| A Collaborative Approach To Reducing Antipsychotics | https://www.providermagazine.com/Issues/2016/May/Pages/A-Collaborative-Approach-To-Reducing-Antipsychotics.aspx | A Collaborative Approach To Reducing Antipsychotics |
<p>When the Centers for Medicare & Medicaid Services (CMS) revised its Five-Star Quality Rating System last year, it added two new Quality Measures: 1.) percent of long-stay residents who received an antipsychotic medication and 2.) percent of short-stay residents who newly received an antipsychotic medication.</p>
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<div>Both measures pertain to residents who are prescribed the so-called “off-label” use of these medications; that is, without a diagnosis of schizophrenia, Huntington’s disease, or Tourette syndrome. </div>
<h2 class="ms-rteElement-H2">Getting A Head Start</h2>
<div><div>But NHC HealthCare, Fort Sanders, in Knoxville, Tenn., had already started to tackle the problem. In 2014 the skilled nursing care center teamed up with Statcare Medical Group, an acute and post-acute care hospitalist group, to address antipsychotic reduction through the use of CMS’ Quality Assurance Performance Improvement (QAPI) process. <br><br></div>
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<div>Statcare uses a model of health care delivery in five skilled nursing facilities in the Knoxville market in which primary care and behavioral health are integrated into one team. </div>
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<div>CMS has encouraged skilled nursing centers to use the QAPI process in their quality improvement efforts. QAPI is defined as “a thorough approach to ensure high-quality, proactive, patient-centered care using evidence-based practices to escalate knowledge for planning, implementing, and sustaining measureable improvement.”<br><br></div>
<div>During 2014, the center began to work on systems to address reducing antipsychotic medications. From the second quarter through the fourth quarter of 2014, leaders’ focused attention resulted in a decline from 21.6 percent, to 20.8 percent, to 18.4 percent on the “long-stay” resident medications. While the center maintained a Five-Star Quality rating, its three-quarter average of 20.3 percent was still above the national average of 19.3 percent. </div>
<h2 class="ms-rteElement-H2">Following QAPI’s Lead</h2>
<div>The first element of QAPI is Design and Scope. In this step, the center focused on the patient’s clinical care and quality of life, emphasizing these objectives to the team as they worked toward achieving their quality objectives. <br><br></div>
<div>In the Governance and Leadership step, the primary stakeholders included the administrator, director of nursing (DON), assistant DON, pharmacist, nursing personnel, and a Statcare Medical Group medical director. This group decided that Kimberly Quigley, MD, a psychiatrist from the Statcare post-acute care medical staff, should be added to implement the program and provide clinical care in an integrated manner with the hospitalists and nursing center staff.<br><br></div>
<div>In the Feedback, Data Systems, and Monitoring step, the center employed several tools to gauge and monitor progress. While the Nursing Home Compare Five-Star Rating data were somewhat helpful, they were not broken down to the needed levels. For that the center turned to the CASPER (Certification and Survey Provider Enhanced Report) and MDS 3.0 Facility Level Quality Measure Reports. <br><br></div>
<div>CASPER uses a more current six-month reporting period and also provides specific patient data, by name, on each of the 11 Quality Measures, allowing for a more detailed review of patient data. </div>
<h2 class="ms-rteElement-H2">Making Progress</h2>
<div>In the Performance Improvement Projects section of the QAPI process, the center used another quality improvement tool called Rapid Cycle. In this process the psychotropic medication monitoring care plans were implemented with specific documentation regarding gradual dose reduction of current medications. New medication substitutions and supporting diagnoses were monitored as alternative interventions.<br><br></div>
<div>During the Systematic Analysis and Systematic Action phase, which gained momentum in January 2015, the center developed a communication board for integrating care with the psychiatrist. In February, Assistant DON Amy Morgan developed an Excel spreadsheet to monitor gradual dose reduction results, diagnosis, and follow-up visits. The primary antipsychotic targets were Abilify, Geodon, Haldol, Risperdal, Seroquel, and Zyprexa.<br><br></div>
<div>In March the team noticed an increase in short-stay resident antipsychotics, so the psychiatrist began a review of all new admissions and reviewed the center’s readmission screening processes. The close communication that the psychiatrist has with the primary medical team, and knowledge of the local acute care medical community, were integral in lowering psychotropic medication rates among the newly admitted residents. The center’s pharmacist also provided a list of other medications for review such as hypnotics, antidepressants, and anxiolytics.</div>
