therapy practice changes with pdgm - new england home care … · 2019. 5. 31. · incorporating...

NEHCC Annual Conference, June 2019 1

CPAs & ADVISORS

Lessons Learned From Pre-Claim Review

Karen Vance, BSOTSenior Managing [email protected]

Therapy Practice Changes with PDGM

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3aEstimated by CMS using 2017 claims data

State Estimated PDGM Financial Impacta

• Negative impact of 10% or more

• 33 agencies

• Negative impact of 5% to 10%

• 38 agencies

• Negative impact less than 5%

• 54 agencies

• Positive impact

• 230 agencies

1%

5%

3%

-1%

2%

1%

So where is our influence on the impact?

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Low therapy utilization pre-PPS

Current high therapy utilization


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Note: Per CMS LDS 2017 data

Accurate OASIS scoring

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Variable Category OASIS Items Points

M1800: Grooming 1 2, 3 4

M1810: Dress upper body 1 2, 3 6

M1820: Dress lower body 12

23

511

M1830: Bathing 123

23, 45, 6

31321

M1840: Toilet Transferring 1 2, 3, 4 4

M1850: Transferring 12

12, 3, 4, 5

48

M1860: Ambulation/ Locomotion

123

23

4, 5, 6

101224

M1033: Hospitalization Risk 4 or more items From 1‐7 11


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Interdisciplinary Collaboration

Begin of Episode

• OASIS ADL items

• Primary diagnosis

• Comorbidities

• Most effective/ efficient POC

• Care coordination

30 Day Review

• Progress toward outcomes

• Barriers to progress

• Change in primary diagnosis?

End of Episode

• Challenge recert & discharge plan

• Identify outcomes that are an unexpected decline or stabilization

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Clinical Grouping Functional: Low Medium High

MMTA – Surgical Aftercare 0‐24 25‐37 38+

MMTA – Cardiac & Circulatory 0‐36 37‐52 53+

MMTA – Endocrine 0‐51 52‐67 68+

MMTA – Gastrointestinal & Genitourinary system 0‐27 28‐44 45+

MMTA ‐ Neoplasms, Infectious & Blood‐Forming Diseases 0‐32 33‐49 50+

MMTA – Respiratory 0‐29 30‐43 44+

MMTA – Other 0‐32 33‐48 49+

Behavioral Health 0‐36 37‐52 53+

Complex Nursing Interventions 0‐38 39‐58 59+

Musculoskeletal Rehabilitation 0‐38 39‐52 53+

Neuro Rehabilitation 0‐44 45‐60 61+

Wound 0‐41 43‐61 62+


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MS Rehab, 16.6%

Wound, 10.5%

Complex Nursing Interventions, 3.9%

Neuro/Stroke Rehab, 8.9%

Behavioral Health, 3.3%

MMTA, 56.7%

Historical Breakdown by Clinical Grouping

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Accurate selection of primary diagnosis


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Capturing other diagnoses

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M54.5 Low back pain

M62.81Muscle weakness (generalized)

R26.2 Difficulty in walking, not elsewhere classified

R26.81 Unsteadiness on feet

R26.89 Other abnormalities of gait and mobility

R26.9 Unspecified abnormalities of gait and mobility

R29.6 Repeated falls

R53.1 Weakness

Z48.89 Encounter for other specified surgical aftercare

9 of the top 50 primary diagnoses used from 2015 –2017 are not on the acceptable list

Unacceptable Primary Diagnosis


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Muscle Weakness (M62.81)

o CMS citing concern with this code since 2008

o One of the top 5 primary diagnoses in past several

years

o CMS believes muscle wasting and atrophy codes could

be more appropriate if muscle weakness is the

primary focus of therapy

o Determine underlying cause for the muscle weakness

OR

o Identify the true underlying reason for therapy

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“Reasonable and Necessary”

o The services must be consistent with the nature & severity of the illness or injury, the patient's particular medical needs, including the requirement that the amount, frequency, & duration of the services must be reasonable;

o The services must be considered, under accepted standards of medical practice, to be specific, safe, & effective treatment for the patient's condition;


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Avoid using diagnoses based on the need for a “therapy diagnosis”. Expect the proper process:o Inquire for patient goalso Assess for functional performance

o Identify gap between performance and goalso Collaborate for engagement in the POC based on

patient needs and identified goalso What are therapy tools to help with all those MMTA

groups?

