You can kiss missed visits’ goodbye with good quality improvement
You can kiss missed visits’ goodbye with good quality improvement
Staff education, protocols drastically cut missed visit rate
Missed visits do more than adversely affect patient satisfaction. Dropping the "billable visit" ball is a fumble that can decrease your home care company’s revenues, hinder adherence to physicians’ plan of care, and interfere with achieving patient care goals.
Not only that, but a continual missed visit problem can display a lack of care coordination that will make a Joint Commission surveyor cringe. And if you think accidentally billing Medicare for a visit that wasn’t made when it was scheduled will be seen as an honest mistake, you haven’t been reading the newspapers in the last few months.
But what to do?
Tommie O. Baker, RN, quality assurance coordinator for San Antonio-based Morningside Home Health Care, found unaccounted visits when comparing physician orders to visit notes in patient charts in 1995. She led the agency on a quality improvement project that reduced the missed visit rate from a high of nearly 4% of total visits to .8% over the course of two years. By February 1997, the small agency’s mere 18 missed visits out of 2,173 total for all disciplines indicated the agency no longer needed to monitor the missed visit rate monthly.
Tracking missed visits is no small feat, considering that all of the agency’s field staff are pool staff, and the agency contracts with other services such as physical therapy, occupational therapy, social work, speech therapy, and nutritional therapy.
Before Baker established strict protocols for reporting missed visits, contracted staff "could have missed visits for an entire week and we wouldn’t have known about it," Baker says. Now, the agency knows at least weekly, and sometimes daily if warranted.
Here’s how she did it:
1. Find out what’s missing.
To find out the scope of your problem, you must first make sure all missed visits are indeed being reported. When Baker first began compiling missed visit data, she included only the missed visit reports on file.
But by comparing physicians’ orders with patient and billing records, Baker was able to find missed visits for which the missed visit reporting form was not filled out. So several months into the project, the number of missed visits seemed to go up as staff became more diligent about filling out and turning in the missed visit form. Though she hadn’t yet solved the problem, she could see that her system for tracking and reporting the missed visits was working.
Of the forms that did reach her desk in the first months of the project, some did not reach her until seven days after the visit was missed.
And the final missing piece: Physicians were not being notified in a timely fashion when a visit was missed, she says.
• Establish protocol for reporting missed visits.
All contracted staff must fill out a missed visit form to turn in with their weekly paperwork if they miss one visit. If they miss more than one a week, they must call the agency immediately. Care coordinators then fax the missed visit report as soon as they get it to the physician’s office so the physician is notified in a timely manner. Also, contracted staff are required to call the agency’s care coordinator weekly to discuss the patient’s status.
Pauline Baca, RN, is one of three patient care coordinators at the agency who use physician orders and visit calendars to make the weekly staff schedules. Home health aides come in weekly to pick up their schedules and approve and sign one copy that stays in the office to prove they agree to the arranged visits. They call in daily to double-check their schedules with the coordinators, who initial that they called in that day.
"Communication is the big problem," she says. "You really have to stay on top of it." Aides who don’t call in are reported to the director of nursing. Any changes in the schedule, such as if a family member calls in to postpone a visit, are relayed by paging the involved staff immediately, says Baca, who also is a member of the QI team.
• Learn who’s missing visits, why, and when.
One way Baker devised to track missed visits is to have patient care coordinators complete "visit calendars" for each patient each month beginning with the start of care. The calendar plots out and color-codes the type of visits ordered each day. The recertification nurse completes new calendars with each recertification.
Baker then color-codes the visit notes, which are turned in weekly, to correspond to the type of service that is ordered, per the visit calendar.
"If we don’t have a visit note, I find out why not," says Baker. In the beginning, she would call contractors to determine the reasons.
Missed visits are circled in red on the calendar, with explanatory codes written next to them. A slash mark through the visit indicates to billing that a visit note is not needed for that day because the visit was made on another day and the frequency was still accomplished. In this way, Baker was able to quickly see who was missing visits and why, without poring through patient records.
She found that the majority of missed visits were skilled nursing and home health aide visits, followed by physical therapy visits. The most common reason for missed visits was that the patient and/or family had decided they did not want the visit. Other reasons included:
staff or scheduling errors;
the patient was at a doctor’s appointment and not at home;
staff encountered no answer or a locked door.
Baker looked for patterns and did not find a higher incidence of missed visits on the weekends as opposed to weekdays. Nor did she find that increases in missed visits correlated to increases in patient census.
She compiled informal weekly reports for the administrator, as well as more formal monthly reports that showed the percentages of missed visits per discipline and per reason for administration and staff.
• Educate all staff.
Pool staff were continually involved in the process and in the quality improvement project’s findings, which were presented during mandatory staff meetings each month or every two months. "A lot were not aware of the importance of why they needed to report this," Baker says.
"Every now and then we have to reinforce the issue with only one or two people, because everyone knows what is expected," she says.
Contracted staff were educated about the agency’s requirements for reporting missed visits, and the agency reserves the right to work with contracted services that adhere to its quality standards and reporting requirements.
• Plan to prevent.
Because patient and family decisions were the biggest reason for missed visits, Baker reviewed the frequency of visits to these patients to see if they were too high. The agency wrote interim orders to decrease visits for patients who had family members available on weekends, for example, and did not want a home health aide then. They then communicated the change to the physicians along with the reason. She increased her staff teaching on patient assessment and homebound status, as well as family education on homebound status.
Staff also were instructed to ask during each visit about the feasibility of the next scheduled visit, and to note answers on the back of the visit note in the section for discussing any changes in the plan of care with the family. During this time, staff would find out if a conflicting doctor’s appointment would interfere with the next scheduled visit, and the agency would be able to reschedule. For those with daily visits, the agency got an order to omit the visit on the day the patient went to the doctor’s appointment.
Likewise, staff would find out if the family planned to take the patient out of town for the holidays, and would get an order to put the service on hold until the patient was returned.
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