Managing Outcomes

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Managing Outcomes

• Lisa Werner, MBA, MS, CCC-SLP
• Director of Consulting Services

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Data Analysis

• Why do we do it?
• Accurate outcome data is a powerful tool that can
  be used to educate key decision makers in the
  hospital, potential patients, payers, and the
  community at large.
• Marketing efforts are enhanced when outcome
  information is used during direct marketing
  calls.
• The team benefits from use of outcome information
  by being able to see where they are the most
  effective and also by being able to focus
  improvement efforts.
• Breaking down your performance may reveal
  opportunities to capture the burden of care and
  yield greater reimbursement.

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Data Analysis

• When conducting data analysis, ask yourself
• Does the data look real?
• It is important to validate that the data that
  you are analyzing is reliable.
• Can you identify any inaccuracies in your sample?
• Do the outcomes meet your expectations?
• Compare your outcomes to your goals and industry
  benchmarks.
• How do you stack up?
• What impact would change make?
• Would there be a positive impact on your patient
  care services if you improved your performance in
  this area?

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Data Analysis

• Selecting Indicators
• Review outcomes
• Determine what is below benchmark
• Figure out what is meaningful to your facility
• Determine what is attainable for your facility

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Facility Report

• Case Mix Index
• Are you getting paid for the work that you do?
• Does it seem like your CMI is lower than your
  burden of care?
• Capturing the proper CMI is essential to enable
  you to staff appropriately.
• Since many of us predict staffing ratios based on
  patient acuity as realized through the CMI, it is
  important to capture what most closely reflects
  the care being rendered on the unit.

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Facility Report

• Case Mix Index
• Benchmark against the nation and the region.
• Investigate the components-
• Rehabilitation Impairment Classification
• Motor Functional Independence Measure Subscale
  Weighted Score at Admission
• Age
• Tier Assigning Co-morbid Conditions
• Investigate the distribution of impairment
  groups, CMG, or RIC.
• Investigate the components for the most common
  groups.

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Facility Report

• Average Medicare Expected Reimbursement
• Based on Medicare reimbursement
• Adjusted for your facility pricer as updated
  through eRehabData
• Includes calculations for transfer payments and
  short stay reductions

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Facility Report

• Transfer Patients
• Percentage of patients that are discharged to
  another Medicare bed
• Acute care
• SNF
• LTACH
• Another IRF
• Discharge Destination
• Breakdown of discharge locations for the
  patients served
• Skilled nursing and subacute designation errors

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Facility Report

• Averages
• Two benchmarks Weighted and unweighted
• Onset days Different instructions by RIC
• Length of stay considerations
• Functional Independence Measure scoring data-
• Admission Totals
• Discharge Totals
• Functional Independence Measure Change
• Motor subscale at admission

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Facility Report

• Individual Functional Independence Measure Items
• Admission, discharge, change, and follow-up
• Explains difference between facility totals and
  benchmark totals
• First glance at isolating Functional Independence
  Measure scoring errors

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Breaking Down the CMI

• Tips
• Evaluate your admission Functional Independence
  Measure scores
• How does your admission Functional Independence
  Measure score compare to those in your region and
  across the nation?

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Breaking Down the CMI

• Determine what percentage of the time you are
  scoring a tiering comorbidity

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Breaking Down the CMI

• Pay attention to the most commonly used
  comorbidity lists

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Breaking Down the CMI

• Pull reports to show your CMG breakdown
• Are you missing high acuity patients, low acuity
  patients?

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Breaking Down the CMI

• Pay attention to the warnings to tell you when
  there is a mismatch between IGC and Etiologic
  diagnosis

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Drill-Down

• Reimbursement
• Determine which populations have the greatest
  transfer payment percentages.
• Evaluate length of stay by RIC, IGC, CMG.
• Review discharge destinations by group.
• Use the patient report to identify outliers.

