Indiana Association for Home & Hospice Care Shaping the Change May 6, Bonny Kohr, FR&R Healthcare Consulting, Inc.

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1 Indiana Association for Home & Hospice Care Shaping the Change May 6, 2014 Bonny Kohr, FR&R Healthcare Consulting, Inc. Rebecca Zuber, Rebecca Friedman Zuber, Inc. Where you are going--destination Desired outcome The end toward which effort is directed Rehabilitation potential The state of affairs that a plan is intended to achieve End point 2 To improve the quality of our care To identify the outcomes we are trying to achieve So that we know when to quit To shape and manage expectations To develop a relationship with the patient/caregiver To ensure that everyone is on the same page To get the patient where they want to go 3 1

2 To help maintain compliance with requirements Medicare COPs (a) Plan of care language does not specifically refer to goals, but goals are implied (b) Quarterly clinical record reviews evaluate whether the goals or anticipated patient outcomes are appropriate 4 To help maintain compliance with (more) requirements Medicare Coverage Requirements Pub , Ch 7, Sec Goals specifically mentioned for therapy services, implied for plan of care Pub , Ch 7, Sec Periodic therapy evaluations examine progress toward goals and likelihood they can be reached with additional services LCDs Home Health Physical Therapy (L31542) Home Health Speech Language Pathology(L31533) Home Health Occupational Therapy (L31530) Home Health Skilled Nursing Care-Teaching and Training: Alzheimer s Disease and Behavioral Disturbances (L31532) 5 Must be measurable Must be achievable Must be meaningful Must pertain directly to the patient s illness or injury Must be mutually agreed upon, or at least known Must be time-limited or specified Progress must be tracked and evaluated periodically Must be adjustable 6 2

3 Specific Measurable Attainable Rewarding Timely 7 Measurement does not always require direct quantification Quantification is more possible in home care than we like to think Measurement is uncomfortable because it represents accountability Measurements don t always capture the intangibles Measurement requires discipline and consistency and appears to challenge professional judgment 8 Wound dimensions TUG score Presence or absence of a Stage 2 decubitus ulcer Score on an OASIS ADL item Pain self-report Blood sugar variation across time How often pain medication is taken each day Extent of epithelialization 9 3

4 Episodes of shortness of breath per day Ability to answer questions about medication regimen Variation in daily weight Frequency of anxiety attacks Self-report value on depression scale Acceptance and use of adaptive equipment Patient/caregiver s ability to identify symptoms of infection 10 We Have Language Confusion 485=Plan of Treatment=Plan of Care Plan of Care=Nursing Care Plan OR Therapy Eval/Plan of Care Here s the Reality Form 485 no longer required by CMS but the content is CMS changed COP language to Plan of Care several years ago to comply with statutory change Indiana regulations refer to the Medical Plan of Care AND to a Nursing Plan of Care 11 Let s Agree on Accurate and Common Terms Plan of Care=medical plan of care that includes all disciplines and frequencies; medications, treatments and interventions; long-term goals of the planned care; all other descriptive components of the 485 Nursing Care Plan=expanded and more detailed description of what the nurse is going to do and how it will contribute to the long-term goals of the Plan of Care Therapy Eval/Plan of Care=documentation of therapy evaluation and expanded and more detailed description of what the therapist is going to do and who will contribute to the long-term goals of the Plan of Care 12 4

5 Let s Agree on Accurate and Common Terms Long-Term Goals The measurable outcomes to be achieved during the current, anticipated period of home health service delivery (one or more episodes) These are what you put in your Plan of Care Short-Term Goals Measurable midpoints to be achieved during a defined period of home health service delivery A single episode of an anticipated multi-episode Plan of Care A specified number of weeks or days in a single episode plan of care These go in your Nursing Care Plan, Therapy Plan of Care and some may be included in your Plan of Care 13 Let s Agree on Accurate and Common Terms Interventions The skilled and unskilled services that will be provided to achieve short-term and long-term goals These go in your Plan of Care Action Steps The details of the interventions that will be provided These go in your Nursing Care Plan, Therapy Eval/Plan of Care, Social Work Care Plan, Home Health Aide Care Plan, etc. 14 What s the Difference? Goal= where we are going Intervention=how we will get there Components of the Goal Who will be affected? (subject or focus) What will happen? (behavior or health status change) When will it happen? (time frame) What will achievement look like? (measurement) 15 5

6 Components of the Intervention What will be done? (action steps) Who will do it? (HHA staff, patient and/or others) When will it be done? (frequency) How will we be accountable? (measurements and documentation) 16 Improvement goals Can we actually facilitate improvement in the patient s condition? Stabilization goals Can we keep the patient from getting worse? Quality of life goals Can we help manage symptoms to maintain quality of life? 17 Will the patient s condition improve and/or can we make it better? Patient s ability to ambulate will improve from a 2 to a 1 on M1860 within 6 weeks Stage 3 decubitus ulcer will progress from not healing to fully granulating within 8 weeks OASIS score on management of oral meds will improve from a 2 to a 1 on M2020 by the end of the third week of the episode 18 6

