Care Plan Appropriateness - Bayada Home Health Care · PDF fileCare Plan Appropriateness ... • ex. Shoulder dislocation- no OT ... your discipline’s plan of care through the team

Care Plan

Appropriateness

Accurate Assessment

Focused Care

October 17, 2012

Director All Hands Pillar Breakout Series

Page 2 Confidential and Proprietary Information

Aligning our Work

“Strive to provide the very best service to our

clients. Set specific goals and work hard and

efficiently to achieve them..”

-The BAYADA Way


At the end of this session you will:

Gain additional insight into how two divisions have

structured the Care Plan Review process:

Review process supported with the DCO role

Review process supported through the Divisional Director /

Director role

This Session Objectives


Why Spend Time Talking About CPR


The assessment should guide our interventions. are our

goals and plan in alignment with the assessed need

Inquisitive - Not Prescriptive

We should constantly be asking if our goals are in alignment

with the assessed need


Steps to Developing the Patient Specific Care plan Prior to Review

Evaluation Documentation

Developing the Patient Care Plan

Review Referral Pages / Continuing

Care Documents / Bayada Referral

Homebound, Skilled Need / Medical

Necessity

Necessity • Diagnoses, Reason for hospitalization/referral

• Comorbidities that may affect care plan

• Medications- indicate other diagnoses

• Consider risks of re-hospitalization

• CMS penalty dx, falls, meds & noncompliance

• Allergies, Diet, DNR

• Therapy DC Assessments, Rehab Potential

• Self Care Abilities/Levels of assist with ADL’s

• Self Care Abilities/Levels of assist with

ADL’s

• ? Services requested appropriate

• ex. Shoulder dislocation- no OT

requested

• HHA requested- No OT requested

• CHF patient- no OT- energy

conservation


SOC Conference Call with Clinician

Review

Homebound & skilled need

Primary & Secondary DX’s

Skilled Interventions

Risk for Rehospitalization

Acuity & Functional deficits

Visit plan (# of visits & plan for each visit)

Plan to recert

High Risk ACH

CMS penalty Diagnoses

Patient Pacing

Developing the Patient Care Plan


Tools Your review from

Referral documents

SOC Oasis

Therapy Evals

Review CFS Score

Review OCS Guidelines on

Home Health Utilization Summary

MCM Overview

RN Coder- reviewing the Care Plan

Set GM % bar for email from Coder

triggering additional discussion re care

plan appropriateness with Director,

CM.

90% of the time there is opportunity to

improve our care plan

Examples of MCM Care Plan

Inquiries

Locked and GM is 64-there are 11

ordered nursing visits/national

average is 9.9 and there are 20

ordered aide visits/national

average is 2.2


ordered nursing visits/national

average is 6.7


aide visits/national average is

2. “These HHA visits will be

removed due to changes in

plan…there will only be 6”

Developing the Care Plan


General Nursing Utilization

Guideline

C1 1-2 nursing visits



Exceptions- Patient Specific

Consult with Clinician- must be

clinically based exceptions

ICD 9 ‘s that drive increased visits

707, 800, 900

Wounds, Pressure Ulcers,

Complications

No evidence that increased # of visits

improves patient outcomes.

In Summary 1. Review Referral Documents

2. In HCHB Review:

485 order- quick look

SOC Visit Note/Assessment &

Coordination Notes

Edit Oasis- see CFS score

Check Oasis answers

Home Health Utilization

Summary

Pulls all the data together

? Visit Utilization appropriate

based on your clinical review

3. Consult with SOC Clinician-

SOC conference.

4. Complete task steps for 485 and

Send to MCM!

Developing the Care Plan


Clover Division: It Takes a TEAM!

THE CLINICAL MANAGER

SOC process

Weekly/ongoing process

CLINICAL MANAGERS PEER TO PEER

Biweekly interactive conference calls

DIRECTOR/DCO/CLINCIAL MANAGER

Biweekly office meeting

DIVISION DIRECTORS BIWEEKLY CALL

Directors & DCO led by Jean Ritter


Clinical Manager

Ensure appropriateness at SOC using the HOME HEALTH

UTILIZATION SUMMARY TOOL on the SOC task ladder


Clinical Manager – It Starts at the Start


Clinical Manager Follow-up Process

HOME HEALTH UTILIZATION REPORT

DAILY / WEEKLY STANDUP IN REVIEW( missed visits,

TIF etc.)


Clinical Managers: Peer-to-Peer

BIWEEKLY CALLS – Structured

Peer to peer case presentation and discussion

• Patient and discipline pacing, patient self-

management

Review of supporting documentation/therapy

progress graphs

Review of other CM processes


Director /Clinical Manager / DCO

Biweekly Office Meeting Agenda REVIEW OF KPI’S : TABLEAU

HH Medicare Key Metrics –DCO

Daily/Weekly stand up in review

Care Plan Review

Review in HCHB Report Manager:

Review of active caseload for recertification needs

• Recerts: examine high utilization; identify :

– Diagnoses with long recovery curves( recent CVA/ hip fractures)

– Chronic diseases with expected decline( CA/Alzheimer's)

– Cases with a history of multiple rehospitalizations within cert or in past episodes



#5. Because you can! Finally, no more chasing paper,

Bayada Boulevard, open paperwork in RN’s trunk.

#4. Because CPR is really the Holy Grail for HH, we’ve been trying to get here since the dawn of home health.

#3. Because once successful, less ‘mismatched’ episodes will come in from the field and require action.

#2. Because success is very unlikely if you don’t do this process consistently well.

#1. Because Bill Dombi pretty much said we better….

Top 5 Reasons why your office must master

Care Plan Appropriateness:



Key Concepts of the Process:

The CPR process will be an exercise in futility if

LEARNING doesn’t occur; DCOs impart knowledge

to CMs, and CMs impart the same concepts to field

case managers and the rest of the clinical team.

In a perfect world, this process would occur primarily

in the field.

In many cases, the CSM is in a great position to help

e.g. scheduling, missed visits, days between

Evaluation and visit #2.



What do we hope to accomplish; big picture view from field case manager to Clinical Manager.

Is there another way to get there; is there a more efficient manner to reach the desired outcome.

Wow! This is looking like a 2 cert period client- what do you think; forces clinicians to think.

What would you do if this were a managed care patient; clinician driven ways to do more with less.

Do you think the team can meet the client goals with this intensity; forces big picture review of POC.

Tools from CM Training Day:

Language for Clinical Managers to use with clinicians once there is a mismatch:



Day after White Shoes prepared your CMs to have these conversations; we promised them support from their Directors and Division Directors.

Care Plan Review Dashboard shows all visits out there; make sure field staff plot only what they believe the client will need so that the actual plan can be evaluated for appropriateness.

At hire, we recommend bringing up this concept with all potential field staff hires: “ At Bayada, client care is determined in a collaborative

manner, meaning that field clinicians of all disciplines collectively determine the best overall plan of care and ultimately utilize the Clinical Manager (often a nurse) to concur with the plan……How do you feel about vetting your discipline’s plan of care through the team and the Clinical Manager?”

Take Home Points