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PDGM COUNTDOWN

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PDGM MILESTONES

JUNE 2019

GET FAMILIAR WITH PDGM

PDGM-OVERVIEW

June 2 - 8

PDGM OVERVIEW – Understand concept for conversion from current Home Health Prospective Payment System (HH PPS) to PDGM

June 9 - 15

HOME HEALTH COVERAGE REQUIREMENTS – Review regulations that are not changing with PDGM
SNF-COVERAGE-REQUIREMENTS
DISCUSS-PDGM-KEY-CONCEPTS

June 16 - 22

DISCUSS PDGM KEY CONCEPTS – Payment based on patient characteristics, therapy service delivery to be outcome-driven, change to 30-day payment periods

June 23 - 29

EVALUATE WHAT YOU HAVE LEARNED – Identify areas of opportunity, focus areas for education and staff training
EVALUATE WHAT YOU HAVE LEARNED

JULY 2019

LOOK AT YOUR DATA

Obtain-PDGM-VS-HH-PPS-Comparison-Data

June 30 - July 6

OBTAIN PDGM vs. HH PPS COMPARISON DATA – Determine if current patient population and current practices project better or worse financial performance with PDGM
  • Run current, completed OASIS assessments and claims from closed episodes through PDGM analytics software, if available, to compare performance under current HH PPS to PDGM
  • Review CMS’s HH PDGM Agency Level Impacts File – Results listed by CCN (CMS Certification Number)
  • Use CMS’s PDGM Grouper Tool – Provides individual patient-level information regarding classification under PDGM

July 7 - 13

ANALYZE DATA FROM A FINANCIAL PERSPECTIVE – Does current practice (coding, utilization) translate to PDGM?
  • If PDGM analytics software is available for current data, start with an overall picture
    • Financial results of current 60-day episodes under HH PPS and PDGM
    • Percentage of LUPAs during 60-day episode vs. 30-day payment period
    • Percentage of outliers
  • If using CMS’s Agency Level Impacts File, review overall financial performance under HH PPS and PDGM
  • Drill down into patient-specific financial impact using CMS’s Grouper Tool
Analyze-Data-From-a-Financial-Perspective
Analyze-Data-From-a-Clinical-Perspective

July 14 - 20

ANALYZE DATA FROM A CLINICAL PERSPECTIVE – Does current OASIS clinical data (e.g., diagnosis codes, functional status) accurately reflect the clinical needs of your patients under PDGM?
  • ICD-10 coding – Review current ICD-10 coding practices on both the OASIS and the claim
    • Look for unspecified and symptom-based ICD-10 codes as these will likely not map to a PDGM Clinical Group
    • Review comorbidity (secondary) diagnosis coding
    • Do you know your return to provider or non-qualifying diagnosis rate?
    • Do key personnel need ICD-10 coding training?

July 21 - 27

DRILL DOWN INTO THE OASIS AND THE CLAIM – Are the items that impact payment under PDGM completed accurately?
  • Review key items on the OASIS: M1021, M1023, M1033, M1800, M1810, M1820, M1830, M1840, M1850, M1860
  • Review Principal and Secondary diagnoses on the claim
  • Do you have the information you need to accurately code all relevant diagnoses upon admission?
  • Does the information on the claim match the OASIS?
  • Does medical record documentation support the OASIS and the claim?
Drill Down Into The Oasis And The Claim
EVALUATE WHAT YOU HAVE LEARNED

July 28 – August 3

EVALUATE WHAT YOU HAVE LEARNED – Identify areas of opportunity, focus areas for education and staff training

AUGUST 2019

LOOK AT YOURSELVES

Optimize-Discharge-Planning-software-services

August 4 - 10

ASSESS YOUR PEOPLE – Do you have the right people in the right places? Are your people informed? Access the Role-Based Assessment tool.
  • Who is involved in the admissions process? Are they effective?
  • Are your nurses and therapists strong, clinical evaluators?
  • Does your staff understand PDGM and the shift in reimbursement?
  • Do your doctors and referring providers understand PDGM and their role?
  • Are your therapists involved in a collaborative team effort to ensure accurate diagnosis and OASIS coding?

August 11 - 17

ASSESS YOUR PROCESSES – Admissions, OASIS coding and completion, patient care conferences, visit scheduling, etc.
  • Are your processes clearly defined? Are they consistently followed?
  • Do your processes need to be improved or is it a “person problem”?
  • Do you have the right person in the right role?
Assess-Your-Processes
EMR-Software-Roles-and-Processes

August 18 - 24

DEFINE NEW ROLES AND PROCESSES – Identify your desired state with respect to workflow, task/process ownership, communication, timeliness and output
  • What and/or who needs to change?
  • What skills and characteristics are needed for each role?
  • Clearly communicate expectations

August 25 - 31

INITIATE ROLE AND PROCESS CHANGES – Continue education and training with a role-based focus, document processes
  • Socialize changes in roles and processes
  • Support staff who are changing roles – consider assigning staff mentor
  • Establish expectations of collaboration and accountability
EMR-software-Initiate-Role-and-Process-Changes

SEPTEMBER 2019

LOOK AT YOUR CONTRACTS

Review Customer Contracts

Sept 1 - 7

REVIEW CUSTOMER CONTRACTS – Assess current contract structure with HHA providers from volume and performance perspective
  • What types of contracts do you currently have in place?
  • How do you perform under each contract?
  • Assess customer/partner relationship – strong (true partner) vs. weak (vendor only)

Sept 8 - 14

CONSIDER ALTERNATIVE CONTRACTING ARRANGEMENTS – PDGM and other value-based care payers
  • Percentage of HHRG
  • Per visit
  • Risk-sharing, performance adjustments
  • Management
Consider Alternative Contracting Arrangements
Schedule Contract Negotiation Meetings

Sept 15 - 21

SCHEDULE CONTRACT NEGOTIATION MEETINGS – Jointly define the metrics that communicate success with PDGM
  • Readmission rates
  • Other metrics?