7 Can we keep the problem from getting worse or keep complications from occurring? The patient s stasis ulcer will be infection free for 6 weeks The patient s cancer pain will be maintained at or below 4 The patient s ability to maintain her current independence in grooming, upper and lower body dressing, even with increased inflammation due to arthritis, will be maintained for the next 8 weeks The patient will avoid emergency room visits due to CHF crises for the next 9 weeks 19 Given the patient s condition, how can we help to provide the best quality of life, comfort, and dignity for the patient? The patient will require diapers for incontinence only during the evenings and at night within 4 weeks The patient s pain will decrease to daily, but not constantly within 4 weeks The patient will maintain her ambulation distance at a minimum of 300 feet in order to attend her granddaughter s graduation in 6 weeks 20 Review the referral information Conduct the comprehensive patient assessment Ensure that the assessment includes patient s prior condition and function Discuss the referral information and the findings of the assessment with the patient and family/caregiver(s) ask patient what they want Identify all potential goals and how they would be measured Discuss the interventions that would be required to achieve these goals &/or that have been ordered by the physician Identify mutually agreed-upon and realistic goals 21 7

8 Begin with the overall reason for home health involvement Why was the patient referred? What goal would support reasonable and necessary? What goal will support the need for the skills of a nurse or therapist? Nursing: Services that must, under state law, be performed by a registered nurse, or practical nurse OR that require the skills of a nurse to deliver to this patient in his/her condition Therapy: Skilled services expected to improve the patient s condition in a reasonable and generally predictable period of time and/or skilled services that are necessary to the establishment (or sometimes delivery) of a safe and effective maintenance program 22 Goals found during review of clinical records Treatment of signs and symptoms Optimal breathing Pt/CG can demonstrate measures to maintain/improve mobility Patient/CG will cope with change in lifestyle Problem This is not a goal What is optimal breathing for this patient? How are you going to achieve it? What measures? No specificity. What skill are you providing? Patient will maintain optimum level of functioning appropriate for stage of disease process Pt. can demonstrate ambulation/weight bearing Wound healing If the patient is at optimum level (maintain) then why do they have home health? Demonstrate with/without an assistive device? Is it met if they demonstrate it for 5 feet? Is it met if they wobble while they walk? Is it met when there is any healing? Is it met when it is completely healed? 23 What might the real goal be? In place of Optimal breathing Patient will be able to perform independent bathing without experiencing shortness of breath by end of week four In place of Pt/CG can demonstrate measures to maintain/improve mobility Caregiver will demonstrate safe transfer of patient in/out of tub 24 8

9 What might the real goal be? continued In place of Pt. can demonstrate ambulation/weight bearing Patient will be able to stand and pivot with standby assist and verbal cueing by end of week 6 Patient will be able to ambulate 50 feet independently with front wheeled walker by the end of week 6 In place of Wound healing Pressure ulcer right hip will be fully granulated by the end of week 8 25 What might the real goal be? continued In place of Patient/CG will cope with change in lifestyle Patient/CG will accept and implement home adaptations recommended by the end of week 4 In place of patient will maintain optimum level of functioning appropriate for stage of disease process Patient will be able to transfer Patient will be able to ambulate Patient will be able to dress self Patient will be able to bathe self 26 Use short-term goals to accomplish longterm goal targets If long-term goal target is greater then two weeks break the goal down into manageable time frames (e.g. short-term goals) May or may not wish to include all short-term goals on the Plan of Care 27 9

10 Long-Term Goal Short Term Goals Patient/CG will be independent in bathing by the end of week 4 Caregiver will obtain tub transfer bench by the end of week 1 WHICH OF THESE WOULD YOU WANT TO INCLUDE ON THE PLAN OF CARE? Patient will demonstrate ability to use tub transfer bench with cueing by the end of week 2 28 Long-Term Goal Short Term Goals Patient will be able to stand and pivot with standby assist and verbal cueing by end of week 6 Patient will demonstrate appropriate strengthening exercise as part of HEP by end of week 1 WHICH OF THESE WOULD YOU WANT TO INCLUDE ON THE PLAN OF CARE? Patient s lower extremity strength will increase from to as demonstrated by end of week 3 29 Long-Term Goal Short Term Goals Pressure ulcer right hip will be fully granulated by the end of week 8 Patient/caregiver will demonstrate accurate wound care technique by end of week 1 WHICH OF THESE WOULD YOU WANT TO INCLUDE ON THE PLAN OF CARE? Wound measurements will be 2cm width x 3 cm length and 2cm depth by end of week

11 Modify the goal(s) as needed based on patient progress and patient/caregiver feedback Patient situation changes Patient determines that they don t wish to accomplish goal as established Health status or problem changes Goal is met earlier than anticipated 31 Identify professional activities, patient activities and caregiver activities Steps that lead toward the goal What needs to be done Who needs to perform the action(s) Frequency-number of visits required per day, week or month to accomplish the goal Time frame or duration-length of time the services will be needed to accomplish the goal 32 Type of interventions which qualify a patient for Medicare reimbursement Nursing Teaching and training Observation and Assessment Management and Evaluation of a patient care plan Direct care 33 11

