases Managed per Clinician
% of Therapy Visits per Threshold
Average visits per episode
Outcomes Improvement
Patient Declines
Productivity by discipline - Actual
Education
• OASIS education must be thorough, credible and
ongoing
• The cost to educate properly will be a fraction of the
dollars you will lose… if you don’t!
• OASIS accuracy or inaccuracy goes right to the
bottom line.
• Put your money where it will have the most effect..
• SOC assessment determines revenue and outcomes
• Value Based Purchasing – SOC = risk adjustment
• Declines will be even more expensive in P4P
Oasis ACCURACY IS THE KEY
• OASIS accuracy is a key driver of clinical and
financial performance
• OASIS – C is the New Key Driver for payment
under Value Based Purchasing
• Clinician assessment accuracy is critical to patient
outcome improvement AND agency financial success
– Clinician assessment determines case weight and revenue
– Clinician assessment determines non-routine supply revenue
– Clinician assessment and completion of OASIS - C process
items will affect aggregated score for VBP
CMS - Value Based Purchasing
• Currently hospital payment is contingent upon;
– Aggregation of performance with process measures,
patient care measures and patient satisfaction measures
(HCAHPS)
• Home Health Care P4P
– OASIS-C provides Home Health Care P4P information
• Outcome Measures
• Process Measures
• Implementation of – HH-CAHPS
Process Outcome Measures
Home Health Compare
Timely Initiation Of Care
(Timely Care)
% of home health episodes of care
during which the start or resumption
of care date was either on the
physician-specified date or within 2
days of the referral date.
(M0102) Date of Physician-ordered
Start of Care
(M0104) Date of Referral
(M0030) Start of Care Date
(M0032) Resumption of Care Date
(M0100) Reason for Assessment
Depression Assessment Conducted
(Assessment)
% of home health episodes of care
during which patients were screened
for depression (using a standardized
depression screening tool) at start of
home health car
(M1730) Depression Screening
Multifactor Fall Risk Assessment
Conducted For Patients 65 And Over
(Assessment)
Percentage of home health episodes
of care in which patients 65 and older
had a multi-factor fall risk assessment
at the start of care/resumption of
care.
(M1910) Multi-factor Fall Risk
Assessment
(M0066) Birth Date
(M0090) Date Assessment Completed
Pain Assessment Conducted
(Assessment)
Percentage of home health episodes
of care during which the patient was
assessed for pain, using a standardized
pain assessment tool, at
start/resumption of home health care
(M1240) Pain Assessment using a
standardized pain assessment tool
Process Outcome Measures
Home Health Compare
Pressure Ulcer Risk Assessment
Conducted
(Assessment)
% of home health episodes of care
in which the patient was assessed
for risk of developing pressure
ulcers at start of care/resumption
of care.
(M1300) Pressure Ulcer Risk
Assessment
Pressure Ulcer Prevention In Plan
Of Care
(Care Planning)
% of home health episodes of care
in which interventions to prevent
pressure ulcers were included in
the physician-ordered plan of care
for patients assessed to be at risk
for pressure ulcers.
(M2250) f. Intervention(s) to
prevent pressure ulcers plan of
care
Diabetic Foot Care And
Patient/Caregiver Education
Implemented During Short Term
Episodes Of Care
(Implementation)
% of short term home health
episodes of care during which
diabetic foot care and education
specified during the physicianordered care plan was
implemented for patients with
diabetes.
(M0100) Reason for Assessment
(M2400) a. Diabetic foot care
intervention(s)
Process Outcome Measures
Home Health Compare
Heart Failure Symptoms Addressed
During Short Term Episodes Of Care
(Implementation)
Percentage of short term home
health episodes of care during which
patients exhibited symptoms of heart
failure for whom appropriate actions
were taken
(M0100) Reason for Assessment
(M1510) Heart Failure Follow-up:
Pain Interventions Implemented
During Short Term Episodes Of Care
(Implementation)
Percentage of short term home
health episodes of care during which
the patient had pain and pain
interventions were included during
the care plan and implemented by
the end of the episode.
(M0100) Reason for Assessment
(M2400) d. Intervention(s) to
monitor and mitigate pain
Drug Education On High Risk
Medications Provided To
Patient/Caregiver At Start Of Episode
(Education)
Percentage of patients/caregivers
educated about high-risk
medications at start/resumption of
care and instructed on how to
monitor the effectiveness of drug
therapy, how to recognize potential
adverse effects, and how and when
to report problems.