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Identify routines to assist in taking as directedMedications

Reinforce with tools for monitoring BP, glucose, skin, weightSelf‐monitoring

Routines to help with oxygen, nebulizer, insulin, pursed lip breathingTreatments

Practice meal prep with new recipes watching glycemic index, sodium, potassium, fat

Diet

Rather than an HEP? Familiar activity, build in energy conservationPhysical Activity

Assist problem solving to attend & participate in encounters Health care encounters

Management of Chronic Conditions (MMTA)


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Care Coordination Between Disciplines

o Instruction from other disciplines integrated into performance and routines by therapy

o Spontaneous, consistent performance is the ultimate teach‐back response

o Use aide services as an opportunity for patient to practice to refine performance (practice that does not require a skilled therapy practitioner to be present)

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Care Coordination Example: CHF

o Patient goal: stay out of hospital, regain access to bedroom and bathroom on upper level of house, be able to stay at home

o Care plan goals: Patient will• Take meds as ordered.• Incorporate energy conservation into ADL/IADL routines.• Be able to use stairs to access bedroom & bathroom.• Prepare meals consistent with dietary restrictions.• Spontaneously and consistently monitor weight.• Self monitor and respond appropriately

Care plan goals focus on patient behavior and promote the patient’s overarching goals.


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Care Coordination Example: CHFRN: Promote symptom monitoring, taking meds as ordered

PT: Increase mobility/activity tolerance (steps)

OT: Incorporate energy conservation, incorporate dietary changes and weighing into existing habits and routines, advance ADLs as access to bathroom/bedroom are achieved

HHA: fading assistance with ADL through transition from sponge bathing/BSC to accessing bathroom, reinforce revised routines

MSW: Ongoing resources for pt and caregiver

Physician: reinforce patient & caregiver, ongoing care coordination

Caregiver: assist/reinforce

Interventions support patient overarching goal and care plan, and are coordinated

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Therapy Strategies to Improve Outcomes

Managing medication routines

Integrating diet into meal preparation

Conserving energy as a lifestyle

Incorporating physical activity into daily routines

Self‐monitoring as a lifestyle

Problem solving (reducing hospitalizations)


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Med Management – Most Important ADL

o Does not require that the therapist• Learn pharmaceuticals

• Learn drug interaction

• Provide medication instruction

o Does require that therapists recognize relationship between medications, medication administration and medication effects and safe, predictable performance of routine activities.

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Medication Management in Therapy POC

o Gather information about the whole routine of a day (a good day & a bad day)

o Identify when the isolated tasks your are assessing occur throughout the day

o Determine where medications are kept in relation to when they are taken

o Assess barriers or interruptions to the usual routine based on recent events


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Dietary Adherence into Daily Routines

o Focus on the task and the routine• Within scope of therapy

• Not medication teaching

o Analysis of the component skills required

o Identification and implementation of appropriate compensatory strategies

o Integration of medication management into daily habits and routines

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Conserving Energy as a Lifestyle

o Analysis of existing routines and habits in relation to energy demands and capacities

o Pacing and planning to balance demands to capacities

o Self‐monitoring energy and energy expenditure

o Adapting routines

o Specific techniques (controlled breathing, relaxation, etc.)

o Use of pulse oximetry as a measure of effectiveness of interventions


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Energy Conservation

o Not a technique, but a principle that must be incorporated into every activity every day

o Learning how to budget time & energy to accomplish high priority needs embedded in daily routine

o Recognition that endurance (activity tolerance) is the limiting factor, not strength (or weakness)

