acfi changes ebook

Wellness & Lifestyles Australia

THE ACFI CHANGES

10 Steps to Prevent Validation Downgrades and Increase Funding

February 2013

2007, 2008, 2009

Table of Contents Page No. INTRODUCTION ................................................................................................................. 1

IMPORTANT NOTICE ........................................................................................................... 1

1. Comply with the ADLs Domain Changes ......................................................................... 2

2. Comply with the Complex Health Care Pain Management Changes ........................................ 3

3. Stop Initial Appraisals from Defaulting .......................................................................... 4

4. Claim the Highest Amount for Low Care Admissions .......................................................... 5

5. Prevent Accidental Daily-Rate Decreases ....................................................................... 6

6. Instantly Determine How Much Funding You SHOULD Be Receiving ........................................ 7

7. Ensure Submission of Appraisals with the Highest Increase .................................................. 8

8. Reduce Documentation… to REDUCE Validation Risk .......................................................... 9

9. Protect RN Performed “Complex” Pain Management Directives .......................................... 10

10. Summary ............................................................................................................ 11

CONTACT US .................................................................................................................. 12

LAST MODIFIED 15/01/2013

www.wlconsultancy.com.au (08) 8363 1344 [email protected]

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INTRODUCTION Welcome to the W&L series of E-Books. You have chosen the edition on the Aged Care Funding Instrument (ACFI). This resource will be beneficial to anyone who: � collates information and performs assessments required for the ACFI appraisal process; � implements clinical interventions and the documentation required for ACFI submission � is involved in the identification of residents and the planning for ACFI appraisals/re-appraisals � is responsible or accountable for managing an aged care facility’s finances � is involved in any of these areas and wants up-to-date information with all the important details. Based on changes that have occurred since March 2008, this eBook will cover information about the common barriers to optimal ACFI funding, a systematic approach to improving ACFI revenue, the ACFI business rules, and the information everyone should know who works with residents from the first day they enter a facility. The information provided is up-to-date and is based on the Aged Care Funding Instrument legislation, and industry feedback. W&L recommends that you should consult a W&L ACFI Consultant to ensure that some of these strategies are specific to your site’s needs and will provide the best outcomes for your residents and facility. The W&L ACFI E-Book was developed based on experiences in over 200 residential aged care facilities. This information has been provided by our W&L ACFI Consultants who work with facilities to ensure that they are receiving all of the funding they’re entitled to for the care they’re currently providing, assist in the submission process, mitigate areas of risk for validation downgrade, and provide online/face-to-face ACFI education.

IMPORTANT NOTICE The information provided in this document can only assist you in the most general way. This document does not replace any statutory requirements under relevant State and Territory legislation.

Wellness & Lifestyles Australia (W&L) accepts no liability arising from the use of, or reliance on, the material contained in this document, which is provided on the basis that the Office of W&L is not thereby engaged in rendering professional advice. Before relying on the material, users should carefully make their own assessment as to its accuracy, currency, completeness and relevance for their purposes, and should obtain any appropriate professional advice relevant to their particular circumstances.

To the extent that the material in this document includes views or recommendations of third parties, such views or recommendations do not necessarily reflect the views of the Office of W&L or indicate its commitment to a particular course of action.

© Copyright Australia 2013 This work is copyright. You may download, display, print and reproduce this material in unaltered form only (retaining this notice) for your personal, non-commercial use or use within your organisation. Apart from any use as permitted under the Copyright Act 1968, all other rights are reserved.


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1. Comply with the ADLs Domain Changes THE FACTS: The changes to the ACFI apply to ALL appraisals completed on or after 1st February 2013. There have been three changes within the Activities of Daily Living (ADLs) Domain, which include:

1) The ACFI User Guide and ACFI Answer Appraisal Pack revised to include the words “assessed need” into the guidelines for questions 1-4

2) The ACFI User Guide and ACFI Answer Appraisal Pack restate the wording on page five of the ACFI User Guide that makes it clear that physical assistance refers to assistance throughout the specified activity, and

3) The ACFI User Guide revised to require approved providers to record the outcomes of evidence based assessments used to support completion of checklists within the claiming documentation held at the service, and produce these assessments as required for validation purposes.