(M2010) Patient/Caregiver High Risk
Drug Education
Process Outcome Measures
Home Health Compare
Drug Education On All Medications
Provided To Patient/Caregiver During
Short Term Episodes Of Care
(Education)
Percentage of short term home health
episodes of care during which
patient/caregiver was instructed on
how to monitor the effectiveness of
drug therapy, how to recognize
potential adverse effects, and how and
when to report problems
(M0100) Reason for Assessment
(M2015) Patient/Caregiver Drug
Education Intervention
Influenza Immunization Received For
Current Flu Season
(Prevention)
Percentage of home health episodes of
care during which patients received
influenza immunization for the current
flu season
(M1040) Influenza Vaccine(M1045)
Reason Influenza Vaccine not received
Pneumococcal Polysaccharide Vaccine
Ever Received
(Prevention)
Percentage of home health episodes of
care during which patients were
determined to have ever received
Pneumococcal Vaccine (PPV).
(M1050) Pneumococcal Vaccine
(M1055) Reason PPV not received
Process Outcome Measures
Home Health Compare
Potential Medication Issues
Identified And Timely Physician
Contact At Start Of Episode
(Prevention)
Percentage of patients whose drug
regimen at start or resumption of
home health care was assessed to
pose a risk of clinically significant
adverse effects or drug reactions
and whose physician was
contacted within one calendar day.
(M2002) Medication Follow-up
Potential Medication Issues
Identified And Timely Physician
Contact During Short Term
Episodes Of Care
(Prevention)
Percentage of home health
episodes of care in which the
patient's drug regimen during the
episode was assessed to pose a
risk of significant adverse effects or
drug reactions and whose
physician was contacted within
one calendar day.
(M0100) Reason for Assessment
(M2004) Medication Intervention
Pressure Ulcer Prevention
Implemented During Short Term
Episodes Of Care
(Prevention)
Percentage of home health
episodes of care in which
interventions to prevent pressure
ulcers were included in the
physician-ordered plan of care and
implemented since the previous
OASIS assessment.
(M0100) Reason for Assessment
(M2400) e. Intervention(s) to
prevent pressure ulcers
Cardiac Status
(M1500) Symptoms in Heart Failure Patients: If
patient has been diagnosed with heart failure, did the
patient exhibit symptoms indicated by clinical heart
failure guidelines (including dyspnea, orthopnea,
edema, or weight gain) at any point since the previous
OASIS assessment?
⃞ 0 - No [ Go to M2004 at TRN; Go to M1600 at DC ]
⃞ 1 - Yes
⃞ 2 - Not assessed [Go to M2004 at TRN; Go to M1600 at
DC ]
⃞ NA - Patient does not have diagnosis of
heart failure [Go to M2004 at TRN;
Go to M1600 at DC
Time Points: Transfer/D/C
Laff Associates 2009
15
Heart Failure Follow Up
(M1510) Heart Failure Follow-up: If patient has been
diagnosed with heart failure and has exhibited symptoms
indicative of heart failure since the previous OASIS
assessment, what action(s) has (have) been taken to
respond? (Mark all that apply.)
⃞ 0 - No action taken
⃞ 1 - Patient’s physician (or other primary care practitioner)
contacted the same day
⃞ 2 - Patient advised to get emergency treatment (e.g., call 911 or go
to emergency room)
⃞ 3 - Implemented physician-ordered patient-specific established
parameters for treatment
⃞ 4 - Patient education or other clinical interventions
⃞ 5 - Obtained change in care plan orders (e.g., increased monitoring
by agency, change in visit frequency, telehealth, etc.)
Time Points: Transfer/D/C
Laff Associates 2009
16
(M2250) Plan of Care Synopsis: Does the physician-ordered
plan of care include the following: Time Points: SOC/ROC
Plan / Intervention
No
Yes
N.A
Not Applicable
a. Patient-specific parameters for notifying physician of
changes in vital signs or other clinical findings
 0
 1
 2
Physician has chosen not to establish patient-specific
parameters for this patient. Agency will use
standardized clinical guidelines accessible for all care
providers to reference
b. Diabetic foot care including monitoring for the presence of
skin lesions on the lower extremities and patient/caregiver
education on proper foot care
 0
 1
 2
Patient is not a diabetic or is a bi-lateral amputee
 0
 1
 2
Patient is not assessed to be at risk for falls
 0
 1
 2
Patient has no diagnosis or symptoms of depression
e. Intervention(s) to monitor and mitigate pain
 0
 1
 2
No pain identified
f. Intervention(s) to prevent pressure ulcers
 0
 1
 2
Patient is not assessed to be at risk for pressure
ulcers
 0
 1
 2
Patient has no pressure ulcers with need for moist
wound healing.