<h2 class="ms-rteElement-H2">Seeing Results</h2>
<div>In December 2014 the center had 19 residents on antipsychotics with 32 orders. By April 2015 they were down to 10 residents with 16 orders. From the fourth quarter 2014 to the first quarter 2015 the average had dropped from 18.4 percent (long-stay) to 10.5 percent. In the short-stay group the average had dropped from 3.4 percent to 2.1 percent.<br></div>
<div><br>The three-quarter average for short-stay was now below the national average, while the long-stay average was well below the national average. The data from the Jan. 1 to June 30, 2015, CASPER report showed even greater results, with long-stay at 6.8 percent and short-stay at 1.2 percent. Throughout this process, employing QAPI and Rapid Cycle, the center also made reports to its Quality Assurance Committee, which is made up of two additional physicians along with the medical director. The involvement of the entire health care team and the systematic and structured approach to the problem enabled the center to reduce the long-stay percentage from 21.6 percent to less than 6.8 percent within a nine- to 12-month span of time.</div>
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<div><em>Kimberly Quigley, MD, is medical director of behavioral health integration for Statcare Medical Group, a division of Summit Medical Group in Knoxville, Tenn. Douglas Ford, MS, NHA, FACHCA, is administrator of NHC HealthCare, Fort Sanders, in Knoxville, Tenn. He has served with National HealthCare Corp. for more than 28 years.</em></div>
<p></p> | CMS has encouraged skilled nursing centers to use the QAPI process in their quality improvement efforts. QAPI is defined as “a thorough approach to ensure high-quality, proactive, patient-centered care using evidence-based practices to escalate knowledge for planning, implementing, and sustaining measureable improvement.” | 2016-05-01T04:00:00Z | <img alt="" src="/Issues/2016/May/PublishingImages/caregiving_t.jpg" style="BORDER:0px solid;" /> | Caregiving | Column |
| New Report Exposes Therapy Challenges | https://www.providermagazine.com/Issues/2016/May/Pages/New-Report-Exposes-Therapy-Challenges.aspx | New Report Exposes Therapy Challenges | <div><img class="ms-rtePosition-1" alt="Judi Kulus, RN" src="/Issues/2016/May/PublishingImages/JudiKulus.jpg" style="margin:5px 15px;" />In an era of increasing transparency, a new report called the “Skilled Nursing Facility Utilization and Payment Public Use File” (SNF PUF) puts SNFs’ therapy utilization under the microscope. In early March, the Centers for Medicare & Medicaid Services (CMS) released the SNF PUF, which contains payment data from more than 15,000 SNFs caring for 2.5 million residents at a staggering cost of $27 billion in 2013 alone.</div>
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<div>For some time, SNF providers and therapy companies have experienced the pressure of government audits for therapy practices. The SNF PUF adds fuel to the audit fire as it highlights concerns that Medicare costs are being driven by therapy volume rather than by individual patient need.</div>
<h2 class="ms-rteElement-H2">Billions Going To High Therapy Groups</h2>
<div>In 2013, according to the SNF PUF, Medicare reimbursed more than $21 billion for the two top-paying Resource Utilization Groups (RUGs) that SNFs use to bill Medicare—the Ultra High and Very High Rehabilitation categories. </div>
<div>The report explains that in order to qualify for an Ultra High (RU) Rehabilitation RUG, a resident must receive at least 720 minutes of therapy each week, among other criteria. To qualify for Very High (RV) Rehabilitation, the resident must receive at least 500 minutes of therapy each week. The criticism leveled at facilities regarding the PUF data centers around the high percentage of claims billed within 10 minutes of the residents’ achieving the RU or RV thresholds.<br><br></div>
<div>For example, 65 percent of all RU assessments showed therapy provided between 720 and 730 minutes. Similarly, 51 percent of all RV assessments showed therapy provided between 500 and 510 minutes. This same 10-minute pattern was followed for more than 75 percent of both RU and RV assessment claims by one in five providers.</div>
<h2 class="ms-rteElement-H2">Report Triggers Reaction</h2>
<div>The SNF PUF is fueling additional government scrutiny. “CMS strives to ensure that patient need, rather than payment system incentives, is driving the provision of therapy services,” says Shantanu Agrawal, MD, deputy administrator for program integrity and director of the Center for Program Integrity.<br><br></div>
<div>“These concerns have prompted us to refer this issue to the Recovery Auditor Contractors (RACs) for further investigation, and our hope is that data transparency will facilitate real changes.”<br><br></div>