WHAT THIS MEANS: The Department of Health and Ageing website indicates that appraisals must be based on the completion of:

• A contemporaneous assessment (or assessment conducted in the previous six-months) • An evidence based assessment of the resident’s needs

This assessment must be stored within the ACFI Answer Appraisal Pack with the resident’s records

YOU WILL COMPLY IF… 1) An evidence based assessment of the resident’s needs is completed (e.g. the Mini-Nutritional

Assessment, the Physical Mobility Scale, and the Bartel Index) 2) The assessment reflects the resident’s day-to-day high frequency need for care at the time of

assessment and not what the resident’s needs may be in the future 3) Physical assistance is only claimed if this relates to a need for physical assistance throughout the

specified activity 4) This assessment is stored within the ACFI Answer Appraisal Pack and is available for validation

NON-COMPLIANCE? A single-category downgrade in ADLs from Medium to Low could be a loss of $13,278 per annum

Not Just Allied Health:

� W&L RNs can complete ALL documentation required

� W&L RNs can compile the appraisal packs

$240,000 in 2-weeks

50 bed facility

They’re using their own physiotherapist too!


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2. Comply with the Complex Health Care Pain Management Changes THE FACTS: The changes to the ACFI apply to ALL appraisals completed on or after 1st February 2013. There have been two changes within the Complex Pain Management Directive-4b claim, which includes:

1) The ACFI User Guide revised to change the frequency requirement for complex pain management under question 12-4b from “at least four times per week” to “at least four days per week”, and

2) The ACFI User Guide and Answer Appraisal Pack revised to clarify the requirement that consistent ongoing treatment must be provided as required by the resident

WHAT THIS MEANS: The Department of Health and Ageing website indicates that:

• Claims have been made where four sessions occur on three or fewer days… which is not the original intention of the ACFI

• Directive-4b’s are not intended for treatment of residents with transient episodes of pain requiring treatment.

YOU WILL COMPLY IF… 1) Residents are treated four days per week (not doing multiple treatments at “separate times” or

“different body parts”) 2) Residents receive ongoing interventions when there is an established and demonstrated assessed

need 3) Evidence is made available at validation to support the requirement for consistent ongoing

treatment 4) Evidence is made available at validation to support that the interventions have been provided over

four-days per week on an ongoing basis NON-COMPLIANCE? A single Directive-4b downgrade in CHC from a High to Low could be a loss of $15,797 per annum

Reduced Validation Risk:

Wellness and Lifestyles attended our site at our request and did an ACFI audit for us. At our validation soon after, 9 packs were checked over. We had not one downgrade, every category was maintained, and we were really confident in our packs and documentation thanks to W&L! I would recommend this service to anyone. It was the only validation that we have not been totally stressed and nervous - Sue Toner, St Louis Nursing Home


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3. Stop Initial Appraisals from Defaulting THE FACTS:

1) Prior to admission, every resident undergoes an Aged Care Assessment Team (ACAT) Assessment. This determines their eligibility for either Low Level of Care or High Level of Care placement.

2) Once the resident moves in, they undergo their initial ACFI appraisal. This determines their rating of High, Medium, Low or Nil in each of the three domains.

3) If an initial ACAT approval is limited to Low-Care and their initial ACFI classification is High Care, they are classified as ‘interim low’ (low care)

This means funding will be the default rate of $47.40 per day… regardless of their care needs! PREVENTING DEFAULT: A submission will not default if the initial appraisal is Low Care. The changes in ACFI guidelines meant that for ACFI purposes, a resident is now deemed High Care if:

� ADLs or CHC = High-Claim � BEHs = High-Claim and there is any other claim in ADLs or CHC � There is a Medium-Claim in more than one domain

THE FUTURE: The resident will be able to ‘age in place’ to High-Care in one of the following ways:

1) An ACFI reappraisal results in a High Care classification 2) Another ACAT approval for High Care is provided 3) A Department Review Officer confirms the classification as High Care

EXAMPLE 1: Joe Bloggs is a resident who is eligible for Low Level of Care. His initial ACFI appraisal is

also submitted within this definition of Low Care as a LLM. This is a daily rate of $77.56/day… or $28,309.40/annum

EXAMPLE 2: John Smith is a resident who is also eligible for Low Level of Care. His initial ACFI

appraisal is, however, submitted within this definition of High Care as a LMM. This ‘defaults’ to a daily rate of $47.40/day… or $17,301.00/annum

Despite John’s higher care needs, this default means $11,008.40 per annum less funding!

