“Care Cost Burden” Why It Matters Clinically

Darlene L. D’Altorio-Jones, PT., MBA-HCM Strategist, Rehabilitation Management

MediServe

• Monitoring of patients ‘present functional status’ or ‘burden of care’ is reflected in functional measurement as described in the IRF-PAI Manual; CMS approved FIM® documentation standards.

• The FIM® instrument is a registered trademark of the Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc.

• Reference to Functional Measurement in this presentation is reflective of FIM® assessment data obtained through the IRF-PAI manual decision tree logic captured through MediServe documentation and displayed within the ‘Functional Status – Daily’ Report.

Disclosures

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• Improve understanding of functional measurement in IRF’s as adopted by CMS …

• As a measure of reasonable resource utilization to guide IRF Payment

• Why weighting of motor scores lends purpose & understanding to actual “Care Cost Burden”

• Participants will appreciate …

• Why care cost burden is relevant for more than just a payment tool

• How continuous monitoring enables an interdisciplinary team to focus on significant patient & caregiver needs that enhance D/C preparedness

• Participants will distinguish that as a measurement of care cost burden…

• Cost of Care effectiveness is represented by the CHANGE from admit to discharge values

• Metrics monitored in real time keeps staff focused & may help to capitalize on efficiency and effectiveness. (? Pay for performance, improved outcomes - Giving credence to, ‘You can’t manage what you don’t measure’ !

Objectives

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• Most often ‘care burden’ is dismissed by rehabilitation units/facilities as a function of the IRF-PAI and nothing more.

• The Realities

• Care Cost Burden is Misunderstood; if understood at all.

• Staff often feel no relevance in day to day care requirements set against FIM® measurement

• CMI & Acuity is disconnected from treatment purpose – or staff can’t define or connect how these pertain to continuous improvement with care

Is ‘Care Cost Burden’ Important?

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• What have you heard?

• “It doesn’t really match what we do in rehab”

• Ignore scores: “payment purpose vs. real clinical documentation”

• “Functional Measurement Assessment takes too long”

• “The FIM is not sensitive enough to show ‘real’ progress”

• “We are going to treat the patient with what they need anyhow”

• BE AWARE: Burden measurement is REAL for the patient and family – weighted scores reflect areas of greatest care difficulty to absorb as caregivers.

Is ‘Care Cost Burden’ Important?

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IS REAL !

DON’T BE FOOLED

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BURDEN

COST

CARE

Measurable Improvement

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Complete Independence?

• Patient is not expected to reach complete Independence

• To Return pt. to ‘highest’ level of function may be a full rehab continuum goal --- Match training to D/C capacity

Ongoing & Sustainable

Improvement

• Of practical value measured against start of treatment

• Most instances – goal is to enable safe return to home or community-based environment

SHIFT OF TRADITIONAL

THERAPY EMPHASIS

• Patient centered therapeutic services shift to

• Patient/Caregiver education & services (are you engaging the those resources early enough to do this?)

Regulatory Facts 110.3

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Have you embraced ‘Measureable Improvement’ Documentation?

• TEFRA (Tax Equity & Fiscal Responsibility Act 1982) Payment methodologies have been GONE for > 11 years

• IRF-PAI Data imported to CMS is used statistically with cost report data to establish payment under IRF PPS. • ACKNOWLEDGE THIS!

• Data must be accurate and reflective of the patient you are treating to align similar characteristics to payment for Part A Medicare beneficiaries. Now & Future!

• PAI data establishes the care cost burden (baseline) for resources to manage the patients disability; this gross patient acuity system generates a CMI (case mix index); translates to payment.

• Staff should understand importance of CMI

Regulatory Facts

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• IRF-PAI Data is utilized for outcomes & efficacy measurement

• Since CMS receives admission & discharge functional measurement data, we can establish that the difference represents the EFFECTIVENSS in reducing the care cost burden during the patients stay.

• PAI DATA must accurately reflect the resources utilized to meet measurable improvement; staff must understand and be dedicated to assuring accuracy. As an industry – it’s what we have to work with – ignoring it’s importance is not an option!

• The present disconnect of clinical resource inputs to financial reimbursement to compensate for the care provided should be important to your staff!

Regulatory Facts

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• Does the disconnect concern you?

