Happy New Year to all of you! We hope you are all doing well.
First of all, thank you for all you do, it doesn’t go unnoticed. Especially true over the holidays-again taking that extra patient, seeing a visit on a Sat and of course learning a new EMR system or two! We have gotten some nice positive feedback from agencies about our clinicians - Thank you!
What is being asked of us as clinicians is unfortunately increasing all the time. We are all aware of insurance companies approving less visits and taking longer to approve extensions. This week a new set of conditions of participation (COP) takes effect. Many agencies are instituting new standards to comply with these regulations. Since we work with many different agencies, the way each one is interpreting and complying with these new COP’s will vary. We must continue to be flexible and diligent to meet the needs of each agency while focusing on the most important part of our jobs, patient care. I know it can be disheartening when all this takes us away from our real job of patient focused care, but it is the reality we now live in.
We would like to make sure we are all on the same page regarding the new COP’s that went into effect January, 13, 2018. As professionals I hope we can do the best we can to treat our patients, do great documentation and communicate and comply with each agency standards.
Timeliness-- preferably 24 hours for the actual evaluation (and never more than 48 Hours!) . Right after the evaluation is done, the agency needs to be contacted to let them know the evaluation was done and what the plan of care is. This has been universal among all the agencies. Do not contact us, contact the agency. Evaluation documentation needs to be fully submitted within 24 hours of doing the evaluation (and never more than 48). Many insurance companies need these evals to get any auth past the first eval. Some insurance approvals can take a full week to get further auth, so the longer the documentation takes the longer the auth will be. Don’t forget some agencies require us to pull your notes out of Kinnser and manually send them and that also takes time.
In order to be effective you will need to get contact information for the other care team clinicians. Please call other members of the care team and document that you did! If you need phone lists/numbers for clinicians, do not hesitate to call the agency, or please let us know, and we will work to provide that information to you! All new patients need to be contacted the night before to set up appointments. If you cannot contact the patient that night or early the next morning, please call the agency. Many times they have a better number they forgot to send us or some other insight. Either way, they want to know in that first 24 hours what is happening with their patients. The new COP demands greater care coordination efforts and interdisciplinary communication to ensure all providers are focused on the patient’s individual needs.
New rule for agencies - discharge summary and/or oasis needs to be processed by the home health agency no later than 5 days from discharge. That means it needs to be in our system, and it needs to be reviewed and approved, and at times we need to physically send it off. If it takes the clinician 3 days, there is no way we can service our agency customers so they can have a coder check it and submit in 5 days. For dc oasis-if you do not have the soc oasis, please just answer the best you can. Most of the time we know the patient well enough to answer most questions, but the rest the coders will address. There are many changes to the Oasis document. If you do SOCs please watch the videos in the link below to familiarize yourselves with these changes. You are responsible for your own education in this and the trainings can be submitted for CEUs.
Transfer oasis needs to be in and submitted within 48 hours of discovering a hospitalization. If you discover this, contact the agency and they will let you know if you need to do the transfer oasis. For some agencies, such as Saint Luke’s and Advocate, with the transfer/discharge summaries there is a smart text template or form for when a pt transfers or discharges (see powerpoint below). All patients who are transferred or discharged must have the template filled out or it will go back to them for completion. Transfers only have a 2-day turnaround, so these are especially important. Discharges have a 5-day turnaround. Our coordinators route the summaries to the physicians once these are complete.
A big topic at a meeting Laura attended was patient centered care. It is a huge part of the new COP’s and will ultimately improve patient care as a whole. Make each eval and goals individualized based on that patient’s unique needs. This may require us to be more creative with our wording and think “outside the box”. Please do not submit a plan of care of 2x4 or 2x5 for every patient. Each patient should be treated individually. Many patients would benefit from 3x/wk for the first week or so because they have little support or they are at a higher risk of hospitalization. We have had comments from agencies that too many of our therapists have the same frequencies. I know 2 visits / week is easier to schedule but it cannot be about us and certainly that cannot be documented. A md visit is not a reason for a MV. Usually an MD appointment is known in advance and you should be aware because you are scheduling ahead of time. A MV should not happen during the first 2 or 3 days of the week. These should be made up. If you have difficulty with your time getting them in, let us know. We have more missed visits than any of the other staffing companies.
We also need to meet the COPs requirement of notifying ALL doctors of ALL changes to care plans. This means PTAs and COTAs you MUST be notifying the evaluating therapist of any changes. For infection control-the main new item would be fulfilling the requirement to document if the patient has a new infection since the past visit. In Kansas, Saint Luke’s has a form "does the pt have an active infection?” to complete if this is applicable.