c. Falls prevention interventions
d. Depression intervention(s) such as medication, referral for
other treatment, or a monitoring plan for current treatment
g. Pressure ulcer treatment based on principles of moist
wound healing OR order for treatment based on moist
wound healing has been requested from physician
Laff Associates 2009
17
(M2400) Intervention Synopsis: Since the previous OASIS assessment,
were the following interventions BOTH included in the physician-ordered
plan of care AND implemented? Time Points: Discharge/Transfer
(M2400) Intervention Synopsis: (Check only one box in each row.) Since the previous OASIS assessment,
were the following interventions BOTH included in the physician ordered plan of care AND implemented?
Plan / Intervention
a. Diabetic foot care including monitoring for the
presence of skin lesions on the lower extremities and
patient/caregiver education on proper foot care
b. Falls prevention interventions
c. Depression intervention(s) such as medication,
referral for other treatment, or a monitoring plan for
current treatment
d. Intervention(s) to monitor and mitigate pain
e. Intervention(s) to prevent pressure ulcers
f. Pressure ulcer treatment based on principles of
moist wound healing
No
 0
 0
 0
 0
 0
 0
Yes
 1
N/A
 2
Not Applicable
Patient is not a diabetic or is a bi-lateral amputee
 2
Formal multi-factor Fall Risk Assessment indicates the
patient was not at risk for falls since the last OASIS
assessment
 1
 2
Formal assessment indicates patient did not meet criteria for
depression AND patient did not have diagnosis of depression
since the last OASIS assessment
 1
 2
Formal assessment did not indicate pain since the last OASIS
assessment
 1
 1
 1
 2
 2
Formal assessment indicates the patient was not at risk of
pressure ulcers since the last OASIS assessment
Dressings that support the principles of moist wound healing
not indicated for this patient’s pressure ulcers OR patient
has no pressure ulcers with need for moist wound healing
Laff Associates 2009
18
Supervise and Manage
• Education without validation and reinforcement is
Money down the drain!
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•
•
•
•
•
•
How do you know?
What checks are in place?
How long does it take?
Who is validating what?
Were the suggested corrections actually made?
What “tools” do you use?
Are there repeated errors? If so – WHY?
– Repeated errors cost money
Supervise & Manage
• Average case weight – by month and by clinician on EOE
• Clinician productivity – actual visits not equivalents!!!
– Expected versus actual
– Number of patients managed by case manager over time
– Total number of admissions (weekly, monthly)
•
•
•
•
•
•
•
•
Documentation timeliness
Documentation accuracy
Average visits per patient within national benchmark or better
Outcomes better than state & national benchmark
Number or percent of OASIS errors
Number of OASIS corrections actually made (are you accepting excuses?)
LOS higher than national benchmark
Number of patient improvements & declines
Continuity
• Continuity = patient management
• Admission Nurse Model
• Hand-offs = errors
• The more staff involved – the less the accountability
• Clinical model must insure actual case
management
• Primary nursing
• Adequate ratio of nurses/therapists to patients
• Productivity expectations must be reasonable
Accountability
• Primary clinician
• May be RN or PT
– Must be accountable for patient and financial
outcomes
– Accurate assessment
– Appropriate care plan
– Constant knowledge of;
• Goals of care
• Projected visits vs. actual
• Team performance – Therapists must be included in the
team
• Patient response to care
• Need for change in plan
Case Conference
• Review of patients on census – not a 2 hour meeting!
• Expect clinician to be prepared
• Manager must question;
–
–
–
–
–
–
–
Clinician “does not know patient”
“Cookie cutter” scheduling
Visits never increase or decrease – always a 60 day episode
Patient declines occur frequently
Abundance of “missed visits”
LOS longer than national benchmark
Extraordinarily low case weight
Clinical Efficiency And Effectiveness
• Learn to be efficient AND effective
– Higher base rate of $2,312.94
• Provide care the patient really needs!
