COPs 2018 Now is the Time HCAC 2017 Conference PreConference
FOCUS & THEMES Revisions of the Home Health Agency provider requirements..focus on a patient-centered, data-driven, outcome-oriented process that promotes high quality patient care at all times for all patients. objective would be to achieve a balanced regulatory approach by ensuring that a HHA furnished health care that met essential health and quality standards, while ensuring this it monitored and improved its own performance. Federal Register/Vol 79, No. 196/Thursday, October 9, 2014
FOCUS & THEMES Revisions of the Home Health Agency provider requirements. The requirements focus on the care delivered to patients by HHAs, reflect an interdisciplinary view of patient care, allow HHAs greater flexibility in meeting quality care standards, and eliminate unnecessary procedural requirements. These changes are an integral part of our overall effort to achieve broad-based, measurable improvements in the quality of care furnished through the Medicare and Medicaid programs, while at the same time eliminating unnecessary procedural burdens on providers. Federal Register/Friday, January 13, 2017
FOCUS & THEMES Measurable Patient Centered Individualized Patient partnership Patient choice Data
Words to Watch Expect Encourage Develop Monitor
PATIENT RIGHTS The entire COP revisions are predicated on patient centered care Patient rights focus has increased Condition: Patient Rights is moved up to highlight that focus Anticipate survey conversations to increase focus on patient rights
PATIENT RIGHTS Participation of the representative Only the legal representative would have to sign consents, notices of rights The rights do have to be provide to a chosen representative, not a legal functionary, within 4 days Representative participation is encouraged throughout the cops
PATIENT RIGHTS Written and Verbal notice in a language understandable and accessible Be provided in writing the names, addresses & telephone numbers of federally and state funded advocacy groups: Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center; and Quality Improvement Organization. Copy of the signed notice would show compliance
PATIENT RIGHTS Right to be advised of right to participate in all assessments TO GIVE INPUT Discharge and Transfer rights are detailed Right to provision of contact information for the administrator and clinical manager
PATIENT RIGHTS Freedom from injury of unknown origin (1) The source of the injury was not observed by any person or the source of the injury could not be explained by the patient; and (2) The injury is suspicious because of the extent of the injury, or the location of the injury (for example, the injury is located in an area not generally vulnerable to trauma), or the number of injuries observed at one particular point in time, or the recurring incidence of injuries over time. Discuss now: communication method, assessment of what by whom and in what time period
PATIENT RIGHTS Complaints is squarely included in patient rights Investigation of a complaint is a right Be sure the depth of investigation is appropriate to the level of complaint Keep clear final investigation report Suggest including recommendations for avoiding repeat complaint or outcome
484.60 (a) Plan of Care Old focus Traditionally responding to patient deficits identified by clinicians as requiring treatment, Clinicians and physician deciding on treatments Patient being told what was going to be done. Patient is made a passive recipient. Multiple studies have shown patients who participate and increase healthcare independence have better outcomes.
484.60 (a) Plan of Care New focus Responding to a combination of clinically assessed needs and patient identified preferences, Requires gathering information on preferences and patient strengths both identified by patient/representative and assessed by clinicians, Patient is advised and agrees. Patient is active in direction of their own care. The goal is better patient outcomes.
484.60 (a) Plan of Care Some things stay the same ~ Established and periodically reviewed by a physician Includes diagnosis, medications, supplies, nutritional requirements, safety, functional limitations, activities permitted, mental status, prognosis, rehabilitation potential Frequency and Duration have not changed
484.60 (a) Plan of Care Some things change~ POC to include: Cognitive and psychosocial status How to consistently define- Where to capture -
484.60 (a) Plan of Care Social needs are to be addressed as that is now in the acceptance of patients standard. May be interpersonal, vocational rehab, PCP/HMK, family social problems, transport or recreational needs. If the social needs of a patient go beyond what the agency can provide or interfere with safe and effective care delivery, HHA is not expected to accept the patient. HHA is to develop referrals to meet all needs and address those plans in the record.
484.60 (a) Plan of Care Some things change~ POC to include: Patient specific interventions and education
484.60 (a) Plan of Care Some things change~ POC to include: Description of risk for ED visits or hospital re-admission AND all necessary interventions to address the identified risk factors
484.60 (a) Plan of Care The Plan of Care is an ever evolving document Addendums, additions, changes should be noted when indicated by assessment, response to services or patient communicating a request to change that can be supported medically. Regular coordination with patient to assure patient needs are met. As always, documentation is key. CMS notes that rapidly changing orders are not typical in most patients.
484.60 (a) Plan of Care Regular coordination with patient to assure patient needs are met. HHA are expected to communicate changes in the plan of care to the patient, representative, caregivers. Communication in a manner that meets the patient s preference is to be used. As always, documentation is key. CMS notes that rapidly changing orders are not typical in most patients.
484.60 (a) Plan of Care There is no verbiage for developed in consultation The plan is established by the physician The Medicare Benefit Manual Chapter 7 still states 30.2.6 - Frequency of Review of the Plan of Care(Rev. 1, 10-01-03) A3-3117.2.F, HHA-204.2.F The plan of care must be reviewed and signed by the physician who established the plan of care, in consultation with HHA professional personnel, at least every 60 days.