Every note has to be unique. Every evaluation and note has to have skilled interventions. It is not enough to check off evaluation at eval-must include treatment. At evaluation is is important to document communication with MD, agency and other care team members. It was also suggested to use the language “patient is in agreement with PT plan of care”. Some EMR’s include this. Also need progress towards specific goals for notes. Please include full vitals on each note. Most agencies require temps for each clinician, Please do them, and please call the MD if vital signs are out of parameters.
Patients have to be informed of their rights and responsibilities at SOC. Many agencies, including Saint Luke’s and Advocate are amending their SOC forms. If you do SOC's, please verify that you have forms that reflect the new COPs. As part of the COP’s, the patient and a representative have the right to know their care plan, why they are getting therapy, go over mutual functional goals, come up with an appropriate time frame. The calendar/folder needs to be filled out with your discipline, frequency, tentative schedule and updated weekly.
There is a greater emphasis on progress toward patient care goals. Are we documenting that our patients are getting better? Home health agencies' progress toward achieving specific outcomes will be tracked and they will be required to participate in performance improvement projects at least annually that measure progress on identified problem areas.
Some exciting changes are in the works for Aptiva Therapy that will mean more new agencies and more referrals. As always, if we are the best at what we do, patients and agencies will continue to seek our services. For your reference we have attached a link to a videos from Axxess, a PowerPoint from Saint Luke’s and a PowerPoint from Advocate. As always, please don’t hesitate to contact the office or any partner if you have any questions!
We look forward to working with you all in this new year!
Laura Nilles & Melissa Hardesty
CMS has implemented a new requirement, Pre-Claim Review (“PCR”). This new rule has been imposed in a whirl-wind “demonstration” project. Initial guidelines were issued on June 8th and the program was adopted and implemented less than two months later, effective August 1st, 2016 for Illinois for patients with a SOC after that date. Illinois is the first of five states subject to the program, which will grow to include Florida, Texas, Michigan and Massachusetts.
The project was explicitly announced as an initiative to reduce fraud. The essence of the pilot is a new process that requires Home Health Agencies (HHAs) to submit documentation relating to a claim earlier than was previously required. This allows CMS the ability to review documentation to ensure sufficient probability of payment of a claim earlier in the episode.
Home Health Agencies will be submitting the same documentation as has always been the case. However, it must now be submitted within the first 30 days of the episode for the PCR. A claim which preliminarily meets the criteria established for payment of a claim will receive an “Affirmation,” meaning that CMS is likely to approve the claim. If CMS determines that the documentation is not sufficient to meet approval criteria, the claim may receive a “Non-affirmation,” which means CMS is likely to deny the claim. The agency may then submit additional documentation, and do so as many times as necessary.
The qualifications for approval remain the same as in the past: the individual must:
For agencies, areas of particular importance will be:
Additional implication for HHAs include:
The implication for clinicians include:
Once gathering the initial documentation has been completed, the HHA must submit the information for the Pre-Claim Review within 30 days of the start of the episode. The CMS Medicare Administrative Contractor (“MAC” - such as Palmetto) will return a finding within 10 days of submission. Each PCR claim also receives a UTN (“Unique Tracking Number”) which follows the claim. A copy of the decision is also sent to the patient.
If the agency does not submit a claim to PCR, it may still be paid upon final submission, but the amount will be reduced by 25%. Thus, while “voluntary”, the implementation of PCR is likely to be virtually universal.
Because CMS will be sending notice of its determination of Affirmation or Non-affirmation to both the agency and patient, patients are likely to ask more questions about the process and their rights and responsibilities. Patients that receive a Non-affirmation finding are likely to want to know what and how they can proceed. Patients have a right to assemble additional information and submit it directly to the MAC just as agencies can. It is highly recommended that they work in concert with their HHA to do so. Only one agency may have a valid UTN at a time, so if a patient changes agency, the case will need to be resubmitted by the new agency.
From a practical standpoint, the PCR process has relatively little impact on clinician’s day to day activities, perhaps with the exception of increased focus on timeliness and quality of notes. Clinicians with strong work habits should be fine in continuing their daily work. That said, the process will have a big impact on HHAs from a documentation timing and administrative follow-up stand-point. Understanding and adapting to these new processes are likely to cause agencies to take additional time and admit fewer patients. This in turn can impact the patient load and opportunity for clinicians.
Aptiva has positioned itself as the premier provider of quality services in the market. We are extremely proud of the quality of the clinical care and documentation that we provide, through you, our expert clinicians. While this may represent a short-term challenge for Aptiva and all HHAs as they adapt to new standards, we believe that in the long-run, it will help us succeed as agencies move toward quality over deeply discounted providers. We ask all of you to stay focused on providing great care, thorough documentation, and ensuring that our patients have the best possible outcomes. While this transition may be a difficult period, we believe that quality, high-value service will ultimately prevail, and our clinicians will enjoy an even greater level of success.
You may have already been contacted by an Aptiva partner regarding a performance review. What’s behind this new requirement?
