Senior Living Consultants
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- Anastasia Lucas
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1 Senior Living Consultants
2 THE PACE MODEL WORKS: IMPROVING BOTTOM LINE THROUGH BEST PRACTICES IN CARE Monday, October 27, :00a-11:30a Dan Gray Scott Ewing Cyndi Young, RN
3 Agenda! Key Operating Practices Support the voluntary caregiver End of life care Management of non-compliant behavior! Critical Factors for Financial Success Census Growth Payment Optimization Utilization of Contractual Services! Other Operating Factors/Practices
4 Learning Objectives! Leave with a framework for evaluating PACE operations! Leave with at least one best practice which could improve your operational performance! Learn best practices from one of the most profitable programs
5 Key Operating Practices! Voluntary caregiver support! End-of-Life care! Management of participant/family member noncompliance
6 Voluntary Caregiver Support! Strategic use of respite! Education! Support in the home! Measurement of caregiver stress using a standardized tool
7 End of Life Care! Values! Present and Advance Directives! Chaplain ( spiritual social worker ) involvement in process! Customization of palliative care
8 Participant/Family Non-Compliance! Frequent flying non-emergent 911 calls to hospitals (which may not have a contract with PACE)! Dump and run families withdraw support and quickly request nursing home placement
9 Financial Success! Critical Factors for Financial Success Census Growth Payment Optimization Utilization management of contract services
10 Census Growth! Focus on referral sources Short-term Medicare/Managed Care skilled nursing stays Medicare home health care Affordable housing Current participants and families target 40%
11 Census Growth! Target a scheduled home visit for all screened leads Primary purpose of home visit is to sell the program! Target to enroll 80% to 100% of all potential enrollees assessed
12 Payment Optimization! Establish a simple workflow process for HCC documentation and billing! Utilize frequency distribution from PDAC report to ask the right questions both about both quality and documentation
13 HCC Management! Physician: Documentation of Medical Problems Must see patient face to face encounter required Enrollment health and physical Semi-annual exam PRN visits Document and submit to EMR Examine common diagnoses for more specific documentation
14 HCC Management! Coder: Coding and Review Process Recording codes evaluate appropriate content Review/validate superbill versus clinical records Code the problem/diagnoses determined by the physician Assign or confirm ICD-9 Codes Ensure accurate and complete documentation
15 HCC Management! Business Office: Data Submission and Distribution Analyze reports - Return Model Output Error (MOR) " Error resolution " Monitor against re-evaluations - Return File Summary Report (RAPS file) - HCCMODR HCC model output report - PTDMODR Part D model output report
16 Using the PDAC Report! Check the predicted scores for consistency with your expectations. Consider Prior years scores Changes in enrollment Other factors that may have affected your results! Check to assure that your program s submittal of RAPS return files to PDAC is complete
17 Using the PDAC Report! Check that all diagnosis codes for dates of service are submitted on a timely basis! Request participant level reports from PDAC to access changes in diagnosis! Consider developing a plan to address any missing diagnosis codes with a service encounter by the appropriate date
18 Utilization of Contract Services! Pre-enrollment meeting with participant/family ( pinky swear )! Establish policy that respite care is not provided in the home except for end of life care
19 Utilization of Contract Services! Rates and utilization of contractual services significantly affect financial performance Hospital Nursing home Home health/home care Specialist Assisted living/supportive housing
20 Utilization of Contract Services! Monthly review of prior month s Hospitalization focused on any way to shorten length of stay or avoided admission! If two teams are in place, have the other team review decision to place a participant long term in the nursing home.
21 PACE Dashboard Illustration
22 Drill Down Illustration
23 Operating Factors/Practices! Participants living alone 5 to 40% (dramatically affects costs)! Prevalence of specific chronic diseases ESRD COPD Behavioral
24 Operating Factors/Practices! Primary care effectiveness! Team performance! Day center attendance! Day center expansion mitosis or start from scratch
25 1501 Greer Lane Signal Mountain, TN Questions
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