• Staff should understand care-cost burden – why?

• The caregiver/patient (at d/c) inherit care cost burden not erased by IRF services. Don’t ignore that fact!

• Why will IRF’s continue to ignore CMI & Care Cost Burden?

• Clinical understanding is the basis for ACCURATE input!!

The HUGE Disconnect

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CMS: Do they read IRFPPS Payment Rules each year?

I surrender, we’ll never get paid what it costs us to care for these patients.

CMS IRF’s

Executive Summary Purpose 2013 IRF Rule Notice:

• “In this notice, we use the methods described in the FY 2012 IRF PPS final rule (76 FR 47836) to update the Federal prospective payment rates for FY 2013 using updated FY 2011 IRF claims and the most recent available IRF cost report data.

• TABLE OF CONTENTS:

I. Background

• A. Historical Overview of the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS)”

Resource Utilization / Cost Reports

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• Care Cost Burden

• Reflects the EXPECTED level of resources to care for like patients presenting with same diagnosis and similar attributes (& comorbidity) that need managed at an IRF level of care.

• To obtain care cost burden, your staff must participate to accurately and consistently assess clinical measurement.

• They need to understand HOW the accuracy of information on the IRF-PAI tool provides the resource allocation to care for your Part A patients.

What is Care Cost Burden?

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Cost Burden Management

Pts Recover @ Own Speed

Inverse Relationships

•First 3 Days Care - Critical

•Fixed Prospective Payment multiplier to the CMI

•Discharge should be based on individual RECOVERY

•Sometimes less than and or more than a published ALOS

•HIGHER CMI = > burden

•As burden reduces CMI is lower & actual cost of care should decrease even though you are paid for the highest level achieved in the first 3 days.

Burden is Reflected in CMI

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Patient Recovery Margin

0

0.5

1

1.5

2

2.5

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00

Day3

Day4

Day5

Day6

Day7

Day8

Day9

Day10

Day11

Day12

Day13

Day14

Day15

Day16

Day17

Day18

Day19

Day20

Day21

Day22

Day23

Day24

TotalFIM

CMI

Cost Burden Management

$ 31,791 $ 1,382

$ 569

Every patient has a ‘recovery curve’

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• To me, Care Cost Burden - Clinically Matters!

• You need accurate information for predictable analysis.

• Scoring must be meaningful for staff to appreciate its value in guiding patient care.

• Staff must also be aware that inherent in predicting CMI; MOTOR items are WEIGHTED based on the burden to perform them.

• This weighting is predictable whether care is provided at the hospital or by a home caregiver for the 18 items measured.

• Areas that can make/break the ability to discharge (barriers to discharge) should be closely monitored and practiced!

Care Cost Burden

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• Utilized for payment CMI calculation (CMG assignment).

• Initiated in 2005 Rule (2006 FY applied) reflect MORE ACCURATE CARE BURDEN Cost Structure

• Made Transparent – unfortunately increasing clinical ignorance of payment methodology.

Why Weighted Motor Scores?

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• More than eighty-five percent of CMGs rely on the weighted motor score alone. • Therefore, accurately assessing these items is critical to

classifying the patient appropriately.

• CMS Places significantly HIGHER WEIGHT on specific MOTOR assessments based on the difficulty to perform this type of care for a patient.

• Reflects true both in the clinic and in transferring the patient’s care to other individuals including the home environment when a caregiver is required.

How Significant is Weighted Motor

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Payment System FY 2006 CFR

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Reduced Care Cost Burden

• Increasing function contributes to reduced CMI

• Greater the function the less burden placed on pt/caregivers @ D/C

Interdisciplinary Treatment

& POC

• Requires carry-over 24/7 to reinforce learning in areas of greatest need

• Demands focus on areas most resistive to improvement

Discharge to Community

• Match training, education & resources that compliment patient/caregiver capability

• Set functional goals to match expected capability with clinical focus to meet those expectations.

Continuous attention & practice increases successful results

• We must concentrate to dispels barriers more quickly.

• YOU CANNOT MANAGE what you do not measure.

• Staff must always know PRESENT status / & fluctuation of pt. ability.