484.60 (a) Plan of Care Evidence based care planning is expected. The record should support clinical decision making in consultation with the patient to determine care plan that suits patient. CMS expects the use of evidence based care planning through implementation of best practices. Remember this for QAPI
484.60 (a) Plan of Care Each patient must receive an individualized written care plan, including revisions or additions. This is a care planning requirement, not a delivery of paper to a patient requirement. CMS specifically removed from Patient Rights484.50 (c) (4) (iii) that the patient receive a copy of the care plan
484.60 (a) Plan of Care Rehabilitation potential in the plan of care should include expected outcomes Historically, Rehab Potential has read: Good for stated goals Outcome focus on Plan of Care will need to be reflected on visit/service notes. Chapter 7 Medicare Benefit Manual Notes must document, as appropriate: H&P exam pertinent to visit Skilled services Patient/Caregiver immediate response to services provided Plan for next visit based on rationale of prior results CMS response to comments indicates that outcomes of observation, assessment and treatment should be present.
484.60 (a) Plan of Care Plan of Care is to be established in partnership with the patient/representative. The plan of care must list measurable goals, AND patient assessment must include patient s desired goals to be incorporated in the plan of care. These may not sound like clinically derived Plan of Care goals, but can be melded with those measureable goals.
484.60 (a) Plan of Care No, HHA does not have to include all the whimsy of the patient. IF there is a conflict between the patient s goals and medically determined goals there MUST be documented education of patient including why the physician established goals must be used for plan of care.
484.60 (a) Plan of Care The plan of care must also list MEASUREABLE goals.
484.65 QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT Thanks Colorado DPHE- Licensed agencies must develop a Quality Management Plan So agencies have had the opportunity to practice
484.65 QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT Good news~ No more PAC No more Annual Agency Evaluation No mention of requisite clinical record review You do know there s a catch?!
484.65 QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT Move from reactive to proactive Move from problem based to monitoring Move from external forces to HHA driven
484.65 QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT The QAPI is to be under the supervision of the Governing Body Defined Implemented Prioritized Further, the Governing Body is to establish expectations for safety
484.65 QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT QAPI is data driven QAPI is expected to be a sustainable plan CMS is reasonable and will give agencies 6 months of data collection to begin Performance Improvement activities
484.65 QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT QAPI is to be specific to the agency s population, identified areas for improvement and past history HHA should not forget either last survey results, or latest QAPI work
484.65 QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT QAPI activities are to focus on Problem Prone High Volume High Risk
484.65 QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT HHA work will not be done upon demonstrating compliance, but rather upon demonstrating sustained compliance.
484.65 QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT THREE PHASES OF QAPI IMPLEMENTATION In phase one, we believe that an HHA will-- Identify quality domains and measurements that reflect its organizational complexity; involve all HHA services; affect patient outcomes, patient safety, and quality of care; focus on high risk, high volume, or problem-prone areas; and track adverse patient events; Develop and revise policies and procedures to ensure that data is consistently collected, documented, retrieved, and analyzed in an accurate manner; and Educate HHA employees and contractors about the QAPI requirement,philosophy, policies, and procedures.
484.65 QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT THREE PHASES OF QAPI IMPLEMENTATION In phase one, we believe that an HHA will-- Identify quality domains and measurements that reflect its organizational complexity; involve all HHA services; affect patient outcomes, patient safety, and quality of care; focus on high risk, high volume, or problem-prone areas; and track adverse patient events;
484.65 QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT THREE PHASES OF QAPI IMPLEMENTATION In phase two, we believe that an HHA will-- Enter data into patient clinical records during patient assessments; Aggregate data by collecting the same pieces of data from patient clinical records and other sources (for example, human resource records);
484.65 QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT Data Elements can be OASIS, HHCAHPS, participation in healthcare quality initiatives or agency specifically designed
484.65 QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT THREE PHASES OF QAPI IMPLEMENTATION In phase two, we believe that an HHA will-- Analyze the data that is aggregated through charts, graphs, and various other methods to identify patterns, anomalies, areas of concern, etc. that may be useful in targeting areas for improvement; and Develop, implement, and evaluate major and minor performance improvement projects based on a thorough analysis of the data collected.
484.65 QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT THREE PHASES OF QAPI IMPLEMENTATION In phase three, we believe that an HHA will-- Identify new domains and measures that may replace or be in addition to the domains and measures already being monitored by the HHA; Develop and/or revise policies and procedures to accommodate the new domains and measures; and Educate HHA employees and contractors on the new domains and measures, as well as the policies and procedures for them
484.65 QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT The QAPI program must result in improving patient care AND agency operations. Improvement must be measurable. Data mining must be efficient for the agency and produce valid actionable data for agencies to meet this requirement.
484.65 QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT Consider all sources of current data collection: OASIS Home Health Compare Satisfaction Surveys
484.65 QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT Consider all sources of current data collection: Internal tracking tools developed for previous QMP activities Current POC activities Complaints/Incidents/Reportable Occurrences Instances of Immediate Jeopardy or Adverse Events
484.65 QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT Consider what action the agency has historically taken with data: Who reviews it How are trends determined When new documentation, processes or EMR are implemented are data fields maked/considered Is data more than a check sheet
484.65 QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT CMS believes that agencies might need to seek outside resources: Participation in QI programs Use of a physician Budgeting for this process is another operational key
484.65 QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT Key takeaways START NOW Ask multiple people in your organization to give you feedback Train Governing Body on the expectations, the regulation and if necessary on Quality Improvement vs Quality Assurance Look at in house resources, budget for others
Resources https://www.thinkculturalhealth.hhs.gov/content/clas.asp https://www.cms.gov/medicare/quality-initiatives-patient-assessment- Instruments/HomeHealthQualityInits/index.html