Recipe for Sweet Transitions and Medicare

Topics

MHCA Medicare Team Members

Beth Branz, North Memorial Homecare and Hospice Vickie Brand, HealthEast Home Care Denise Edgett, HealthPartners Integrated Home Care Dori Finch, Superior Home Health Care Mary Jane Fraser, Allina Home and Community Services Deb Klein, Guardian Angels Home Care Deanna Hammond, Firstat Nursing Services Mary Riha, Fairview Home Care and Hospice Jennifer Stark, St. Lukes Home Health Services Sue Shampine, Presbyterian Homes Geri Wagner, All Homecaring

Introduction

Many of us have accepted referrals where little information has been provided by referral source

A half baked transition is a recipe for a disaster

Presentation will provide the tools to enable your safe patient transitions during handovers in care

What are “Care Transitions”?“The movement of patients from one healthcare practitioner or setting to another, as theircondition and care needs change” Eric A. Coleman, MD, MPH

Can occur: within a specific setting (such as moving from ICU to a

general care unit) between settings (hospital to homecare, homecare to

ambulatory care; sub-acute facility to ALF) across health states (curative care to end of life care;

independent community dwelling to ALF)

“Sweet” Transitions Goals

Improve Safety Reduce risk of re-hospitalization Improve patient satisfaction Responsible stewardship of health care

resources

Ingredients for “Sweet” Transitions:

Sharing of crucial information, including clinical status, plan of care, patient goals, and preferences of patients, caregivers and family

Agreement by and education of patient and family

Procuring needed supplies, equipment, transportation

Consistent processes insure coordination and continuity of care as patients transfer between locations, providers or levels of care

Results of “Half Baked” Transitions = Poor Outcomes Patient, caregiver or healthcare team unprepared Delays in initiating or resuming care Medication errors or wrong treatment provided Harm to patient- severe adverse events and delayed

recovery Increased healthcare utilization, including acute care

readmission, duplication in tests, procedures, etc Complaint/dissatisfaction of patients and caregivers Legal or regulatory action, litigation and harm to the

reputation of care providers

Characteristics of a “perfectly baked” transition All information exchanged crucial to the

transition, including plan of care and patient safety is relayed

Patient, caregivers and healthcare team in agreement and prepared

Elegance- timely transitions occur without gaps, duplication or incidents

Transitions to be Discussed Transition to Homecare

Transition to Hospital or Sub Acute Facility

Transition to Ambulatory Care Providers

Recipes for Sweet Transitions

Homecare Regulatory and Accreditation Requirements

Bill of Rights and MN regulations Homecare Bill of Rights

#17. Right to a coordinated transfer when there will be a change in the provider of services

MN 4668.0160 subpart 4 Transfer of ClientIf a client transfers to another home care provider, other health practitioner or provider, or is admitted to an inpatient facility, the licensee, upon request of the client, shall send a copy or summary of the client’s record to the new provider or facility or to the client.

Medicare Requirements 484.18

Patients are accepted for treatment on the basis of a reasonable expectation that the patient’s medical, nursing, and social needs can be met adequately by the agency in the patient’s place of residence

“Timely initiation of care”- within 48 hr of referral, unless otherwise ordered

Homecare Regulatory and Accreditation Transition Requirements Joint Commission Standard PC.02.02.01 Coordination is recognized as a major challenge

in the safe delivery of care. Due to the rise of chronic illness and acuity, patients are likely to have a array of providers in a variety of health care settings. The most frequently cited root cause of

sentinel events evaluated by the joint commission on accreditation of heath care organizations is communication.

Joint Commission Standards (continued)PC.02.02.01

EP 1: organization maintains continuity in the way it shares and receives patient information with other providers of care treatment or services

EP2: the organizations process for handoff , communication provides for the opportunity for discussion between the giver and the receiver of patient information.

EP 17: The organization coordinates care, treatment or services within a time frame that meets the patient’s needs

Joint Commission Standards (continued)Standard PC 02.02.02

EP1:The organization maintains continuity in the way it shares and receives patient information with other providers of care, treatment, or services.