Sept 22 - 28

EVALUATE WHAT YOU HAVE LEARNED – Identify areas of opportunity, focus areas for education and staff training
Evaluate What You Have Learned

OCTOBER 2019

LOOK AT YOUR REFERRAL SOURCE DATA

Analyze-Market-Segmentation-Variables

Sept 29 - Oct 5

ANALYZE YOUR MARKET SEGMENTATION VARIABLES
  • Complete Market Strategy Framework (Updated - July 19, 2019)
  • Record averages from trailing 12-month period to show percentage of referrals by:
    • Payer mix (Managed Care, Medicare, Medicaid)
    • Percentage of readmissions – focus on strategies to reduce avoidable readmissions
    • Percentage from each hospital referral source
    • Percentage by specific insurance contract
    • Percentage by hospital networks, ACOs and bundles
    • Percentage by primary patient diagnosis
  • Analyze the behavior, decision process and characteristics of each segment: Know who pays what and for how long and what the documentation requirements are

Oct 6 - 12

FORM JOINT OPERATING MEETINGS WITH HOSPITALS AND PROVIDER NETWORKS
  • Aligning behaviors with mutual goals and objectives
    • Discuss strategies to standardized care
    • Discuss readmissions and how to improve outcomes with complex patients
    • Define new processes and expectations
  • Identify who is responsible for intake and whom they notify with all details communicated
    • Identify who is responsible for intake in the gaps (Friday-Sunday and holidays)
  • Ultimately, these strategies should reduce avoidable hospital readmissions, reduce cost, and improve outcomes and patient/family satisfaction
Meetings-with-Hospitals-Provider-Networks
Evaluate Current Payer Contracts

Oct 13 - 19

EVALUATE CURRENT PAYER CONTRACTS – Must know all payer contract requirements on admission or could be a financial liability
  • How are we performing? Are we ready?
  • Are current contracts financially positive for the agency?
    • If not, which areas are causing loss?
    • How can we improve performance?
    • Can contracts be renegotiated?

Oct 20 - 26

ASSESS MARKET DEFINITION – Determine where you fit in the market and where you want to be
  • Analyze strength of clinical programs offered
  • Identify opportunities to strengthen your position in the market and/or services offered
  • Develop a clinical grid to assist admission coordinators to more readily accept referrals
  • Create messaging / branding campaigns
  • Identify collateral and equipment needs
  • Identify training and educational initiatives
  • Consider specialties / competencies to assist in reducing variation in clinical care (e.g., Memory Care, Disease Management, Behavioral Health, Post-acute Rehab, etc.)
Assess Market Definition
Evaluate-What-you-have-learned

Oct 27 - Nov 2

EVALUATE WHAT YOU HAVE LEARNED – Take time to review changes made thus far and assess overall progress
  • Are employees gaining competence and confidence in new roles?
  • Is additional staff training on PDGM necessary? ICD-10 coding, Function coding (also consider adding training for staff on Section GG to ensure accuracy)
  • Have you completed contract negotiations?

NOVEMBER 2019

OPTIMIZE YOUR SYSTEMS AND PROCESSES

Optimize-Therapy-Software-Processes

Nov 3 - 9

OPTIMIZE THERAPY PROCESSES – Discharge readiness, clinical pathways
  • Ensure readiness for discharge, assess for additional skilled needs (e.g., outpatient therapy, community resources)
    • If transitioning to OP or community program, ensure hand off is successful
    • Assure efficacy of caregiver training
  • Begin peer review of therapy goals set vs. goals met
    • Provide objective feedback on functionality and appropriateness of goals
    • Standardized tests used routinely
  • Ensure adoption of clinical pathways and evidence-based interventions

Nov 10 - 16

OPTIMIZE NURSING PROCESSES – Interdisciplinary meetings, OASIS coding, clinical competency (with respect to decreasing visits to ED and readmissions to hospital)
  • Evaluate effectiveness of interdisciplinary meetings – Is IDT collaboration evident?
  • Assure new admissions are being viewed as a PDGM case?
    • Does the team use PDGM terminology (e.g., principal diagnosis, comorbidities, functional impairment)?
    • Are ICD-10 codes being determined and utilized efficiently?
Optimize Nursing Processes
Optimize-Discharge-Planning-software-services

Nov 17 - 23

OPTIMIZE DISCHARGE PLANNING – Downstream communication, caregiver training, manage readmission risk
  • Referrals to next level of care (OP, community resources/programs)
  • Ensure caregiver training is comprehensive and complete – from a therapy (function) and nursing (medical management) perspective
  • Be able to accept calls/questions from patient and/or caregiver after discharge
  • Consider follow-up contact/communication after patient has transitioned off caseload at 72 hours, 1 week and 4 weeks
  • Review CMS’s Care Coordination Toolkit

Nov 24 - 30

EVALUATE WHAT YOU HAVE LEARNED
Optimize-Discharge-Planning-software-services


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