2012 PPS FINAL RULE. What Home Health Agencies Need to Prepare For. Arnie Cisneros, P.T. 10/9/12. HEALTHCAREfirst

Transcription

1 What Home Health Agencies Need to Prepare For Arnie Cisneros, P.T. HHSM 30 years Medicare Care Continuum 30 year Home Health clinician/contractor Home Health consultant & speaker Clinical Expert Home Health Audits Progressive clinical delivery/management Home Health coach/educator Authors Home Health Forum 2012 PPS FINAL RULE HEALTHCAREfirst

2 2012 PPS Reforms Case Mix Creep Adjustment Market Basket Reduction Hypertension Therapy Payment Re-Allocation Face to Face Clarification 2013 (And Beyond) Reforms Accountable Care Organizations Post Acute Bundling Removal of Direct Therapy Reimbursement Potential Copayments - Non Post Acute Dombi s Thoughts on the Future Ten years from now, homecare will still be around but it will be different; it will not be what we see today, it will be a much, much bigger realm of homecare services; it may not even be called Home Health anymore. HEALTHCAREfirst

3 Dombi s Thoughts on the Future It s not just price per visit, it s outcomes. If I m an ACO, I don t want you because you re cheaper, I want you because you cost less in a dynamic way: less rehospitalizations, better management of patients, better integration, etc. We have the skill set and the infrastructure, we just have to adapt. Dombi s Thoughts on the Future Budget some of your energy and resources towards keeping the ship afloat, dealing with current care, the proposed cuts, etc., while devoting energies as well to those new opportunities that are out there. If you don t, somebody else is, and they will be the one who succeeds. PATIENT PROTECTION AND AFFORDABLE CARE ACT (PPACA) HEALTHCAREfirst

4 ACCOUNTABLE CARE ORGANIZATIONS POST-ACUTE BUNDLING We will discuss key elements of the PPACA and how the Rehabilitation Institute of Michigan (RIM) is building the case to incorporate a post-acute strategy into the Accountable Care Organization (ACO) model at the Detroit Medical Center (DMC), an integrated healthcare system. HEALTHCAREfirst

5 Triple Aim Philosophy PPACA was created with a triple aim in mind: 1. Improve the health of patient populations 2. Improve patients experience of healthcare 3. Reduce per capita costs of healthcare The components of the Triple Aim are not independent of each other. Changes pursuing any one goal can affect the other two sometimes negatively, sometimes positively Donald Berwick, Triple Aim: Care, Health and Cost; Health Affairs; 27, no. 3 (2008) Key Components of PPACA ACO metrics Payment bundling Care transitions management Value-based reimbursement (large acute care focus.for now!) Insurance reform (increased access to care for patients) Accountable Care Defined An ACO is an entity introduced by the Patient Protection and Affordable Care Act of It is defined as an organized group of healthcare providers who share a financial incentive to be accountable for managing the quality and cost of care across the continuum HEALTHCAREfirst

6 Acute Care Hospital Pharmacy Outpatient Centers ACO Physician Alignment (PHO) LTACH/IRF/ SNF/HHC 16 Post-Acute Benefits to Acute Care Pre-PPACA : Reduce LOS Follow hospital/physician treatment plan Volume-based payments Minimal transparency Post-PPACA : Improve continuity of care and quality Improve patient experience Decrease post-acute care costs Decrease avoidable readmissions Value-based payments (bundling and quality) Increase transparency Care Transition Model Post-Acute Bundling Re-invent Acute Discharges Decreased Re-hospitalizations Find Savings/Efficiencies Re-examines Acute Episode HEALTHCAREfirst

7 Post Acute Bundling Preferred Vendor Roster Long-term Acute Care Hospital Inpatient Rehabilitation Facility Skilled Nursing Facility Home Health PPS Legacy per Care Site PPS History per Vendor Type Inpatient Rehab 75% Rule Decreased Census Decreased LOS Care Relocated SNF Care Relocated HH PPS History per Vendor Type Skilled Nursing Facility 1996 PPS RUG Method Decreased LOS Care Delivery Reassessments HEALTHCAREfirst

8 PPS History per Vendor Type Home Health 1999 IPS 2000 PPS OASIS High Therapy Threshold OASIS-B--Reassessments Graded Therapy Payment Therapy Reallocation Hardwiring Value Expedient acceptance of patients (barriers delay care) Proven ability to manage high acuity patients Clearly define clinical vulnerabilities and strengthen them Better care integration and coordination Data integration Improved efficiency and streamlined processes Outcomes measurement/reporting - transparency Provide expertise in Accountable Care strategy Medicare Home Health What Will the Future Look Like? HEALTHCAREfirst

9 Home Care of the Future Resemble Inpatient Care of the Past Rather than Home Care of the Past Home Care of the Future It s not about HOME CARE It s about MEDICARE HEALTH CARE 2012 THERAPY RE-ALLOCATION HEALTHCAREfirst

10 C-F Profile Clinical/Functional Stages clinical/functional severity as a separate step, avoiding un-desired influence from payment levels on care volumes. Home Health Resource Group (HHRG) HHRG Components C F S Clinical C Nursing Component Functional F ADL/IADL Declines Service S Therapy Visit Volume Clinical/Functional Profile Variable Service (Therapy) Component HEALTHCAREfirst

