New agency teaches all staff,disciplines how to be PPS-ready
New agency teaches all staff,disciplines how to be PPS-ready
Director offers tips on getting most out of OASIS assessment
When Athens (GA) Regional Home Health/Home Infusion opened its doors on Dec. 10, 1998, the home health industry was going through a very tough time. The interim payment system (IPS) had forced hundreds of agencies to close their doors, and Medicare reimbursement looked increasingly grim.
But since the Athens Regional Medical Center had been planning to open a home care agency for years and had to wait to receive state approval, its leaders were instead optimistic, believing that the home health agency opened at the perfect time. This new agency had the opportunity to hire and immediately train staff to work and think in terms of a prospective payment system (PPS) world. There were fewer old habits to break and fewer old attitudes to overcome, says Carol Jelke, RN, BBA, executive director of the agency, which serves five counties in northeastern Georgia. "We just decided that we would adopt the philosophy of PPS from day one," Jelke says. "We’ve been working toward that all along, even though we didn’t know how it was going to play out when we opened."
Staff focused on teaching independence
For instance, the agency’s staff never were permitted to approach their jobs from a fee-for-service perspective. Rather than think of cases in terms of the number of visits they might require, nurses were encouraged to think in terms of providing a reasonable number of visits, working toward the goal of helping patients become independent.
That means there is much less emphasis on home health aide visits than what has been typical among home care agencies. Jelke reports that while a typical agency in 1998 or earlier might have 30% to 40% of all visits being made by a home health aide, the Athens agency only had 9% to 10%.
"We never attempted to go down that road," she says. "From day one, we’d say, Does this home health aide and the scope of service she’s going to provide really fall in line with the whole plan for this patient?’"
While nurses sometimes think of home health aide visits as being a way to help patients and families with increasingly difficult activities of daily living (ADLs), the new philosophy caused them to look at the negative side, which is that aide visits can increase a patient’s dependency, Jelke says.
The agency also expects all physical therapists (PTs) to open new cases for patients who will receive only therapy visits. This saves unnecessary nursing time, and it only required educating PTs about the Outcome and Assessment Information Set (OASIS) and PPS, she adds.
Physical therapists serve as staff educators on how to perform the best functional assessment using OASIS. The agency started this type of education last year, and the benefit has been that chart reviews show nurses are consistent in how they assess functional limits.
"We’ve been doing a good job and it’s been consistent over time," Jelke says.
In addition, nurses are taught to look at their productivity not in terms of the number of visits they make in a given day, but in terms of how well they can teach patients and caregivers to become independent of nursing care. So nursing visits at the Athens agency typically last 50-54 minutes, as opposed to the 30-36 minutes that is more common in the traditional agency, she explains.
"We spend the time doing a lot more teaching," Jelke says. "Some of the philosophy I’ve adopted and tried to communicate to nurses is that their patients and clients come out of the hospital ready to learn and wanting to learn. You should get most of your teaching done within the first three weeks of seeing them, when they’re more willing."
Old way: Teach a little each visit
The old philosophy at some home care agencies was to teach a little bit on each visit; and so long as there was a skill involved, the agency would be reimbursed, she adds. "So you’d drag it out — but now you do it quickly, and ultimately, I think it’s better for patients."
When the proposed rule came out during the agency’s first year, Jelke began to look for specific ways she could improve staff education about PPS and the agency’s potential reimbursement under PPS. Here’s how she did that:
• Assess patient profiles. "First, we collect data by the patients [who were] discharged each month, and then we look at which home health-related group [HHRG] they fall into, and how many visits did we have to serve them," Jelke says.
After collecting the first data in December and January, Jelke determined that the staff needed to learn how to appropriately select diagnoses for patients. "We had a big program in mid-February, and we are now collecting data from February, March, April, and May, and we have so far seen a significant change in our groups of utilizations," she says.
C-2, C-3 ratings receive more reimbursement
• Look for trends on OASIS assessments. While diagnosis-related groups (DRGs) are driven by diagnosis, HHRGs are not, except for the diagnoses of neural, ortho, and diabetes. "We now have a payment system driven with information off the nursing assessment," Jelke explains.
This is why staff education is so crucial. If nurses are consistently making mistakes on the OASIS tool, or if they are overlooking certain patient problems, then the agency will not be reimbursed for all that it is entitled to receive. And a lot of those decisions involve ADLs, such as whether the patient can dress or bathe.
The agency discovered through audits that its nurses were consistently and accurately assessing patients’ functional status. But the audits spotlighted discrepancies in how nurses assessed the clinical dimension indicators. For example, by examining the answers to the OASIS questions related to scoring the clinical dimension as a whole, it was determined the staff had assigned a C-0, which means there is little or no problem on a particular indicator, to 32% of patients. Nurses gave a C-1 rating to another 30% of patients. At C-2, there was an average of 17%, and the C-3 rating received 21%.