• Focus on newest technologies
• Improve clinical knowledge, skills and practice
Operational Efficiency
Think “Process”
• Accurate Care Planning
– Right number of home visits – no more – no less
• Efficient workflow processes
– Focus on doing it right the first time – not constant correction for poor
performance
– Don’t duplicate work processes
– Right staff performing clerical tasks – time is money
• Use of Tele-monitoring
– To identify incremental changes in the patient’s condition
• Intervene in a timely manner
• Prevent unnecessary hospitalizations
– To provide the right amount of CARE most efficiently and effectively
Start The Episode On Top
• OASIS errors set the scene for negative revenue
and patient outcomes
• Revenue and patient outcomes can not improve
if the initial episode is submitted incorrectly
• Manage the patient care episode by teaching
case managers how to manage
• Hold them accountable…
Here Is How An Incorrect OASIS Might Impact
Episode Revenue and Outcomes…
Elizabeth Allen
Elizabeth Allen is an 85 year old woman who was admitted to
home care following hospitalization for an ORIF due to a hip
fracture as a result of a fall at home. She has insulin
dependent Diabetes Mellitus, she had an acute exacerbation
of COPD while in the hospital and the MD stated she also had
Mild Senile Dementia. She was referred to home care for
surgical wound care for an infected surgical wound, physical
therapy, supervision and management of her COPD and
stabilization and monitoring of her Diabetes and monitoring
of her response to a change in her insulin dose. Mrs. Allen
lives alone but has a daughter who lives 2 miles away and
checks on her each day. She has been independent in her
home with daily checking and meal assistance from her
daughter and granddaughter until she fell and fractured her
hip. She will be seen by nursing for daily dressing changes to
her surgical wound, 3xwx4 by therapy for transfer training,
gait training, strengthening and ambulation.
Clinician Diagnosis Coding
Diagnosis
Points
M1020 a V58.31 Aftercare for change of surgical
dressings
0
M1022 b 781.2
Gait Abnormality
0
M1022 c 250.00 Diabetes Mellitus
2
M1022 d 496.00 COPD
0
M1022 e 290.00 Dementia
0
M1022 f
0
OASIS
Case Mix Variables
M1030 IV Therapy
OASIS Score
Points
4
0
(None of the Above)
M1200 Vision
0
0
M1242 Pain (Daily but not constantly)
3
1
M1308 Pressure Ulcers
0
0
M1320 Most Problematic Pressure Ulcer
0
0
M1330 Stasis Ulcer
0
0
M1342 (Most Problematic) Surgical Wound
3
4
OASIS
1
0
M1620 Bowel Incontinence
0
0
M1630 Ostomy
0
0
M1700 Cognitive Functioning*
2
N/A
1
N/A
0
N/A
0
0
M1400 Dyspnea
When walking 20 feet or climbing stairs
Requires assistance and some direction in specific situations
M1740 Behaviors*
Significant memory loss so that supervision is required
M2020 Oral Medications*
Able to independently take correct medications at correct times
M2030 Injectable Drug Use*
Able to independently take the correct medications at correct times
Total Clinical Points
7
Functional Scores
M1810 / 1820 Upper OR Lower Body Dressing
1
2
2
M1830 Bathing
2
3
M1840 Toilet Transferring
2
2
M1850 Transferring
2
0
M1860 Ambulation
2
1
Total Functional Points
8
Revenue
Table 6 NRS Points = 14
C2 F3 S5
(Non healing surgical wound)
(Table 6) NRS Severity Level = 2
Case Weight 1.7737
HHRG + NRS Revenue =
$51.96 + $4,102.46
(Table 6) NRS Revenue = $51.96
Revenue = $4,102.46
Total Revenue = $4,154.42
OASIS EDITS - P4P
The Quality Review staff identified the following issues;




M1342 was a score 3 (Non Healing Surgical Wound) and there was
no diagnosis listed in M1020 or M1022 to support the (complicated)
non-healing surgical wound
ICD-9 496.00 is a general DX with no associated points for revenue.
Her hospitalization information indicted an acute exacerbation of
chronic bronchitis (COPD).
ICD-9 290.00 DX is a non-specific general code with no associated
case mix points and her MD stated she had stated that she had
senile dementia.
An inconsistency was identified with a score of 2 at M1700 and a
score of 1 at M1740 indicating the need for assistance and some
direction in specific situations and the inability to recall events of
past 24 hours requiring supervision for some activities while her
OASIS scores indicated she was able to take oral and injectable
medications independently.