• Pt. & caregiver will absorb what ever the greatest burden is throughout any given day. (ON YOUR TEAM)

– monitoring capability and matching education, training and resources for carry-over is how you successfully meet the discharge PLAN.

• Continuous review toward the REALISTIC PLAN is key.

– Present status knowledge allows you to measure feasibility or the need to modify the original plan.

• Payment methodology and the ability to gather mass amounts of data for similar patient populations to predict and trend FUTURE payment / resources.

• Ultimately we would expect that comparable data will also enable us to see ‘high performers’ over ‘low performers’.

• Change in score provides data toward efficacy of care provided.

• The more often staff utilize the scale to set baseline and track performance change the more familiar and accurate this tool will be for both clinical and financial performance!

End Result of the IRF-PAI

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• YOU DECIDE…

• Every patient has functional disability.

• Every patient has an individual set of resource capability post discharge.

• Every patient has a goal to achieve IN ORDER to return to the community.

• Care Cost Burden is not Medicare Isolated!

• REFRAMES interdisciplinary TEAM focus.

• Enables more data to validate progress toward continuous expected results.

• Provides functional roadmap for ALL patients.

Is there ‘Medicare Only’ Relevance in PAI Data?

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Tier 2, CVA - C0110, Age 63

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• IRF 101 should be required training for all IRF clinicians.

• Functional Measurement cannot be an ‘after thought’ chased by the IRF-PAI coordinator.

• Real time assessments that take note of decision specific elements!

• Care Cost Burden reflects the RESOURCES required to ‘do the job’ correctly and to appropriately ‘reward’ you for that intensity.

• The longer staff believe the assessments generated for the PAI are insignificant, the harder it is for them to appreciate pt./caregiver reality.

• Reconnect care burden to discharge goals!

Go BACK to BASICS

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• NO logical way you can DISCONNECT CLINICAL ASSESSMENT and Medicare Payment if you are an IRF PPS paid facility.

• STOP TRYING!

• STOP IGNORING CARE COST BURDEN!

• EMPHASIZE ACCURATE ASSESSMENT.

• The longer clinical staff do not make the correlation between functional assessment and resource utilization & CMI; the LONGER you will experience payment NOT commensurate to your real cost of care.

Medicare Payment

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• Have continual awareness of patient capability toward the EXPECTED end result.

• Working toward that end with continuous assessment helps to close the gap more effectively/efficiently! Be ready – Pay for Performance can’t be far off. Accountable Care Organizations are here NOW!

BRIDGE THE GAP

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• Providing slow continuous gains in a numeric system is easy for payers to understand.

• Progress toward expected in aggregate defends 110.3 --- ‘making functional improvement of practical value measured against admission throughout the stay.’

• Current status aggregate data for a physician to comment specifically to individual recovery in function no less than 3x/week is huge & is an IRF Medicare part A payment requirement.

Additional Bonus

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• Physicians must update medical and FUNCTIONAL recovery no less than 3x/week specifically:

• CONSISTENT measurement toward a numeric goal is easily communicated and trended

• Identifying ‘deal breakers’ for home going when tied to functional areas improves realistic discussions toward ability to meet and or need to modify treatments affecting capability to manage in the discharge plan.

• Is the GAP closing?

• Is the LOS appropriate to meet the patients individualized goals? Individual patients are not ‘average’.

• Is the patient progressing faster than expected or slower than expected so that realistic length of stays are set.

Help Physicians update 3x/week

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• IF clinicians utilized Functional Independence Measurement & consistently measured as defined in the IRF-PAI Manual decision trees THROUGHOUT a patients stay; information would be more reflective of the assistance required to complete self care and HOW much training is required prior to discharge!

• Motor Goal 64/84 = 76%

• Start @ 40/84 = 48%

• Now @ 55/84 or 65%

Revisit Care Cost Burden as a TOOL

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ACCOMPLISHMENT PLAN ?

• TO ACCOMPLISH this you need STAFF to accurately provide DATA on functional recovery that can be captured discretely for trending.

• Staff must be able to see the data and to work cohesively to manage the areas of GREATEST NEED based on each individual patients OUTCOMES – ongoing toward expectation.