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Drill-Down

• Averages
• Onset days should be evaluated on a RIC basis to
  ensure you are hitting your targets given the
  definition stated in the IRF-PAI Training Manual.
• RIC Report
• Referral date to admission date
• Length of Stay should be evaluated to ensure you
  are hitting your targets.
• RIC, IGC, CMG, Patient Report

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Drill-Down

• Averages
• Functional Independence Measure Scores
• Total Admission Functional Independence Measure
  shows patients overall burden of care and
  potentially indicates barriers to progress or
  expected rate of progress.
• Total Discharge Functional Independence Measure
  shows patients achieved performance. Scores are
  gathered across the last 3-days of the stay.
  Facility identifies patients best performing
  24-hour period and the lowest scores from that
  day are reported on the IRF-PAI.
• Functional Independence Measure Change is the
  amount of gain from admission to discharge and is
  also reported on a per day gain basis.
• Considerations
• Totals reviewed for total population
• Totals reviewed by RIC, IGC, CMG
• Items reviewed in for total population
• Items reviewed by RIC, IGC, CMG
• Functional Independence Measure Scoring
  Comparison Graph
• Time-Series Graph
• Metrics

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Strategies

• Averages
• Evaluate screening and admission process to
  determine if patients are being admitted at the
  right time in their recovery.
• Evaluate initial IRF-PAI scores for proper
  scoring
• Be sure that the lowest score is taken from the
  documentation
• Be sure that a full set of scores is captured
  daily
• Set the stage for accuracy through communication
  among team members
• Evaluate the effect of the volume factor.
• Start an ADL program, ambulation group, cognitive
  group, etc to focus on enrichment of skills
  learned in 11 sessions.

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Functional Gain

• Functional Gain The Functional Independence
  Measure change between admission and discharge
  measures the degree of functional improvement
  demonstrated by patients.
• Effectiveness Ensuring patients obtain
  sufficient gain to be able to return to their
  prior level of function.
• What are the problems?
• Outcomes are too high
• Outcomes are too low
• Discrepancy between the scoring of items within
  the same category

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Functional Gain

• Why would outcomes that are too high be a
  problem?
• Admission Functional Independence Measure scores
  were too low during the assessment period.
• Failure to assess areas of the Functional
  Independence Measure (i.e., bathing, stairs) can
  lead to gains above the benchmark.

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Functional Gain

• Tip Focus on Gain Above Benchmark
• Look at the number of 0s on particular
  Functional Independence Measure items
• Remember 0 is not a score and there are only
  three
• reasons that justify the use of 0.
• 1. The clinician determines it is not safe.
• 2. Medical condition or treatment
• 3. Patient refusal
• Look at reliability of the scoring for items that
  exceed benchmark.
• Look at facilitators within the environment that
  enable gains to exceed benchmarks to explain the
  outcomes.

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Functional Gain

• Why dont we want gains that are too low?
• Why gains are less than the benchmark
• Patients are not admitted from acute in a timely
  manner
• Therapy protocols or techniques need to be
  examined
• Lengths of stay are not sufficient
• Functional Independence Measure scoring during
  the admission process may be delayed
•  

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Functional Gain

• Tip Focus on Gain Below Benchmark
• Look at the average length of stay
• Look at interdisciplinary treatment processes
• Look at patient mix
• Look at volume

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Functional Gain

• Look at admission scores for individual
  Functional Independence Measure items
• Look at point at which Functional Independence
  Measure scores are collected (early within 3 day
  look back or on day 3)
• Look at LOS on acute

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Functional Gains

• Look at returns to acute
• Look at discharges to settings other than home

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Goal Attainment

• Goal setting is important!
• Patient metrics page reports admit, discharge,
  goal, and gain.
• Review again goal at team and following discharge
  for success with goal attainment.

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Strategies

• Goal Attainment
• Emphasize goal revision on the plan of care.
• Inservice on goal setting to include proper goal
  setting and progression of treatment through
  incremental goal achievement.
• Begin reviewing long term goals in the weekly
  team conference.
• Determine a method to communicate current status
  and goals regularly through a functional status
  board, stand-up meetings, and/or team conference.