<div>Can the government automatically deem it wrong if the reported minutes are within 10 minutes of achieving the RUG threshold? No. The therapy services furnished may have been what the individual resident required. However, claims and Minimum Data Set (MDS) data are often insufficient to determine medical necessity. If CMS identifies atypical utilization patterns, it may employ the tool of complex medical review to make a coverage determination.<br><br></div>
<div>“It is common practice for government program integrity efforts to use statistical profiling to identify patterns of service delivery that they want to investigate further,” says Dan Ciolek, associate vice president, therapy advocacy, at the American Health Care Association. “Determining the right amount of therapy to furnish to achieve a desired clinical outcome is not an exact science, but high-quality care that is well-documented should withstand the increased scrutiny announced by CMS.”</div>
<h2 class="ms-rteElement-H2">Steps Providers Should Take</h2>
<div>SNF leaders should respond to the emerging audit potential with a methodical, organized quality assurance plan. They can start by identifying how their facility RUG utilization stacks up on the SNF PUF. Facility-specific data can be downloaded via the SNF PUF Excel document, “Medicare Therapy Minutes Aggregate Table, CY 2013, Microsoft Excel (.xlsx).” Once facility leaders know how their facility rates, they’ll have a better idea of their risk for audit. If they find that their facility RU and RV RUG levels fall close to the RUG thresholds, they’ll know that additional action is required.<br><br></div>
<div>A formal Performance Improvement Project (PIP) process can be used to identify the facility’s statistics and therapy practices. Facility leaders should also discuss with the nursing and therapy teams how effectively therapy case management focuses on the individual needs of the residents.<br><br></div>
<div>SNF responsibilities are spelled out in a recently established corporate integrity agreement between the Office of Inspector General and a facility group, which outlines the delivery, management, and oversight that rehabilitation therapy services must have. Therapy services should: </div>
<div>■ Be delivered pursuant to a comprehensive assessment and individualized therapy treatment plan;</div>
<div>■ Be consistent with the nature and severity of the patient’s individual illness or injury;</div>
<div>■ Comply with accepted standards of medical practice;</div>
<div>■ Be reasonable in terms of duration and quantity;</div>
<div>■ Be reasonable and necessary given the patient’s condition and the therapy treatment plan to improve, maintain, or slow deterioration of the patient’s condition; and</div>
<div>■ Only include services that are inherently so complex that they can be safely and effectively performed only by, or under the supervision of, a qualified therapist.<br><br></div>
<div>A formal PIP can be used to audit a sampling of recent therapy cases to ensure that the documentation indicates the services were reasonable and necessary, they required the services of a licensed therapist, and the length of stay was appropriate given the resident’s condition.<br><br></div>
<div>The results of an audit will help to home in on specific training needs that facility staff may have. The PIP plan should include training and auditing to ensure accurate documentation and appropriate clinical case management. </div>
<h2 class="ms-rteElement-H2">MDS/Therapy Discrepancies</h2>
<div>Systems can be shored up by auditing for accurate therapy minute logs. The outcome of an accurate therapy log should be an accurate MDS. Far too many recovery audits have found discrepancies between the MDS and the therapy log. <br><br></div>
<div>Charted minutes must never be rounded; logs should always contain the actual minutes of therapy provided. The therapy minutes and days and the type of therapy must then be transferred accurately to the MDS. Recovery auditors have found cases where group or concurrent therapy has been incorrectly captured as individual therapy. Internal audits can help identify errors and prevent them from occurring.<br><br></div>
<div>Charting should include a clear description of how the services are medically necessary for the resident to maintain or improve his or her status, according to the written plan of care. Details should also be included on how the licensed therapist’s services are instrumental in meeting the resident’s treatment goal.<br><br></div>
<div>With the transparent information about therapy and care outcomes being broadcast to the world, it’s important to have transparency within the facility. Facility leaders must never abdicate their responsibility for oversight of therapy services to an outside therapy company. Strong coordination and collaboration between facility staff and therapist are essential to avoiding government fines.<br><br><img class="ms-rtePosition-2" src="/Issues/2016/May/PublishingImages/2015_AANAC.jpg" alt="" style="margin:5px 15px;width:297px;height:71px;" /><em>Judi Kulus, MSN, MAT, RN, NHA, DNS-CT, RAC-MT, is vice president of curriculum development for the </em><em>American Association of Nurse Assessment Coordination. She can be reached at (800) 768-1880.</em></div>