OASIS EDITS - P4P




The Quality Review staff discussed the patient with the clinician and the intake
nurse; together they determined that wound care for the infected wound was
the primary reason the patient was referred; physical therapy was the
additional reason for the referral.
M1020 should be a non-healing surgical wound DX. They also discussed the
diagnoses of COPD and Dementia with the intake staff and reviewed the referral
documentation that indicated an acute exacerbation of CHF. They also noted
that the MD has specifically indicated the patient had senile dementia, a DX
with associated case mix points. They discussed the DX with the clinician and
suggested a change in the DX codes.
They reviewed the scoring inconsistencies with the clinician and the clinician
corrected the OASIS to reflect a score of 1 at M02020 (management of oral
meds) and M2030 (management of injectable meds).
Without these corrections, outcomes in medication management would
potentially have declined; with the correction, outcomes will remain stable (no
decline) and P4P will not be in jeopardy.
→ With OASIS accuracy - look what happened to the episode
revenue….
Coding Corrections
Diagnosis
Points (Table 2a)
M1020 a
998.59 Post Operative Infection
10
M1022 b
781.2 Gait Abnormality
0
M1022 c
250.00 Diabetes Mellitus
2
M01022 d
491.20 COPD (Chronic Bronchitis) 1+1 Amb. Score 2
M01022 e
331.2
2
1
Dementia
(Psych 2)
M021022 f
*(Aftercare codes are not used with wound complications)
Coding Corrections
4
M1930 IV Therapy
0
(None of the Above)
M1200 Vision
0
0
M1242 Pain
2
1
M1308 2 or ↑ Pressure Ulcers Stage 3 or 4
0
0
M1320 Problematic Pressure Ulcers
0
0
M1330 Stasis Ulcer
0
0
M1342 Surgical Wound
3
4
Coding Corrections
M1400 Dyspnea
When walking 20 feet or climbing stairs
1
0
M1620 Bowel Incontinence
0
0
M1630 Ostomy
0
0
M1700 Cognitive Functioning*
Requires assistance and some direction in specific situations
2
N/A
M1740 Behaviors*
Significant memory loss so that supervision is required
1
N/A
M2020 Oral Medications*
Able to independently take correct medications at correct
times
0
N/A
M2030 Injectable Drug Use*
Able to independently take the correct medications at
correct times
0
1
Total Clinical Points
21
No Change
M1810 / 1820 Upper OR Lower Body Dressing
1
2
2
M1830 Bathing
2
3
M1840 Toilet Transferring
2
2
M1850 Transferring
2
0
M1860 Ambulation
2
1
Total Functional Points
8
Coding Corrections = $547.38
(Table 6) NRS Points = 37
HHRG Score = C3F3S5
(Table 6) NRS Severity Level = 4
NRS Revenue = $211.69
Case Weight = 1.9413
(HHRG Revenue + NRS $ = Episode Revenue)
$4, 490.11 + $211.69 =
Revenue = $4,490.11
Total Revenue =
+ $547.38
$4,701.80
OASIS Edits/Corrections = Revenue
• Let’s Recap the Change After Editing:
– Change in the HHRG due to ↑in clinical points
• C2 F3 S5 to a C3 F3 S5
• $4,102.46 to = $4,490.11= + $387.65
– Change in NRS Revenue
• Severity Level 2 to Severity Level 4
• $51.96 to $211.69 = + $159.73
• Total additional revenue $547.38
Clinical Episode Management Goal
• “Provide the right amount of care
efficiently and effectively to achieve
anticipated or desired patient &
financial outcomes”
Clinicians and Finance…
A Language Apart
•
•
•
•
Patient Outcomes vs. Bottom Line
Home Health Compare Scores vs. Unit Costs
Case Weights vs. Realized Revenue
Diagnosis (Disease) Management vs. Episode Costs
Clinicians and Finance…
A Language Apart
Clinicians learned financial language quicker than
Finance has been learning clinical language and
operations because Clinicians already understand that:
• Accurate assessments generate the most appropriate
Case Weights that translate into revenue
• Good outcomes with fewer visits reduces costs
• Productivity, increased case capacity and efficiency
result in lower unit costs
• Better Home Health Compare scores will mean
increased revenue under Value Based Purchasing
Clinicians and Finance…
A Language Apart
As a CFO you need to understand the Bottom Line Impact
of…
– Disease Management…the most appropriate disease specific
levels of care
– Patient Case Management…the most appropriate frequencies
and duration of visits by discipline
– Primary Nursing Model…OASIS C implications and the
consistency and continuity of care
– Positive Outcomes and Home Health Compare Scores..VBP
– Staff Satisfaction…Positive Outcomes and recognition are a
“feel good”!