Now, PPS will pay agencies slightly more for patients who receive the higher ratings of C-2 and C-3, because this means the patient has more clinical deficits and likely will need more skilled care. So if nurses are under-reporting clinical problems, this could cost the agency money, Jelke explains.
• Educate staff on ways to improve assessment. Once Jelke identified that clinical assessment could be a problem for nurses, she developed some educational material and held an inservice to teach nurses how to better assess patients.
For example, a nurse might ask a patient, "Do you have a lot of pain?" And the patient, who is old and expects that pain is part of being old and therefore believes it does no good to complain, may answer, "Oh no, I’m OK." So, the nurse would check the 0 box on the pain indicator/MO420.
But suppose the truth is that the patient is in pain, even considerable pain, and just doesn’t want to appear to be complaining about it. Assuming that for many patients this might be the case, the nurse could assess this indicator in a more thorough way. The nurse could say to the patient: "Let me see you get up from your chair and try to walk over to here." Then, the nurse could observe the patient to see if the patient ignores the request or grimaces when slowly trying to stand and walk. Those would be indication that the patient is experiencing some pain.
Also, nurses could closely examine all of the patient’s medications to see if there are any painkillers or anti-inflammatories that may indicate the patient is in pain. "We look at how they are having these pain medications refilled," Jelke says, "and we try to talk with them about activities they are not doing anymore and why they are not doing them, because this could be the result of pain."
These are strategies the agency uses to dig for the truth on the clinical indicators. "You’re not asking these questions to just get a higher score, but these questions can help us to be better clinicians," she says.
Jelke took each of the OASIS items that are included in the PPS payment determination and wrote some strategies for making sure the assessment is complete. Then she handed them out to staff as part of the inservice. For instance, one page of the handout has the title, "OASIS Item (MO488)" at the top. Below, it reads, "Status of Most Problematic (Observable) Surgical Wound: 1 — Fully granulating; 2 —Early/partial granulation; 3 — Not healing; NA — No observable surgical wound.
The page also includes the definition of the intent of the question, and a PPS calculation impact as to how many points are given for each box.
Box gives nurses reminders on 485 impact
Jelke wrote a "485 Impact" box that gives nurses reminders, such as "Do not forget to identify supplies to be used in the care of the wound," and "Be specific on the wound treatment."
Below that she has a box stating the "Impact of answers on need for other services." Finally, there are boxes listing "Response-Specific Instructions," and "Strategies to obtain and collect accurate data and responses."
Under the latter box for surgical wounds, it reads, "Inspect each surgical wound to determine its status. Based on this information and that from the health history, use clinical reasoning to determine the most problematic (observable) stasis ulcer."
The final box item is a list of time points when the item is completed. In the surgical wound item’s case, those would be at the start of care, resumption of care, follow-up, and discharge from the agency — not to an inpatient facility.
The additional staff education on the clinical dimension had a striking impact. Chart reviews showed that after the education, the percentage of patients who fit into the C-0 category was 18.5%; in C-1, the number fell slightly to 27%; C-2 rose to 27%, and C-3 stayed about the same at 22%.
• Show staff how to be cost-efficient.
"It’s not only cutting costs, it’s changing a philosophy," Jelke says. "You have to do this because these payments are not great, and it will be extremely challenging to at least break even under PPS."
This means the staff must work hard at encouraging caregivers and patients to do more for themselves earlier in their home care treatment. This will be the most important way to cut visits and still maintain quality, Jelke says.
For instance, nurses need to teach families and patients that the home care agency isn’t the answer to all of their problems, but is only there to guide them to independence.
"The biggest thing is you have to help your staff understand and appreciate that they are the skilled caregiver, and their role is to deliver a skill — not to become the caregiver for the patient," Jelke says.
Another important strategy is to provide total case management, including bringing in social workers when needed, or keeping in close contact with the patient’s physician. That way, the agency can recommend medication, social service referrals, and other changes when they might help a patient make faster and better improvements.
"You have to be tight in case management," Jelke says. "You can’t let those visits get away, and you can’t delay taking action."
The agency’s staff have become so efficient in care that when Jelke did a preliminary PPS analysis to see what the agency might have been paid under PPS, vs. IPS, she found that the agency would have received more reimbursement under PPS.
• Carol Jelke, RN, BBA, Executive Director, Athens Regional Home Health/Home Infusion, 1199 Prince Ave., Athens, GA 30606. Telephone: (706) 559-5500. E-mail: [email protected].
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