| For some time, SNF providers and therapy companies have experienced the pressure of government audits for therapy practices. The SNF PUF adds fuel to the audit fire as it highlights concerns that Medicare costs are being driven by therapy volume rather than by individual patient need. | 2016-05-01T04:00:00Z | <img alt="" src="/Issues/2016/May/PublishingImages/therapy_t.jpg" style="BORDER:0px solid;" /> | Management;Caregiving | Column |
| The Challenges Of Interoperability | https://www.providermagazine.com/Issues/2016/May/Pages/The-Challenges-Of-Interoperability.aspx | The Challenges Of Interoperability | <div> </div>
<div><img class="ms-rtePosition-1" alt="Doc DeVore" src="/Issues/2016/May/PublishingImages/DocDeVore.jpg" style="margin:5px 15px;" />The Healthcare Information Management and Systems Society (HIMSS) held its annual meeting Feb. 29-March 4 in Las Vegas. At HIMSS 2016, many leading health information technology (HIT) vendors and providers made an interoperability pledge that was acknowledged by U.S. Department of Health and Human Services Secretary Sylvia Mathews Burwell.</div>
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<div>The Centers for Medicare & Medicaid Services defines interoperability as the ability of two or more systems or components to exchange information and use the information that has been exchanged. The pledge represents a commitment to three things: consumer access, transparency/no blocking, and standards. Vendors and providers promising to work together to achieve meaningful interoperability is definitely a step in the right direction; getting it done is the challenge.</div>
<h2 class="ms-rteElement-H2">The Next Step</h2>
<div>To understand the progress that has been made and the challenges that remain, it is helpful to use the three core elements of interoperability—payload, transport, transaction—as a frame of reference.<br><br></div>
<div>With respect to payload—the data that will be exchanged—there are standards in place. The HL7-ordained Continuity of Care Document and Consolidated Clinical Document Architecture (C-CDA) definitions provide a comprehensive care summary. Health Level-7, or HL7, refers to a set of international standards for transfer of clinical and administrative data between software applications used by various health care providers. The vision of the Office of the National Coordinator for Health Information Technology (ONC)—the agency at the forefront of the administration’s HIT efforts—for the use of the C-CDA begins to describe the common content that providers should share to manage care longitudinally.<br><br></div>
<div>That being said, challenges remain. First, there is a need for a common code set. If one system is using LOINC codes for laboratory results and other clinical observations and another is using SNOMED, translation is required before the information can actually be used. Logical Observation Identifiers Names and Codes (LOINC) is a database and universal standard for identifying medical laboratory observations, while the Systematized Nomenclature of Medicine (SNOMED) is a broader systematic, computer-processable collection of medical terms to provide codes for anatomy, diseases, findings, procedures, microorganisms, substances, and so forth.<br><br></div>
<div>Second, while the C-CDA is comprehensive, it may contain more information than is needed for a specific workflow. Defining the essential clinical workflows involved in a transition of care and the small subset of truly valuable data points within the care summary will require focused collaboration between provider clinicians and health information technology (HIT) vendors across all health care sectors.</div>
<h2 class="ms-rteElement-H2">ONC Lends A Hand</h2>
<div>As for transporting the data from one system/provider to another, historically this has been done through one-on-one interfaces that are complex and difficult to maintain. As electronic health records (EHRs) became more widely used, it became obvious that HIT vendors would not create an interoperability standard on their own, so ONC initiated the Direct Project to develop standards to facilitate interoperability.<br><br></div>
<div>Direct Messaging is based on standards for encrypted email as a basis for communication and private/public key infrastructure to authenticate recipients who view encrypted information. While the current workflows supported by Direct Messaging are simple, even though how they have been implemented by EHR vendors varies, they are low-cost and easy to use. Providers that don’t have a Direct address should get one as it will prepare them for the interoperability that will come as more systems adopt a standards-based information exchange.</div>
<h2 class="ms-rteElement-H2">Biggest Hurdle</h2>