Knowledge is Everything!
Clinicians and Finance…
A Language Apart
How much time has your finance staff spent
– In the field with Clinicians making visits?
• Have the CFO make an admission visit with a clinician!
– At patient staff meetings to learn and truly understand
the ongoing care planning process?
– Really trying to understand OASIS C? IT IS ADVANCED
ROCKET SCIENCE!
– Understanding documentation requirements and the
time required?
– Point of Care technology?
– Travel patterns
Clinicians and Finance…
A Common Language
Clinicians and Finance have to listen to each other and
understand what is being said!
– A sincere willingness to learn
– A willingness patiently teach without being
condescending
– Improvement in the levels of understanding is
critical
Clinicians and Finance…
A Common Language
The Clinicians generate the revenue and determine
the related unit expense components. They should
understand:
• What contributes to Direct Costs of their discipline and
those they case manage, and
• What comprises Indirect Costs, over which they have
little control
Clinicians and Finance…
A Common Language
The Finance staff need to learn and understand:
• Differences in visits (and OASIS C) and how they
effect per visit costs
–
–
–
–
Admission
Follow-up
Recertification
Discharge
• How different diagnoses effect the length of a visit and
the documentation requirements
• How visit frequency factors and diagnostically specific
standards of practice effect productivity, efficiency and
costs per visit and episode of care
Necessary Financial Drilldowns
• Revenue Recognition as Costs are incurred
• Identify Accurate Direct Costs by Discipline, Supply
and Tele-health day
• The Measure of Average Visits by Discipline and
Supply Use by Diagnosis and Cost
Calculating Direct Costs Per Visit
Calculating Direct Costs Per Visit
Calculating the Direct Cost
Per Telemedicine Day
Elizabeth Allen
Revenue and Cost Analysis
Visits
Charge
per Visit*
Skilled Nursing - Admission
1
$ 175.00
Skilled Nursing – Follow-ups
9
Physical Therapy
Discipline
Recognized
Revenue
Cost per
Discipline/NRS
Profit
(Loss)
175.00
$ 121.10
$ 121.10
$ 150.00
1,350.00
$ 121.10
1,098.90
251.10
15
$ 160.00
2,400.00
$ 120.34
1,805.10
594.90
Speech Therapy
-
$ 160.00
-
$ 124.89
-
-
Occupational Therapy
-
$ 160.00
-
$ 124.66
-
-
Medical Social Service
-
$ 160.00
-
$ 117.60
-
-
11
$ 55.00
605.00
$ 51.44
565.84
39.16
Home Health Aides
Adjustment
(Visit Charge Variance)
$
Cost
Per Visit*
-39.89
Non-Routine Supplies
Adjustment
(Supply Charge Variance)
* Actual charges and costs from a large
VNA in the Northeast adjusted to base
rate!
36
53.90
-39.89
$ 4,490.11
$ 3,590.94
899.17
186.23
169.30
16.93
25.46
TOTAL
$
$ 4,701.80
25.46
$ 3,760.24
$ 941.56
Disease Specific
Profitability Analysis
• Disease specific Standards of Practice, subject to designed variation,
quantifies the resources to be used and the cost of those resources
–
–
–
Staffing
Incorporate telemedicine into a telehealth approach
Projected episode gross profit and net profit (loss)
• Profit planning (budget) and forecasting based upon case mix, not a
single average case weight
–
Determine average revenue for specific disease (average of the
specific Case Weight values)
• Comparison of actual practice to designed standards
–
Should the standard be modified or was the variation patient specific?
The Value of Telemedicine
• The acquisition cost (purchase or lease) should be
considered an Operational Direct Cost, not a Capital
Expenditure
• The physiological data, not an IT System scheduler,
identifies when hands-on visit are needed
• Reduces the number of nursing visits per episode,
depending upon specific Disease Management protocol
• Increases RN Case Capacity by approximately 5 patients
• Increases patient observation to 7 days a week
• Telehealth improves outcomes and reduces rehospitalizations
Diagnosis - CHF
• *Average Visits per Patient Episode (all diagnoses) 13.00
• *Average Visits per CHF Episode
12.33
• *Average Visits per “Frequent Flyer” CHF Episode
with Telehealth Disease Management Protocol
(43 Episodes)
15.68
SN
PT
OT
ST
MSW
HHA
9.30
3.90
0.95
0.09
0.14
1.30
The selected “frequent flyer” patients have a rehospitalization rate of 10% -- What a great result!
