Managing OutcomesLisa Werner, MBA, MS, CCC-SLPDirector of Consulting Services

Data AnalysisWhy 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.

Data AnalysisWhen 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?

Data AnalysisSelecting Indicators:Review outcomesDetermine what is below benchmarkFigure out what is meaningful to your facilityDetermine what is attainable for your facility

Facility ReportCase Mix IndexAre 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.

Facility ReportCase Mix Index:Benchmark against the nation and the region.Investigate the components-Rehabilitation Impairment ClassificationMotor Functional Independence Measure Subscale Weighted Score at AdmissionAgeTier Assigning Co-morbid ConditionsInvestigate the distribution of impairment groups, CMG, or RIC.Investigate the components for the most common groups.

Facility ReportAverage Medicare Expected Reimbursement:Based on Medicare reimbursementAdjusted for your facility pricer as updated through eRehabDataIncludes calculations for transfer payments and short stay reductions

Facility ReportTransfer Patients:Percentage of patients that are discharged to another Medicare bedAcute careSNFLTACHAnother IRF

Discharge Destination:Breakdown of discharge locations for the patients servedSkilled nursing and subacute designation errors

Facility ReportAverages:Two benchmarks: Weighted and unweightedOnset days: Different instructions by RICLength of stay considerationsFunctional Independence Measure scoring data-Admission TotalsDischarge TotalsFunctional Independence Measure ChangeMotor subscale at admission

Facility ReportIndividual Functional Independence Measure Items:Admission, discharge, change, and follow-upExplains difference between facility totals and benchmark totalsFirst glance at isolating Functional Independence Measure scoring errors

Breaking Down the CMITips: Evaluate your admission Functional Independence Measure scoresHow does your admission Functional Independence Measure score compare to those in your region and across the nation?

Breaking Down the CMI

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

Breaking Down the CMIPay attention to the most commonly used comorbidity lists

Breaking Down the CMIPull reports to show your CMG breakdownAre you missing high acuity patients, low acuity patients?

Breaking Down the CMIPay attention to the warnings to tell you when there is a mismatch between IGC and Etiologic diagnosis

Drill-DownReimbursement: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.

Drill-DownAverages: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 ReportReferral date to admission date

Length of Stay should be evaluated to ensure you are hitting your targets.RIC, IGC, CMG, Patient Report

Drill-DownAverages:Functional Independence Measure ScoresTotal 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 populationTotals reviewed by RIC, IGC, CMGItems reviewed in for total populationItems reviewed by RIC, IGC, CMGFunctional Independence Measure Scoring Comparison GraphTime-Series GraphMetrics

StrategiesAverages: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 scoringBe sure that the lowest score is taken from the documentationBe sure that a full set of scores is captured dailySet 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 1:1 sessions.

Functional GainFunctional 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 highOutcomes are too lowDiscrepancy between the scoring of items within the same category

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.

Functional GainTip: Focus on Gain Above BenchmarkLook at the number of 0s on particular Functional Independence Measure itemsRemember 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 treatment3. 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.

Functional GainWhy 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

Functional GainTip: Focus on Gain Below BenchmarkLook at the average length of stay

Look at interdisciplinary treatment processesLook at patient mixLook at volume

Functional GainLook 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

Functional Gains

Look at returns to acuteLook at discharges to settings other than home

Goal AttainmentGoal 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.

StrategiesGoal 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.

Other ViewsTime Series Graphs:Look at performance over timeMultiple indicators can be viewed simultaneouslyData tables are useful tools for report preparation

Other ViewsFunctional Independence Measure Scoring Comparison Graph:Graphs admission, discharge, and change scores for the facility and region/nationReview weighted and unweighted comparisonsHelps identify items that may require special attention in order to accurately represent the burden of care

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

Other Views60% Rule Report:

Know how you will report your compliance to the FI: admissions or dischargeKnow your cost report year and look back periodsManage conditionally compliance closely

Other Views60% Rule Report:Confirm the final IRF-PAI with the patients status on the compliance reportPresumptive 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.

Other Views60% 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.

Other ViewsDashboard:Great tool for daily census updateOffers a 14-day projection of census decline for current case mixProvides 30-day analysis of several indicators: CMI, 60% rule compliance, RIC distribution, and payor source breakdownIn order to provide data, your bed configuration and pricer need to be up to date

Referral TrackingReferrals 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.

Other ViewsReferrals Outcomes:

Use information to determine referral trends by-Referral sourceReferring physicianInternal versus external fillZip code breakdownPayor source breakdownConversion ratesReasons for denial

Drill down by RIC, CMG, and Patient Patient reports list patients denied

Conducting a Non-Admission ReviewNon-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 ReasonsToo impairedToo functionalNo bed availablePhysician did not agreePatient or family refusedInsurance did not authorizeNot 60% rule compliant

Conducting a Non-Admission ReviewWhat can we do about the too impaired category?

Determine if the admission denial was based on objective criteriaIdentify if the denial was based on staffs lack of competencyClarify with Medical Director his/her comfort level with the staff managing a patient with that diagnosis or at that level of acuity

Conducting a Non-Admission Review

Denial because Too Functional

Review the referral date against the actual date of the screenWould 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.

Optional ItemsPatient Satisfaction Instrument:3-Step Satisfaction Tools specific to rehabService RecoveryDischargeFollow-Up

Feedback from Stakeholders:Reported with demographicsItem by item averages of responses for each itemSame drill-down capabilities as facility reports

Optional ItemsPatient Satisfaction Instrument:Graphs responses to questions from each survey type for selected time periodGraphs historical trends for each question asked on the surveysTime Series Graphs available to drill-down by patient type or demographic profileStores and reports narrative comments provided by patients

Putting It All TogetherBest 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!

Questions?

Lisa Werner, MBA, MS, CCC-SLPLwerner@erehabdata.com202-588-1766