<div>The third element of interoperability, transaction or consumption of the data, is where the real challenges exist. Despite agreement on the payload and transport mechanism, HIT vendors have to agree on standards in order to request data from and provide information to other systems. To begin developing transport standards, key use cases must be defined; for example, transitions of care or requests for medical records from a physician’s office.<br><br></div>
<div>Many HIT vendors have implemented Admission, Discharge, and Transfer (ADT) feeds, but providing a clinician with a true longitudinal view of a resident’s health is going to take more than that. Standard “calls” based on use cases, GetChart or WriteOrder need to be developed along with open Application Programming Interfaces to facilitate the sending and consumption of data.<br><br></div>
<div>While technical challenges are interesting problems to solve, achieving meaningful interoperability will require health care partners to develop trust in each other’s clinical practices and standard of care. Unfortunately, today there is a pervasive attitude of distrust that results in the care setting receiving the resident starting from scratch because they don’t trust what happened in the discharging care setting.<br><br></div>
<div>This is where organizations like HIMSS can help advance interoperability by facilitating conversations and collaboration to lay the foundation for trusting partnerships that in the end can deliver integrated care and better outcomes for seniors. </div>
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<div><em>Doc Devore is the director of clinical informatics and industry relations with MatrixCare.</em></div>
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<div>Sponsored by MatrixCare</div>
| The Centers for Medicare & Medicaid Services defines interoperability as the ability of two or more systems or components to exchange information and use the information that has been exchanged. | 2016-05-01T04:00:00Z | <img alt="" src="/Issues/2016/May/PublishingImages/tech_t.jpg" style="BORDER:0px solid;" /> | Technology | Column |
| Don’t Get Shortchanged: A Guide To ACO Prep | https://www.providermagazine.com/Issues/2016/May/Pages/Don’t-Get-Shortchanged-A-Guide-To-ACO-Prep.aspx | Don’t Get Shortchanged: A Guide To ACO Prep | <div><div> </div>
<div>The Centers for Medicare & Medicaid Services (CMS) anticipates that, by the end of 2016, at least 30 percent of Medicare payments will have shifted to alternate payment models and that by 2018 that percentage will have shifted to 50 percent.</div>
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<div><span><img width="93" height="133" class="ms-rtePosition-1" alt="Carl Bloomfield" src="/Issues/2016/APril/PublishingImages/CarlBloomfield.jpg" style="margin:5px 10px;" /></span>The most notable payment models are Accountable Care Organizations (ACOs) and bundled-payment arrangements. These new alternative payment arrangements will require changes in the operations of all affected providers. While providers are busy readying themselves for these alternate payment models, they may be failing to take the most important steps to mitigate risk and protect their businesses. </div>
<h2 class="ms-rteElement-H2">Preparing For The New Alternatives</h2>
<div>Regardless of type, the new alternative payment models require providers to optimize their quality outcomes and collaborate with other providers within the continuum of care. Toward that end, and to improve their Five-Star CMS ratings, providers are taking several measures, including optimizing their quality outcomes by analyzing their quality measures and benchmarking various rehabilitation metrics, such as length of stay.</div>
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<div>Many providers are also sharing the results of their quality assurance performance improvement (QAPI) projects with other providers in the continuum of care to convey their commitment to being an effective partner. There are many proactive providers that have worked with hospitals to improve the hospital readmission rates by streamlining the hand-off process at patient discharge. Another way to improve rates is to interface among providers and their electronic health records to optimize better sharing of pertinent data to minimize errors in prescribing, facilitating accurate discharge instructions, and promoting compliance with follow-up visits. </div>
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<div>While these operational improvements in efficiency and quality of care make a provider an attractive partner for inclusion in a network or an ACO, these are not the most important steps to ensure success under these new payment arrangements. </div>
<h2 class="ms-rteElement-H2">Potential Risks With New Payment Models </h2>
<div>As traditional fee-for-services payment shifts to the new alternative payment arrangements, providers are being required to enter into some type of risk-sharing arrangement. For example, under an ACO, providers can bear risk to the adverse impact of unforeseen, catastrophic claims. <br><br></div>
