Senior Living Consultants

THE PACE MODEL WORKS: IMPROVING BOTTOM LINE THROUGH BEST

PRACTICES IN CARE Monday, October 27, 2014

10:00a-11:30a

Dan Gray Scott Ewing

Cyndi Young, RN

Agenda !  Key Operating Practices

•   Support the voluntary caregiver •   End of life care •   Management of non-compliant behavior

!  Critical Factors for Financial Success •   Census Growth •   Payment Optimization •   Utilization of Contractual Services

!  Other Operating Factors/Practices

Learning Objectives

!  Leave with a framework for evaluating PACE operations

!  Leave with at least one best practice which could improve your operational performance

!  Learn “best practices” from one of the most profitable programs

Key Operating Practices

!  Voluntary caregiver support !  End-of-Life care !  Management of participant/family

member noncompliance

Voluntary Caregiver Support

!  Strategic use of respite !  Education !  Support in the home !  Measurement of caregiver stress using a

standardized tool

End of Life Care

!  Values !  Present and Advance Directives !  Chaplain (“spiritual social worker”)

involvement in process !  Customization of palliative care

!  Frequent flying—non-emergent 911 calls to hospitals (which may not have a contract with PACE)

!  Dump and run—families withdraw support and quickly request nursing home placement

Participant/Family Non-Compliance

Financial Success

!  Critical Factors for Financial Success •   Census Growth •   Payment Optimization •   Utilization management of contract services

Census Growth !  Focus on referral sources

•   Short-term Medicare/Managed Care skilled nursing stays

•   Medicare home health care •   Affordable housing •   Current participants and families—target 40%

Census Growth

!  Target a scheduled home visit for all screened leads •   Primary purpose of home visit is to sell the

program !  Target to enroll 80% to 100% of all

potential enrollees assessed

Payment Optimization !  Establish a simple workflow process for

HCC documentation and billing !  Utilize frequency distribution from PDAC

report to ask the right questions both about both quality and documentation

HCC Management !  Physician: Documentation of Medical

Problems •   Must see patient—face to face encounter

required •   Enrollment health and physical •   Semi-annual exam •   PRN visits

•   Document and submit to EMR •   Examine “common” diagnoses for more

specific documentation

HCC Management !  Coder: Coding and Review Process

•   Recording codes—evaluate appropriate content

•   Review/validate superbill versus clinical records

•   Code the problem/diagnoses determined by the physician

•   Assign or confirm ICD-9 Codes •   Ensure accurate and complete

documentation

!  Business Office: Data Submission and Distribution •   Analyze reports

-  Return Model Output Error (MOR) "   Error resolution "   Monitor against re-evaluations

-  Return File Summary Report (RAPS file) -  HCCMODR—HCC model output report -  PTDMODR—Part D model output report

HCC Management

Using the PDAC Report !  Check the predicted scores for consistency with

your expectations. Consider •   Prior years’ scores •   Changes in enrollment •   Other factors that may have affected your results

!  Check to assure that your program’s submittal of RAPS return files to PDAC is complete

Using the PDAC Report !  Check that all diagnosis codes for dates of

service are submitted on a timely basis !  Request participant level reports from PDAC to

access changes in diagnosis !  Consider developing a plan to address any

missing diagnosis codes with a service encounter by the appropriate date

Utilization of Contract Services

!  Pre-enrollment meeting with participant/family (“pinky swear”)

!  Establish policy that respite care is not provided in the home except for end of life care

!  Rates and utilization of contractual services significantly affect financial performance •   Hospital •   Nursing home •   Home health/home care •   Specialist •   Assisted living/supportive housing

Utilization of Contract Services

! Monthly review of prior month’s Hospitalization focused on any way to shorten length of stay or avoided admission

!  If two teams are in place, have the other team review decision to place a participant long term in the nursing home.

Utilization of Contract Services

PACE Dashboard Illustration

Drill Down Illustration

Operating Factors/Practices

!  Participants living alone—5 to 40% (dramatically affects costs)

!  Prevalence of specific chronic diseases •   ESRD •   COPD •   Behavioral

!  Primary care effectiveness !  Team performance !  Day center attendance !  Day center expansion—mitosis or

start from scratch

Operating Factors/Practices

Questions

1501 Greer Lane Signal Mountain, TN 37377 423.517.0567 dan.gray@consulting-cds.com www.consulting-cds.com