The answer lies in recent (2015) guidance provided by CMS to field auditors, and subsequent interpretation by credentialing agencies such as the Joint Commission, CHAPS and ACHC, that all clinicians engaged in home health, including contractors, must be able to demonstrate compliance with the Code of Federal Regulations Section 484.14 (c). That section requires that agencies demonstrate that they use “qualified personnel” and have adequate “staff education and evaluation.” These guidelines have been interpreted by the accrediting organizations as requiring that staffing firms (including Aptiva) fulfill certain basic practices including: (1) a basic orientation regarding policy and procedures; (2) annual performance and competency/skill assessments; and (3) on-going continuing education.
In practice, employee and contract clinicians engaged by staffing firms have been able to avoid these administrative processes, since they were not considered as subject to the same requirements as an agency’s directly hired employees. Unfortunately, the implementation of the 2015 audit guidelines has made it clear that independent contractors must present evidence of the same levels of orientation, performance review and in-service content as agency employees. We have been receiving a steady increase in requests for this information from our home health agency customers, and we are now at the point where it has become critical we accomplish these in short order. We hope to complete the processes by August 1st, 2016.
We are also sensitive to the fact that contractors are often engaged in multiple relationships and may in fact be receiving in-service and performance reviews from other resources, such as an agency or full time employer. We also recognize that many individuals may not have access to these resources and may not have had in-service or a performance reviews in the recent past.
To address these issues, we are initiating programs to meet the related requirements.
Contractor Guidebook or Employee Handbook
All three accrediting bodies noted above view a new clinician orientation as an important part of of establishing policy and procedure guidance, and are requesting documentation of the orientation. For individuals new to Aptiva, we have been documenting orientation since the middle of 2015 by means of a written Handbook (for employees) or Guidebook (for contractors). Clinicians working with us from before middle 2015 have not necessarily had a documented Aptiva orientation. If you have not reviewed the Handbook or Guidebook, please review the appropriate version of the document (located in the forms section of this website) and sign the acknowledgement found on the last page. Note that if you transition from a contractor to an employee, you must complete a new employee acknowledgement form. An acknowledgement must be submitted by all employee and contracted clinicians who have not previously done so.
If you have received a performance review from any other source within the past year, and are are comfortable sharing the written review with us, please submit a copy. That may serve as sufficient documentation. Please forward a copy directly to email@example.com, along with a note of explanation as to when, where and by whom the review was completed.
If you have not had a performance review within the last year, then we require that you participate in a performance review process. To complete our performance reviews, we are using a peer-review process, where our clinician partners and a small number of other experienced clinicians perform the reviews.
The reviews are very simple and straight-forward based on one observed visit. Performance is judged as either “competent” or as “needs work.” The review takes into consideration elements of the visit including patient communications, therapeutic techniques and treatment plans. The process consists of three steps: a pre-visit discussion & planning call, the actual visit, and the post-visit follow-up discussion, which can typically occur immediately after the visit. The pre-visit discussion establishes the specific patient, the time and sets the stage for the reviewer. The visit portion is an observation of actual application of skills. It is likely to include discussion of goals and treatment plans, patient or care giver communications, and may include other topics such as exercise dosing or other facets of care. The post-visit process is a review of the probable documentation, follow up on care-team communications if appropriate, and a summary performance discussion between the reviewer and the clinician. These steps are documented on a simple form and that form will become a credential that may be shared with agencies.
In addition, all clinicians must update their skills inventory on an annual basis. This consists of a simple review and self-rating on the various skills associated with your clinical discipline.
The performance review and the skills inventory must be completed by August 1st of this year and annually thereafter.
If you wish to use a review from another source, please submit it as soon as possible. If not, you will be contacted to schedule a review.
Part of the competency requirement is demonstrating staff education. We ask you to provide us with a list of the courses which you have completed as part of your CEUs. You can do that via email list with the date, offering resource, content description and including certificates of completion. We will enter those in our database to document your continuing education. You may also fax or send copies of certificates, so long as they clearly state the relevant information.
In addition, Aptiva will be offering a series of Webinars aimed specifically at clinicians. We are in the process of getting Illinois CEU certification for these offerings, which will be provided by outside vendors. The initial session we have is scheduled for Wednesday, September 21st, 2016 at 1:00 pm CDT. That session will focus on PT Therapy Test & Measures.
A second session is tentatively scheduled for Tuesday, November 1st, 2016, at 1:00, with that topic to be determined.
There are also a number of in-service sessions currently available on-line on the Aptiva Website. These sessions fulfill requirements in Kansas and Missouri for annual in-service education on specific topics, including Infectious Diseases and Blood Borne Pathogens, Alzheimer’s and Dementia, and HIPAA and Patient Privacy. You are welcome to take any of these courses, and will receive a certificate of completion based on your test results, although they are not currently eligible for Illinois CEU credit.