?

No, You Won’t Be Targeted!

Increased funding by $423K p.a. Completed uplift 10 months ago No validation


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4. Claim the Highest Amount for Low Care Admissions THE KEY POINTS:

1) If an initial ACAT approval is limited to Low-Care and their initial ACFI classification is High Care, they are classified as ‘interim low’ (low care) where the funding will be the default rate of $47.40 per day

2) When the ACFI commenced in March 2008 the highest rate that could be claimed without ‘defaulting’ was a LML

THE CHANGES: The most that can be claimed for an initial ACFI appraisal when the resident ACAT is limited to Low-Care is now as per the following rates:

MLL $88.24/day = $32,207.60/year LLM $77.56/day = $28,309.40/year LML $59.43/day = $21,691.95/year Default $47.40/day = $17,301.00/year

A MLL generates close to $15,000 more funding p.a. than a MML… despite higher care needs!

It’s Funding for Work You’re Doing

You’re Already Providing the Care

Increased funding by $226K 100% success at validation

71 bed facility

W&L Consultancy just helps put the pieces together


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5. Prevent Accidental Daily-Rate Decreases THE KEY POINTS:

1) The change in weighting of Question-3 (Personal Hygiene) brought the points to be in alignment with those of Question-2 (Mobility).

2) The change in the Complex Health Care Supplement matrix meant that a resident’s funding, where their only needs were related to a D-Claim in Question-11 (Medication), would now be rated as a CHC-Low

3) This means there are residents could have their daily rate decreased, without a change in care needs, if a reappraisal was completed

EXAMPLE 1: Joe Bloggs is a resident who is a MLL ($88.24/day). If a reappraisal was completed

because their care needs actually increased, their rate could actually now be a LMM ($85.13/day). This is a decrease of $1,135.15 per annum despite their ADLs needs staying the same, and both their BEH and CHC needs increasing!

There are multiple examples of where a resident’s funding will decrease even if care needs increase! PREVENTING DECREASE: Points to note that there are 1024 ADL combinations, and 64 ACFI rate combinations… with each of the domains rated differently. Specific tools that should be used for every submission include an:

a) ADL-Change Calculator – download for free at www.wlconsultancy.com.au (see below) b) ACFI Rate Calculator – this will allow a comparison of domain weightings and overall funding rate

Download the free ADL Change Calculator at www.wlconsultancy.com.au

?

Safe as Houses


120 bed facility


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6. Instantly Determine How Much Funding You SHOULD Be Receiving THE KEY POINTS:

1) W&L consultants have never visited a facility where every residents’ funding matched their current care needs

2) A residents’ clinical needs may change gradually, or a subtle clinical change may be sufficient to trigger an ACFI funding change

3) Although often criticised, the old Residential Classification Scale (RCS) had the benefit that it made facilities look at the funding for every resident at least every year.

WHAT THIS MEANS: It is highly likely that your facility is not receiving funding that it is entitled to for

care that is already being provided. ENSURING THE RIGHT FUNDING: Facilities that receive the funding they’re entitled to:

1) Appoint someone (either internally or externally) who has the responsibility of regularly reviewing clinical needs in comparison to their ACFI rate

2) Have systems to ensure communication of clinical changes (e.g. development of wounds, decreased mobility, etc)

3) Utilise an objective tool such as the W&L iPhone ACFI Calculator App

This free download will allow you to quickly and easily calculate a resident’s ACFI rate based on their current care needs… and compare it to what you’re currently receiving. Using this calculator means you could:

� Save Time – in less than a minute, you can find out what rate you should really be getting for your residents

� Eliminate Unnecessary Paperwork – quickly and easily work out which residents you don’t need to be doing reappraisals for

Download the free ACFI Calculator App at the Apple Store or www.wlconsultancy.com.au

We’re doing okay, but since you don’t charge unless you find an increase, a second set of eyes can’t hurt…


60 bed facility


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7. Ensure Submission of Appraisals with the Highest Increase THE KEY POINT: Sites frequently focus on either the RCS-saved rate residents or the lowest funded

residents in the facility. THE QUESTION: What would you prefer your staff to focus on?