* Based upon information and data from the VNA of Western Pennsylvania – December 1, 2009 – February 28, 2010
Diagnosis – CHF
The Cost
Standards of Practice
VNA of Western PA
Average Visits
Average Visits
all Episodes
Telehealth Episodes
Visits
SN
5.95
PT
3.90
OT
0.95
ST
0.09
MSW 0.14
HHA 1.30
Cost/Visit Cost
$121.10 $ 720.55
$120.34
469.33
$124.66
118.43
$124.89
11.24
$117.60
16.46
$ 51.44
66.87
$1,392.88
Visits
9.30
3.90
0.95
0.09
0.14
1.30
Cost/Visit
Cost
$121.10 $1,126.23
$120.34
469.33
$124.66
118.43
$124.89
11.24
$117.60
16.46
$ 51.44
66.87
$1,798.66
Are the Outcome results worth the additional $405.68 per episode to
the Agency? To the Hospital? To the patient and their family?
Questions Often Asked
• Recommended Clinical Model:
Primary Nurse – Care Management
• Productivity and Case Capacity
– RNs:
minimum 25 – 27 visits (hands on) / week
25 – 30 Patients (without Telemedicine)
– PTs & OTs: minimum 27 – 30 visits (hands on) / week
Questions Often Asked
• Visit weighting – Based the Requirements and
Complexities of completing OASIS C
Visit
Weight
Time
– Admission (evaluation) visit
– Resumption visit
– Recertification Visit
– Discharge Visit
– Follow-up Visit
– Virtual Telephone Visit (Telehealth)
1.90
1.30
1.20
1.25
1.00
0.25
182 min
125 min
115 min
120 min
96 min
24 min
Weekly Management Report
Mon
Total Referrals
No. of Admissions – (Intake – Managers)
No. of Ended Episodes Transmitted (Finance)
Average Closed Episode Revenue (Finance)
No. of Telephone Calls made to patients seen 1x w or less
(documentation required to support call)
No. of Tele-monitors in Use (on day specified) (Managers)
Total no. of Actual Visits made by all RNs (Managers)
No. of Transfer OASIS completed (by clinicians)
No. of Patient Transfers (unplanned hospitalizations- reasons for transfers – attach
short audit form – send to PI)
No. of OASIS transmitted (Business Office – Finance)
Total % of OASIS Errors corrected (data scrubber system)
Total no. of OASIS Errors Not Corrected –outstanding (data scrubber system)
Caseload/Census by Case Manager (separate list)
No. of Actual Visits made by RNs (List by Team and Name below)
Tue
Wed
Thu
Fri
Sat
Sun
Total
Performance Incentives
for all Agency Staff
Design a Comprehensive Agency-wide Incentive
That Will Unify the Agency Culture
These Incentives are Best Achieved using a Primary Nurse Care Model
• Improved Clinical Outcomes
– Homecare Compare Scores
– Outside Benchmarking
– Reduced Non-planned Re-hospitalizations and Emergency
Department Incidents
• High Risk Patients
– OASIS Timeliness and Accuracy
– Development of Disease Management Standards of Practice Adopting
“State of the Art” Clinical Technology
• Patient Satisfaction
• Admission Within 24 Hours of Referral
Performance Incentives
for all Agency Staff
Design a Comprehensive Agency-wide Incentive
That Will Unify the Agency Culture
• Administrative and Financial Outcomes
– Timeliness of OASIS Submissions, RAPs, Signed Orders, End of
Episode Billing (no recoupments)
– Achieving Planned Costs per Unit of Service
– Achieving Planned Process Productivity
– Reduced Absenteeism – Sick Days
• Increased Referrals
– New Referral Sources
– Additional Referrals from Existing Sources
Contact Information
Lynda Laff, RN, BSN, COS-C
Pat Laff, CPA
Laff Associates
Consultants in Home Care & Hospice
Phone: (843) 671-4170
Email:
[email protected]
[email protected]
Website: www.laffassociates.com
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