11 HHRG - Based PPS REIMBURSEMENT (2012) C1F1 HHRG Payments $6,500 $6,000 $5,500 $5,000 $4,500 $4,000 $3,500 $3,000 $2,500 $2,000 $1,500 GROSS PAYMENT/PER HHRG $4,812 $4,363 $ $3,913 $ $3,464 $ $3,122 $ $2,438 $2,096 $1,754 $ $ $ $2,780 $ GROSS PAYMENT/PER VISIT $ S1 S2 S3 S4 S5 S1 S2 S3 S1 (0-5) (6) (7-9) (10) (11-13) (14-15) (16-17) (18-19) (20) C1F1 C1F2 HHRG Payments $6,500 $6,000 $5,500 $5,000 $4,500 $4,000 $3,500 $3,000 $2,500 $2,000 $1,500 $5,154 GROSS PAYMENT/PER HHRG $4,662 $ $4,170 $ $3,678 $ $3,379 $3,079 $ $2,780 $ $2,502 $2,203 $ $ GROSS PAYMENT/PER VISIT $ $ S1 S2 S3 S4 S5 S1 S2 S3 S1 (0-5) (6) (7-9) (10) (11-13)(14-15)(16-17)(18-19) (20) C1F2 HEALTHCAREfirst

12 C2F1 HHRG Payments $6,500 $6,000 $5,500 $5,000 $4,500 $4,000 $3,500 $3,000 $2,500 $2,000 $1,500 $5,218 GROSS PAYMENT/PER HHRG $4,769 $ $4,320 $ $3,849 $ $3,464 $ $3,037 $2,630 $ $ $2,203 GROSS PAYMENT/PER VISIT $ $1,775 $ $ S1 S2 S3 S4 S5 S1 S2 S3 S1 (0-5) (6) (7-9) (10) (11-13)(14-15)(16-17)(18-19) (20) C2F1 Non-Visit Therapy Payments Clinical / Functional Analysis C1 C2 Progression = $21.00 F1 F2 Progression = $ Functional / Clinical Ratio = > 20/1 THE FUNCTIONAL SECTION F HEALTHCAREfirst

13 S.U.R.C.H. SERVICE UTILIZATION REVIEW for CARE in the HOME (S.U.R.C.H.) S.U.R.C.H. PLAN OF CARE Create clinical expectations for programming based on QA identified clinical concerns or deficits share expectations with front line clinical staff prior to care initiation. HEALTHCAREfirst

14 SURCH PROTOCOL SURCH PROTOCOL Clinical Profile -Start of Care date -Age -Diagnosis SURCH PROTOCOL M1000 Inpatient Facilities M1100 Patient Living Situation M ADL/IADLs HEALTHCAREfirst

15 SURCH PROTOCOL M1000 Inpatient Facilities - Acute Hospital - Inpatient Rehab - Skilled Nursing Facility - Community Referral M1100 Patient Living Situation - Caregiver SURCH PROTOCOL M1240 Pain Assess M1400 Short of Breath M1610 Incontinence SURCH PROTOCOL M1400 Short of Breath - SN unless functional decline - Rehab if ADL declines present - Respiratory HEP not Pursed breathing HEALTHCAREfirst

16 SURCH PROTOCOL M1300 Pressure Ulcer M1330 Stasis Ulcers M1340 Surgical Wound SURCH PROTOCOL M2020 Oral Medications M2030 Injectable Meds M2040 Prior Medication Mgt FUNCTIONAL DOMAIN M1810 M1820 M1830 M1840 M1845 M1850 M1860 DRESSING UPPER - OT DRESSING LOWER - OT BATHING OT TOILETING OT/PT TOILETING/HYGIENE OT TRANSFERRING - OT/PT AMBULATION - PT HEALTHCAREfirst

17 SURCH Functional Domain DUB DLB BATH TT/TH TRANS GAIT Functional Domain Intrinsics N/A 0/1-2 3 Ambulation SURCH PROTOCOL - PLOF Self Care Ambulation Transfers Household Tasks (M1900) HEALTHCAREfirst

18 SURCH CASE CONFERENCE MULTI-DISCIPLINARY CASE CONFERENCE TEAM SUPERVISOR RN PT OT ST MSW SURCH CASE CONFERENCE RN Monday 4 p.m. PT Monday 10 a.m. TEAM SUPERVISOR MSW Wednesday 9 a.m. OT Tuesday 2 p.m. ST Thursday 1 p.m. HEALTHCAREfirst

19 CONFERENCE DIALOGUE Objective Findings/Programming Skilled Care Plan Skilled Programming Home Program/Compliance/Caregiver Clinical Education Skilled Progression/Documentation Skilled Discharge/Care completion Home Health Checklist Eliminate Certification Period Orders Establish SOC Utilization Per Agency Validate All Care Plans At Eval Constantly Review Utilization Eliminate Social Visits with Vitals Control Therapy Content/Skill/Outcomes 2013 Home Health Checklist Assure Clinical/Utilization Progression Improve Staff Productivity Decrease Clinical Utilizations Refine Strict PPS-Adherence Eliminate Outdated Agency Protocols Embrace the Future of Home Health HEALTHCAREfirst

20 WHAT IF THE PATIENT WAS YOUR AUNT? Home Health Strategic Management HHSM HEALTHCAREfirst HEALTHCAREfirst