1) Reappraise a NLL ($20.96/day) to LML ($59.43/day) for a $14,041.55 p.a. increase, or 2) Reappraise a HML ($121.74day) to HHH ($181.21/day) for a $21,706.55 p.a. increase

TELL-TALE SIGNS THAT ELIGIBLE FUNDING IS NOT BEING RECEIVED:

X Reappraisals are planned based on resident anniversary dates X Reappraisals are planned based on residents who have low daily rates (or are RCS-saved) X Reappraisals are only planned based on residents who have major clinical changes

ENSURING THE RIGHT FUNDING: In an ideal world this shouldn’t matter, as every resident’s clinical situation would be continually reviewed vs. funding being received. In reality, sites that allocate resources effectively to ensure that they receive the right level of funding as quickly as possible:

� Complete a full site analysis to determine for every resident what their ACFI rate should be � Prioritise submissions by knowing which residents can be reappraised for the biggest increase first

An example planning table prioritising the order of submissions at a 49 bed facility where it was identified that there were 21 residents who could be reappraised immediately (and one who could not be reappraised for another couple of months). The facility was planning on working on resident 19 first because this was the resident they ‘had to get up’ as they were currently the lowest funded resident!!!

“But our site is too small to get a consultant”

It’s not about the size of your facility… but what you’re getting out of it


16 bed facility


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8. Reduce Documentation… to REDUCE Validation Risk

THE KEY POINTS:

1) There are a number of assessments and charts that are completed because of the ACFI; they do not contribute to clinical outcomes or care planning.

2) Due to significant variation between testing conditions, these charts and assessments do not “establish a baseline”… there is low inter and intra-tester reliability

3) Formal assessments and charting may be completed when either the outcomes are not significant enough to generate above an A-Claim, or they do not contribute to the overall claim (e.g. the resident will already be High in that domain).

WHAT THIS MEANS: Essentially, staff may be completing unnecessary documentation. The effect of this is that:

X Staff are spending time completing assessments which are unnecessary both clinically and financially

X Care staff are completing charts which are unnecessary both clinically and financially; this leads to a situation where they are spread thin, reducing the effectiveness of the charts that DO make a difference

X In the ACFI Appraisal Pack there is information that is unnecessary for the claim, and can increase the risk of incongruency for the claim

EXAMPLE: Joe is a resident who’s Behaviours and Cognition Claim is as follows: Question 6 (Cognitive Skills) D-Claim Question 7 (Wandering) D-Claim Question 8 (Verbal) C-Claim Question 9 (Physical) DOES NOT CONTRIBUTE TO CLAIM Question 10 (Depression) DOES NOT CONTRIBUTE TO CLAIM In this example, even without the physical behaviours chart or the Cornell Scale for Depression being completed, this resident will already be a High in this domain. Completion of these charts and assessments may not contribute to the resident’s care, does not establish a baseline, and does not contribute to the claim. The end result is that it is likely to increase the risk of incongruency and risk of downgrade! HOW TO REDUCE YOUR WORKLOAD:

1) A screening assessment should be completed to identify resident care needs in each question 2) Utilise an objective tool such as the W&L iPhone ACFI Calculator App to determine the effect of

these 3) Only commence charts that either (a) contribute to the claim, or (b) assist in care planning 4) Only perform assessmentss that either (a) contribute to the claim, or (b) assist in care planning

“I’m glad we didn’t put it off, it was money down the drain”

50 beds $442K increase The care was already being provided

That’s $8,500 a week


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9. Protect RN Performed “Complex” Pain Management Directives THE FACTS:

1) Directive-3 is “Pain management involving therapeutic massage or application of heat packs” 2) Directive-4a is “Complex pain management and practice undertaken by an allied health

professional or registered nurse. This will involve therapeutic massage and/ or pain management involving technical equipment specifically designed for pain management”

THE KEY POINTS: Often pain management is being provided that does not meet the criteria of the Directive-4a:

X Heat packs do not fit the criteria for a Directive-4a… an RN providing a hot pack is not complex pain management.