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Other Views

• Time Series Graphs
• Look at performance over time
• Multiple indicators can be viewed simultaneously
• Data tables are useful tools for report
  preparation

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Other Views

• Functional Independence Measure Scoring
  Comparison Graph
• Graphs admission, discharge, and change scores
  for the facility and region/nation
• Review weighted and unweighted comparisons
• Helps identify items that may require special
  attention in order to accurately represent the
  burden of care

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Other Views

• Percentile Ranking Report
• Allows comparison of your facilitys performance
  with other units
• Ranks your performance by report item
• States your facility ranking among all units for
  that time period
• Offers benchmarks of what performance level you
  would need to reach your desired percentile
  ranking
• Case Mix Index Example
• Facility CMI 1.1180
• National average CMI 1.2686
• Facility Percentile Rank 16.48
• Facility desires to be ranked at 60 of database,
  so their target CMI 1.2849

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Other Views

• 60 Rule Report
• Know how you will report your compliance to the
  FI admissions or discharge
• Know your cost report year and look back periods
• Manage conditionally compliance closely

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Other Views

• 60 Rule Report
• Confirm the final IRF-PAI with the patients
  status on the compliance report
• Presumptive or conditional?
• In order to appear on this report correctly, you
  will answer questions on the eRD tab to determine
  if the patient is 60 compliant or not.
• Review the detailed assessment to determine what
  makes the patient compliant.

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Other Views

• 60 Rule Compliance Threshold
• Provided that each patient is properly identified
  on your 60 report, the compliance threshold
  established for your current reporting period is
  adequate.
• Every patient that meets the criteria for
  inpatient rehabilitation deserves to receive that
  level of care.
• Therefore, operating at a higher compliance while
  beds are empty is essentially denying a patient
  an opportunity to regain independence.
• The key is to be sure that you capture the 60
  status of each patient correctly.

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Other Views

• Dashboard
• Great tool for daily census update
• Offers a 14-day projection of census decline for
  current case mix
• Provides 30-day analysis of several indicators
  CMI, 60 rule compliance, RIC distribution, and
  payor source breakdown
• In order to provide data, your bed configuration
  and pricer need to be up to date

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Referral Tracking

• Referrals Outcomes
• Designed to trend referral sources, referring
  physicians, and conversion rates.
• Offers information on reasons for denied
  admission.
• You can filter the information to drill down on
  physician, referral source, internal vs. external
  fill, and reason for denied admission.

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Other Views

• Referrals Outcomes
• Use information to determine referral trends by-
• Referral source
• Referring physician
• Internal versus external fill
• Zip code breakdown
• Payor source breakdown
• Conversion rates
• Reasons for denial
• Drill down by RIC, CMG, and Patient
• Patient reports list patients denied

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Conducting a Non-Admission Review

• Non-admission review
• The review of all patients that have not been
  admitted to rehab unit. This is done by
  reviewing the pre-admission forms and reviewing
  the section that notes the reason for not
  admitting to the rehab unit to help identify
  trends and changes that occur over a quarter.
• Common Reasons
• Too impaired
• Too functional
• No bed available
• Physician did not agree
• Patient or family refused
• Insurance did not authorize
• Not 60 rule compliant

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Conducting a Non-Admission Review

• What can we do about the too impaired category?
• Determine if the admission denial was based on
  objective criteria
• Identify if the denial was based on staffs lack
  of competency
• Clarify with Medical Director his/her comfort
  level with the staff managing a patient with that
  diagnosis or at that level of acuity

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Conducting a Non-Admission Review

• Denial because Too Functional
• Review the referral date against the actual date
  of the screen
• Would reducing the number of onset days have
  resulted in a decision to admit?
• Determine what the patients deficits really were
  and if they could have benefited from a stay in
  an IRF.

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Optional Items

• Patient Satisfaction Instrument
• 3-Step Satisfaction Tools specific to rehab
• Service Recovery
• Discharge
• Follow-Up
• Feedback from Stakeholders
• Reported with demographics
• Item by item averages of responses for each item
• Same drill-down capabilities as facility reports

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Optional Items

• Patient Satisfaction Instrument
• Graphs responses to questions from each survey
  type for selected time period
• Graphs historical trends for each question asked
  on the surveys
• Time Series Graphs available to drill-down by
  patient type or demographic profile
• Stores and reports narrative comments provided by
  patients

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Putting It All Together

• Best Practices in Performance Improvement
• Communicate
• Inservice
• Peer Auditing
• Use Case Studies to facilitate learning
• Select a manageable number for performance
  indicators to work on
• Report change and what worked to facilitate
  change
• Dont fear it!

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Questions?

• Lisa Werner, MBA, MS, CCC-SLP
• Lwerner_at_erehabdata.com
• 202-588-1766