EP2: The organization’s process for hand-off communication provides for the opportunity for discussion between the giver and receiver of patient information.

Joint Commission Standards (continued)Standard PC. 04.02.01: When a patient is discharged or

transferred, the organization gives information about the care, treatment, or services provided to the patient to other service providers who will provide the patient with care, treatment, or services

Joint Commission Standards (continued)

Standard PC. 04.02.01: EP 1: At the time of the patient’s discharge or transfer,

the organization informs other service providers who will provide care…. To the patient about the following: The reason for the patient discharge or transfer A summary of care….., provided to the patient The patient’s progress toward goals A list of community resources or referrals made or

provided to the patient

Joint Commission Standards (continued)

Standard IM.01.01.01 EP 1, 2

The organization identifies the internal and external information needed to provide safe, quality care

The organization identifies how data and information enter, flow within , and leave the organization

Joint Commission Standards (continued) Additional standards

LD 03.02.01 EP 2,3,4LD 03.04.01 EP 1,3,5RC 01.01.01 EP 8, 13

Joint Commission Standards (continued) Additional standards

PC.04.01.01 EP 15 PC.04.01.03 EP 2 PC. 04.01.05 EP 1 LD. 03.02.01 EP 2,3,4 LD. 03.04.01 EP 1,3,5 RC. 01.01.01 EP 8,13 NPSG. 03.06.01 EP 3,4

Transition to Homecare Homecare is often asked to operate with

limited patient information and physician involvement

The transition from hospital/facility to home and the period immediately following is crucial to insure patient safety and care efficacy.

Patients most vulnerable- error rates documented in up to 50% of transitions (Boling, 2009)

Dartmouth Study 1 in 6 Medicare patients re-hospitalized within 30 days Dartmouth study included 10.7 million Medicare patient

Hospital Discharges from 2003-2009 Widespread and systematic failures cited in coordinating

care for patient’s after they leave the hospital These findings underscore the need for hospital, the

patient, the outpatient and in patient providers to work together in a coordinated fashion to make sure the patient receives the quality of care that minimize the risk for preventable hospital readmission

Medicare penalize hospitals for high re-admission rates of targeted diagnosis beginning in 2012

Look familiar?

“OK for homecare”“Continue previous meds”

“Home nurse for wound care”

“Home safety eval”

Home Health Referral – Crucial Information

Date and time of referral/transfer Physician ordered start of care, if applicable Patient Demographics:

Name DOB Gender Address Phone Caregiver/Emergency Contact Interpreter needs Power of Attorney

Home Health Referral – Crucial Information Providers: - Referral source and contact information - Attending physician and contact

information - Specialists and contact information - Other community providers, such as

county case managers, insurance case coordinator, if applicable

Home Health Referral – Crucial Information Insurance Information

Name of insurance companyPolicy numberContact information if known

HHA is responsible to verify details of home care coverage

Home Health Referral – Crucial InformationMedical Information:Recent Clinic Visit Note/History & Physical/ Facility Discharge SummaryMedication listAdvance Directive/POLST( Physician order for life sustaining treatment)Treatment/ discipline Orders: examples labs, precautions, wound care specificity…Status of prescriptions, supplies/equipment needs

Home Health Referral – Crucial InformationMedical Information:Follow up appointmentsDate/Documentation of the Medicare Face to Face Encounter, if applicableOther pertinent information as appropriate such as safety concerns, vulnerable adult issues, leaving against medical advice

Home Health Referral – Crucial Information Talking Points

“The information you provide insures a safe transition for the patient”

“The information we request is consistent with that of other community providers”

HIPAA: sharing information for treatment is permitted

The “Unbaked” ReferralReferrals Not Admitted Referring facility discharge plan is home

care services When this does not happen as planned

then loop back to referral source HHA should have policy to define practice

(see example policy)

Transition to Hospital or Sub Acute Facility

Date and reason Meds and Allergies Primary Diagnosis Physician Precautions Advance directives/POLST