X A directive for a personal care worker to provide therapeutic massage to a resident will fit the criteria for a Directive-3. A directive for an RN is provide therapeutic massage to the same resident, using the same wording/terminology/instructions is not differentiated from the Directive-3… it is not demonstrating the complex nature of it.

Both of these situations have been downgraded from a Directive-4a (3-pts) to a Directive-3 (1-pt) NON-COMPLIANCE? A single Directive-4a downgrade in CHC from a Medium to Low could be a loss of $9,380.50 per annum

Not For Profit Organisation?

Not For Loss!

� 3 sites � $1.21 million increase � Only 2 sites validated � 100% success


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10. Summary We’ve noticed that many aged care facilities are not accessing all of the funding they’re entitled to, often for care that is already being provided. When resident increases are identified, getting re-appraisals done immediately can be difficult, leading to funding being lost each day. Also, as all the staff involved in the process may not have had ACFI specific training (especially regarding the changes), appraisal packs are frequently placing facilities at risk of losing funding they’ve already received. A thorough and in-depth knowledge of these changes and the ACFI business rules can quite often mean the difference between preventing unnecessary assessment documentation, preventing unnecessary mandatory reappraisals, or losing significant amounts of funding that is available with no extra documentation requirements. Here at W&L Consultancy we’ve made it our job to know the ACFI intimately. We recommend that you should discuss the information in this e-book with one of our consultants to ensure that these strategies can be tailored to your site’s needs. If you need any assistance, we guarantee an increase in funding, or there is no charge. Our ACFI appraisal pack audits identify risk, provide action plans to reduce this risk, and focus on prevention of recurrence. We emphasise staff education through a combination of face-to-face education and access to our online resource library. To date, using these methods, the lowest amount that we’ve identified for facilities to improve their funding, from any facility, is $100K per annum. For more information regarding how we can specifically help your facility, visit www.wlconsultancy.com.au or call for an obligation free quote on (08) 8363 1344 All the best for better resident and financial outcomes, The W&L Team PS - What makes the Wellness & Lifestyles ACFI Consultancy Service different? � We physically assess every resident only using aged care experienced nurses and allied health

professionals… our claims are based on fact, not just a documentation review � We review every resident to ensure that you’re getting the right level of funding for your whole

facility… not just 10 residents! � No up-front fees – we only invoice if we find increases and you’ve started receiving the funding � From day one we provide face-to-face education and training to all levels of staff in your facility � Free access to a large range of online training resources at www.wleducation.com.au � We provide you with an action plan for the next 12-months � 24-hour phone support, 7-days per week � We guarantee our work – it’s in our contract that if you were to lose money at validation, we’d

refund the bill for that resident! ACFI Consultants – Guaranteed Increased Funding ACFI Registered Nurses – Submitting Your ACFI Claims… Faster ACFI Treatment Nurses – Improving Care & Keeping Claims ACFI Appraisal Pack Audits – Reducing Risk of Downgrade (inc. desktop audits for anywhere in Australia!) ACFI Education – Improving Knowledge, Care, & Claims W&L Consultancy: Ensuring residents receive the care they need, aged care facilities receive the ACFI funding they’re entitled to, and it’s kept at validation

Not Just About the Funding:

They provide ongoing support, training and education to assist our clinical staff in meeting their goals and achieving better results both in ACFI funding and resident outcomes - Rosemary Jeffery, MRCS, Frontier Services (11 sites)


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CONTACT US

Wellness & Lifestyles Australia 41 Sydenham Road, Norwood, SA 5067 P: +61 8 8363 1344 F: +61 8 8132 0745 E: [email protected] W: www.wellnesslifestyles.com.au www.wleducation.com.au www.wlconsultancy.com.au W&L services include: � Physiotherapy � Aged Care Funding Instrument (ACFI) Consultancy � Podiatry � Speech Pathology � Dietetics � Diabetes Education � Occupational Therapy � Psychology � Physiotherapy Aide � Diversional Therapy � Aromatherapy � Massage � Exercise Physiology � Educational Training � Locum Services � Medicare Billing � Aged Care Funding Instrument Documentation � Online Training W&L products include: � Posters � E-books � E-learning modules � Audio/visual � Hot tips/articles

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