12 Type of interventions which qualify continued Therapy Assessment of rehab needs and development and /or implementation of a therapy program Therapeutic exercises Teaching Gait training Establishing and performing a therapy maintenance program 34 Type of interventions which qualify continued Medical social work Assessment of social and emotional factors related to illness, response to treatment and recovery Assessment of home situation, financial resources and community resources available to meet needs Action to obtain community resources Counseling services needed by patient Medical social services provided to family/caregiver to clear a direct impediment to patient s treatment (brief) 35 Type of interventions which qualify continued Home Health Aide Personal care Assistance with therapy Simple dressing changes Assistance with medications ordinarily selfadministered Other services incidental to personal care Light housekeeping and laundry Meal prep and feeding 36 12

13 Orders (actions) found during review of clinical records Teach importance of diet SN: Assess support systems, community resources/financial resources SN to perform wound care MSW to evaluate financial status PT/OT/ST to evaluate and treat PT to perform home safety/falls prevention Problem Diet restrictions not specified, who is being taught, who is doing the teaching Purpose is not identified Action not included Wound treatment not specified, frequency not specified Purpose is not identified This is not an order for ongoing service Falls prevention is different for each patient 37 What might the action steps look like? In place of teach importance of diet SN to instruct patient/cg on low sodium diet and effects on fluid retention In place of SN to perform wound care SN to provide skilled observation and evaluation of surgical site, to teach sterile dressing changes to pt/cg and to perform sterile dressing changes. Wash wound with sterile saline, apply sterile 4x4 and cover with ABD What s still missing? 38 What might the actions steps look like continued? In place of MSW to evaluate financial status Social worker to assess financial barriers related to home adaption needs Social worker will assist in securing resources to fund home modification equipment as needed by pt/cg Social worker will provide counseling to patient to assist in acceptance of the need for home adaptation 39 13

14 What might the actions steps look like continued? In place of PT to perform home safety/falls prevention Physical therapy for transfer training, strength training and HEP design Home Health aide to assist with transfers and bed bath while encouraging patient to implement home exercise program and using verbal cues 40 If the actions are ineffective, determine what can be changed Choice of treatment Person(s) responsible for the care Environment 41 If the actions are ineffective due to nonadherence, determine if changing the action will improve compliance Too difficult? Too costly? Too time consuming? Too much too soon? Not challenging enough? Not really what the patient wants? 42 14

15 Does the change in the action steps require new intervention orders? Yes, if it alters the care as ordered by the physician Example: change in type of wound dressing No, if it does not impact the disciplines and frequencies; medications, treatments and interventions on the previous order Example: initial order was for pt/caregiver to be taught dressing changes. The action steps changed from teaching the patient to teaching the caregiver 43 (see attachment # 1) Keep it simple and specific Share goals and tracking with patient/caregiver Review goal progress at each visit 44 Stage 3 Pressure Ulcer Admit date 01/17/11 Visit frequency 3 times per week for first two weeks (see attachment # 2) 45 15

16 Review goal progress at each visit Documentation should include review of short-term and long-term goals with patient/caregiver Document if the pt/cg verbalizes continued support of the goal(s) Document actions taken by pt/cg which support the goal(s) or oppose the goal(s) Document notification to MD and other caregivers when pt/cg no longer support action steps or goal(s) 46 Review goal progress at each visit continued Document what progress is occurring - not simply that progress is occurring Poor example: Goals partially met; patient continues to make progress according to plan of care Better example: Patient verbalizes accurate dietary restrictions but acknowledged failure to follow them. Patient demonstrated correct syringe preparation using magnifier. Patient failed to demonstrate correct injection technique. Patient injected insulin into the air. 47 Review goal progress at each visit continued If lack of progress, document patient/caregivers response to the lack of progress Do they care, do they need more education, are they frustrated? What s the plan to deal with the response? 48 16

17 Assessments + Interventions = Goals (SN) Patient s caregiver will be independent in medication administration/compliance in two weeks (OT) In two weeks patient will have increased fine motor coordination w/left upper extremity as indicated by ability to button shirt (PT) In two weeks patient will ambulate with caregiver assist x1 and use of FWW demonstrating step through gait pattern and upright posture What assessments/interventions would you expect to see? 49 Assessments + Interventions = Goals (ST) Patient will tolerate all oral intake of liquids, solids, and medication without risk of aspiration within 6 weeks (AIDE) Patient s caregiver will be independent in assisting patient to shower using shower chair within 4 weeks (MSW) Patient will have food stamps and a grocery delivery account in place in 3 weeks allowing him to meet nutritional needs What assessments/interventions would you expect to see?

18 Patient has COPD and has been hospitalized four times in the past two months The most recent hospitalization was for an extended stay where she went into respiratory failure and was on a ventilator for 3 days She is referred to home health for nursing, physical therapy, occupational therapy and home health aide services

19 55 56 Patient is a diabetic who is newly insulin dependent The patient has rheumatoid arthritis and reports that he can not prepare syringes or administer insulin injections The physician writes orders for diabetic teaching 57 19

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21 61 Rebecca Friedman Zuber Rebecca Friedman Zuber, Inc Bonny Kohr FR&R Healthcare Consulting, Inc