Transition to Hospital or Sub Acute FacilitySBAR ( Situation, Background, Assessment, Recommendation)1.Situation: immediate needs of the patient2.Background: History3. Assessment:

Sensory (mental status, behavior, communication) Mobility ADL Pain, Respiratory, elimination GI & GU Skin, Nutrition Alteration in Coping/Spiritual Alteration in Family Processes/ Social Support

4. Recommendations: what needs to be followed up on?

Transition to Ambulatory Care Providers Progress of home care plan of care: still

active or discharged from home care Up to date medication list Clinical status and progression while

receiving home care Questions or concerns Contact information: home care staff,

county workers, worker comp rep…

Summary Regulatory and Accrediting requirement for

coordination of care at time of transition Dartmouth Study findings underscore the need

for hospital, the patient, the outpatient and in patient providers to work together in a coordinated fashion to make sure the patient receives the quality of care that minimize the risk for preventable hospital readmission

Dartmouth study included 10.7 million Medicare patient Hospital Discharges from 2003-2009

Medicare Topics

HHCAHPS Observation StatusHH Compare ICD 10PECOS OIG Work PlanNew Survey TherapyNOMNC F2FMEDPACRAC

HHCHAPS Home Health Consumer Assessment of Healthcare Providers and Systems Medicare Certified Agencies with unduplicated census of fewer than 60

clients over 12 months can file for an exemption for 2013. Publically reported April 2012 Official website where you can view preview reports

https:/homehealthcahps.org/ HH Compare 3 composite measures

Care of patient (Q9, Q16, Q19 and Q24) Communication between providers and patients (Q2, Q15, Q17,

Q18, Q22 and Q23) Specific care issues ( Q3, Q4, Q5, Q10, Q12, Q13 and Q14)

HH Compare: 2 global ratings Overall rating of care given by HHA care providers (Q20)i.e. ranked

as 9-10 Patient willingness to recommend the HHA

Home Health Compare Outcome measures Changes to publically reported outcome

measures

1. No longer reporting improvement in incontinence

2. No longer reporting increase number of pressure ulcers

PECOS Provider Enrollment Chain and Ownership System Physician ordering home health must be enrolled in the

PECOS file or future services may not be paid Phase 1- the enrollment process, currently the claim will still

be processed and paid Phase 2- Implementation has been delayed. Future services

will not be paid if the physician is not enrolled in PECOS Recent MLN matters dated 1/20/12 (SE1201) regarding

home health services Home Health Agency (HHA) services may be ordered or referred

by a Doctor of Medicine (MD), Doctor of Osteopathy (DO) or Doctor of Podiatric Medicine (DPM). Claims for HHA services ordered by any other practitioners will be denied

Revalidation Affordable Care Act section 6401(a) require that all enrolled

providers and suppliers to revalidate their enrollment This revalidation is for all providers that were enrolled prior to

March 25, 2011 Notices are being sent to agencies already enrolled and the

agency will have 60 days to respond The agency will receive 2 reminder letters Authorized official must sign off on the form this should match

the original official who signed initially. If this official is no longer available the agency is to submit a change form

Penalty: first layer is suspension of payment once CMS received the letter it will take 3 business days upon

receipt of the letter to release suspension Website

https://www.cms.gov/MedicareProviderSupEnroll/11 Revalidations.asp

New Survey Guidelines Focus on interview process esp. regarding

patient care process Standard Survey

CMS identified 9 of the 15 CoPs and highest priority standards called Level 1 standards are addressed in standard survey

Partial Extended Survey Extended Survey

May be conducted at any time at the discretion of CMS Must be conducted when any condition-level deficiency

is found

RAC Recovery Audit Contractor for MN is CGI, identify and correct

under and over payments for Medicare FFS claims. Is one of 5 claim review programs that review claims both

before and after payment RAC are beginning to release Home Health Issues, which are

posted on the CGI web site Home Health Agencies are beginning to receive RAC

requests Can not request the same patient’s information twice or

review a claim previously reviewed by another entity. “ Look back” of claims is up to 3 years from the date claim was paid.