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Physical Activity into Daily Routines

o Analysis of overall daily physical activity

o Incorporate physical activity into daily activity

o Analysis of avocational or leisure preferences

o Identification of long term options to sustain physical activity and physical activity capacities

o Increasing daily activity rather than a home exercise program (HEP) for specific extremity muscle strengthening


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Self Monitoring as a Lifestyle

o Analyze skills and capacities relative to demands of the task the patient is expected to perform

• Blood pressure

• Blood glucose

• Skin integrity

o Integration of condition‐specific self‐monitoring tasks into daily routines

o Identification of compensatory strategies or needs for caregiving/supervision to support self‐monitoring

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Problem Solving

o Actual performance in context (location/time of day) shifts teach‐back from words to actions

o Analysis of performance in context to identify and problem solve to reduce risk and promote consistent performance

o Promote patient and caregiver problem recognition and problem solving

o Focus on “what to do” to identify an emerging need, problem, risk at earliest possible stage


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Return Demonstration is Not Enough

o Simply observing a patient giving a return demonstration of any activity

• While being cued/supervised

• In a place where it won’t typically be done

• At a time when it won’t typically be done

provides little or no information about the patient’s ability to perform the activity routinely, consistently and effectively

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Don’t Confuse….

Knowledge Behavior

Verbalize Understanding Implementation

Return Demonstration Spontaneous Performance

One Time Routine


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Planning Frequency for Patient Engagement

Clinician frequency

Patient engagement

Patient engagement

Clinician frequency

Beginning of episode End of episode

1 | | | 5 | | | | 10 | | | | 15 | | | | 20 | | | | 25 | | | | 30 | | | | 35 | | | | 40 | | | | 45 | | | | 50 | | | | 55 | | | | 60

1 | | | 5 | | | | 10 | | | | 15 | | | | 20 | | | | 25 | | | | 30 1 | | | 5 | | | | 10 | | | | 15 | | | | 20 | | | | 25 | | | | 30

1 | | | 5 | | | | 10 | | | | 15 | | | | 20 | | | | 25 | | | | 30 | | | | 35 | | | | 40 | | | | 45 | | | | 50 | | | | 55 | | | | 60

Current PPS

PDGM

Front‐loaded visits Tapered visits

Front‐loaded visits Tapered visits

Full 30‐day payment Managed Utilization or a LUPA??


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Coding Collaboration

Accurate dataAccurate payment

Accurate outcomes

Care Coordination

Best skill mix, best value to outcome

More appropriate therapy utilization

Better utilization, less cost to episode

Patient Engagement

In‐between visit progress

Fewer visits with good outcomes

Less cost to the episode

Tapered Frequency

Reduced hospitalization

risk

Outcomes monitored over

time

Visits spread over time,

reduce LUPA risk

Influence on PDGM Impact

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Value to Agency OutcomesMeasure HHA State Nat’l

How often patients got better at walking or moving around. 72.3% 76.5% 75.6%

How often patients got better at getting in and out of bed. 76.9% 75.3% 74.8%

How often patients got better at bathing. 77.1% 80.7% 77.9%

How often patients had less pain when moving around 67.8% 79.9% 78.6%

How often patients breathing improved. 82.4% 75.8% 77.8%

How often HH began patients’ care in a timely manner. 96.5% 96.8% 94.3%

How often patients got better at taking their drugs by mouth. 59.0% 70.2% 66.7%

How often the HH team checked patients’ risk of falling. 100.0% 99.6% 99.6%

How often the HH team checked patients for depression. 99.4% 97.8% 97.6%

How often HH patients had to be admitted to the hospital. 17.8% 16.1% 15.8%

Would patients recommend the agency to friends and family. 79.0% 83.0% 78.0%


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Low therapy utilization pre-PPS

Current high therapy utilization

Appropriate therapy utilization

CPAs & ADVISORS

Lessons Learned From Pre-Claim Review

Karen Vance, BSOTSenior Managing [email protected]

Therapy Practice Changes with PDGM

therapy practice changes with pdgm - new england home care … · 2019. 5. 31. · incorporating...

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