<div>Additionally, the Bundled Payment for Care Improvement Initiative (BPCI) sets a payment for an episode like a joint replacement and after-care rehabilitation. Under a BPCI, some providers may be responsible for the actual cost of care for some patients because it may be greater than the standard benchmarks, leaving the provider to pick up the check for the difference.<br><br></div>
<div>Despite the payment model that is in place, many providers are reluctant to venture into an ACO due to these risk-sharing arrangements and their potential financial business risks. As a result, many providers have adopted a “wait and see” approach. However, choosing not to pursue these alternative payment networks and care organizations is not ideal. If a provider is not involved in these collaborations, it may result in that provider being excluded, which can inevitably affect the organization’s future viability.</div>
<h2 class="ms-rteElement-H2">Navigating Risk In An ACO </h2>
<div>Providers that enter risk-sharing arrangements need protection from the potential of substantial financial loss due to catastrophic claims or high-cost cases. Provider Excess Insurance, otherwise known as stop-loss insurance coverage, can protect the financial business risk of providers in an ACO. This coverage offsets the impact of unforeseen, catastrophic claims or excessive care costs under either a capitation payment or other risk-sharing arrangement. <br><br></div>
<div>While this insurance coverage has been available for years, most providers did not opt for it because the same financial risks and exposures simply did not exist under conventional fee-for-service payment arrangements. <br><br></div>
<div>To better demonstrate how stop-loss insurance works, consider if a post-acute care provider accepted a client under a bundled payment arrangement for joint replacement aftercare and rehabilitation and the cost of care due to unforeseen complexities far exceeded the benchmark target and totaled $300,000. If the applicable deductible is $100,000, the stop-loss insurance policy would reimburse (if the coverage was 100 percent) the remaining $200,000.<br><br></div>
<div>According to Michael Smith, RN, LNHA, regional director of Mid-Atlantic Operations for Marquis Health Services, a third-generation, family-owned company that acquires and operates subacute rehabilitation and skilled nursing facilities throughout the Northeast corridor, capitation payment is generally a foreign language to some health care operators today. In fact, senior care providers have historically provided individualized care for each resident—care that is not based on statistics or benchmarks.<br><br></div>
<div>Because each person has differing abilities and challenges, a provider must adapt a care plan according to the resident’s needs. Perhaps that means more time in the physical therapy gym or more days in the skilled rehabilitation unit so less therapy can be provided over more days. Neither of these adaptations may fit into the actuarial data used by these alternate payment arrangements and, therefore, providing care that best fits a resident’s needs can be costly.</div>
<div>Because there are so many risks to consider in an alternate payment arrangement, stop-loss insurance can cover any anticipated losses.<br><br></div>
<div>Coverage for this insurance varies in each policy, and the financial protection is substantial. After any applicable deductible or coinsurance, the policy covers 80 to 90 percent of financial loss of the provider. </div>
<h2 class="ms-rteElement-H2">The Future Of ACOs </h2>
<div>Because traditional fee-for-service payment has proven to be an unsustainable payment model, the health care industry continues its transition to new alternatives that require a risk-sharing arrangement among providers. Long term/post-acute care providers are working to streamline their operations and promote collaboration with various providers in order to be included in future ACOs.<br><br></div>
<div>These operational improvements cannot protect an organization from unforeseen catastrophic losses nor mitigate the risk of higher costs of care outside industry benchmarks. However, stop-loss insurance can offset some of these risks and financial exposures and ease concerns about entering risk-sharing arrangements and securing a spot within an ACO or other network. </div>
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<div><em>Carl Bloomfield, AAI, is a vice president and leader of the Health & Human Services Division at The Graham Co., an insurance and employee benefits brokerage in the Mid-Atlantic region. He can be reached at cbloomfield@grahamco.com or (215) 701-5420. Follow @TheGrahamCo.</em></div> | Many providers are also sharing the results of their quality assurance performance improvement (QAPI) projects with other providers in the continuum of care to convey their commitment to being an effective partner. There are many proactive providers that have worked with hospitals to improve the hospital readmission rates by streamlining the hand-off process at patient discharge. | 2016-05-01T04:00:00Z | <img alt="" src="/Issues/2016/April/PublishingImages/mgmt_t.jpg" style="BORDER:0px solid;" /> | Management | Column |