RAC request letters can be from CGI or from a sub-contractor Have agency processes in place to quickly identify notifications

or information received from RAC’s .Time limits on appeals, interest accruals on recoupment's

Have designated staff at each agency to be alerted immediately regarding RAC requests

Observation Status vs. In-Patient Admissions Hospitals are receiving RAC requests re: 3

day hospital stays Increase number of patients held in Observation

status instead of full In-Patient admissions Work with ACH partners to determine if

Observation status vs. In-Patient admission Patients can be held in Observation status for a

number of days and never officially admitted as an In-Patient status

OASIS implications since a Transfer OASIS is not required if not admitted to In-Patient facility

ICD 10 and Oasis C 2 All HIPPA “ covered entities are required to adopt ICD-10

CM/PCS codes. Implementation is anticipated for October 2014. Does not affect CPT or HCPCS codes. Watch the CMS ICD 10 website for more details.

ICD-10 codes will be much more descriptive than ICD-9. The transition to ICD-10 is a major undertaking and will go more smoothly for agencies that plan and prepare. Take steps NOW Talk to billing service, clearinghouse or soft wear

vendors Review processes that could be impacted and ensure

necessary training is performed

ICD 10 and Oasis C 2 continued To process ICD-10 claims, the version

5010 Electronic Health Transaction Standards, mandated by HIPPA had to be implemented first. Compliance date for 5010 was 1-1-2012 enforcement date extended to June 2012.

Oasis C -2 more details to be released In August 2012. Anticipate and plan for staff training and education

OIG Work Plan 2012 States’ Survey and Certification Process: Timeliness,

Outcomes, Follow-up and Medicare Oversight Medicare Oversight of Home Health Agencies Patient

Outcome and Assessment Data Increase focus on oasis submitted within 30 days

Missing or Incorrect Patient Outcome and Assessment Data Questionable billing characteristics of HHA services HHA Claims’ Compliance with Coverage and Coding

Requirements Medicare Administrative Contractors’ oversight of HHA claims Wage indexes used to calculate HH Payments MA: looking at states who try to enforce HB criteria, dual

eligible OIG work plan 2012 website

http://oig.hhs.gov/reports-and-publications/archives/workplan/2012/Work-Plan-2012.pdf

MEDPAC Recent report to Congress Medical review activities in counties with aberrant home

health utilization Two-year rebasing of the home health rates and

eliminate the market basket rate for 2013. Recognized home care’s ability to improve functional

status in non-hospitalized patients Revise the case mix system and eliminate the number of

therapy visits as a payment Co-pay for community referrals, non post acute

episodes. Also copay on second adjacent episode of home care services.

NOMNC Notice of Medicare Non-Coverage

Release of new version Notice of Non Coverage March 2012.OMB-Approval # 0938-0953/ CMS Form-10123

Combination form to cover both Medicare and Medicare/HMO plans

Agencies to utilize this form by May 2012

Face To Face Waiting for guidance regarding use with

Medical Assistance patients Work with electronic medical records

vendors as they are tweaking and making changes to systems to increase efficiency with face to face.

January 2012 CMS Q&A clarification on how to handle late Face to Face

Designate a champion at agency to assist with Face to Face

Therapy Functional Assessments Learning Work with Electronic Record Vendors as they improve

tracking mechanisms Remember it is billable visits that are included in the

count Multiple therapy disciplines involved

utilize “close to but not beyond” threshold criteria Single therapy discipline involved

assessment must be on the 13th and 19th visits. The “ close to but not beyond” guidance does not

apply to single therapy service involvement Minimal every 30 day assessment

Crosses over certification time periods

CMS New Innovation Center CMS Innovation Center still expects to play

an important role in new care delivery models and forging new payment

Accountable Care Organizations (ACO) Demonstration projects are beginning Health Systems are participating in the pioneer

demonstration projects Develop relationships with partners in order to

prepare for ACO involvement Value Based Purchasing

No new updates Demonstration projects have been completed

Additional items NP - reintroducing legislation MAC update

NGS protested and received MAC back from Noridian

Now another protest filed and no resolutionContinue business as usual till we learn more

Q & A