No Tier CVA – A0110, 76 YO

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No Tier- A0802, Repl LE jt, 72 YO

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Tier 3 – D0702, Fx LE, Age 74

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Neurological – A0604; 79 YO

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No Tier- A0704, Fracture LE, 57 YO

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• ONLY WE can perpetuate that rumor!

• Measurement of effectiveness happens in REAL time NOT after the fact.

• It’s unfortunate that CMS set up IRF PPS for a start/finish measurement because ongoing use provides actionable information.

• Recovery is not a ‘straight line’.

• Recovery requires attention to recovery as it relates to care cost burden…believe it – patient and families recognize and become anxious to those realities.

• With enough data we can improve expected outcomes and focus on areas of greatest need more seamlessly.

Scoring is for IRF-PAI Purpose ONLY

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• Often stated ‘not sensitive enough to describe recovery’ • In total, not true.

• In trending recovery, staff that provide accurate assessments scores CAN rely on meaningful information to fulfill the patients required POC.

• FIM measurement remains a good indicator of resource requirement to manage functional care cost burden. • Someone accepts this burden post IRF discharge.

• Improving accuracy will benefit IRF’s in the near ‘distant’ future.

Sensitivity During Recovery

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• Focus training on areas with resistant recovery or those that fluctuate most often.

• Staff must provide information on improvement trending that relates to the TOOL used to measure our effectiveness. Your outcomes will improve if you do!

• Clinical concentration on areas of greatest need enable real interdisciplinary model of care and reinforcement to occur 24/7 as expected by regulation.

• Targeting problematic areas enables greater practice and reinforcement for the patient and caregivers.

• In theory this should accelerate the recovery curve.

• Rehab is ALL about functional recovery.

Barrier to Discharge Focus

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• Recovery patterns need studied and aggregated from large volumes of data provided on a more frequent basis during the patients’ stay.

• Real time scoring helps you spot deviance that is clinical scoring outlier vs. accurate data points so you can educate & reduce inappropriate scores!

• Some of you are positioned now to demonstrate management to this capacity!

Real Recovery Patterns

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Adapting to Continuous Change

Success is more than compliance

Success is dependent upon setting a desired result, creating a plan and monitoring performance with accurate, timely & meaningful information - then quickly correcting any variance to expectation

ARE YOU READY TO CHANGE?

YOU DECIDE….

DOES IT MATTER CLINICALLY?

www.mediserve.com/blog

Care Cost Burden

Care Cost Burden, Why it Matters Clinically

(Darlene L. D’Altorio-Jones, PT., MBA-HCM)

• Grace M. Carter, Daniel A. Relles, Gregory K. Ridgeway, Carolyn M. Rimes (Spring,2003). Measuring function for Medicare inpatient rehabilitation payment. Health Care Financing Review. 19 Apr., 2012.

• Institute of Medicine: Crossing the Quality Chasm: A New Health System for the 21st Century. National Academy Press. Washington, DC. 2001

• Medicare Payment Advisory Commission: Report to the Congress: Medicare Payment Policy. Washington, DC. March 1999.

• Newhouse, J. P., Cretin, S., and Witsberger, C.J.: Predicting Hospital Accounting Costs. Health Care Financing Review 11(1):25-33, Fall 1989

• Code of Federal Regulations : Dated: July 26, 2005. Mark B. McClellan, Administrator, Centers for Medicare & Medicaid Services. Approved: July 27, 2005

Bibliography/Resources:

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Care Cost Burden, Why it Matters Clinically

(Darlene L. D’Altorio-Jones, PT., MBA-HCM)

• Michael O. Leavitt, Secretary. Table 3, which was Table 5 in the FY 2006 proposed rule (70 FR 30188, 30211). Rand Analysis, weighting recommendations. http://www.gpo.gov/fdsys/pkg/FR-2005-08-15/html/05-15419.htm van Baalen B, Odding E, van Woensel MP, Roebroeck ME. Reliability and sensitivity to change of measurement instruments used in a traumatic brain injury population. Clin Rehabil. 2006 Aug;20(8):686-700.

• Bob Habasevich. Care Cost Burden. www.MediServe.com/blog. January 17th, 2012

• Bob Habasevich. Best Practices for Managing Outcome and Optimizing the Value of Patient Care. www.MediServe.com/blog . March 13th, 2012

Bibliography/Resources: (cont)

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