Across the industry, home health agencies have been faced with scrutiny, both clinically and operationally. Specifically, documentation is being audited and scrutinized by payors. ADRs are abundant and Targeted Probe and Educate has ramped up, but it’s not only Medicare. Many private insurances are running their own audits on charts going back as far as two years. In addition, RAC audits have returned to home care.
Pre-Claim Review Demonstration for Home Health Services was initiated in August 2016. Initially, Illinois, Florida, Texas, Michigan and Massachusetts were going to be impacted by the demonstration. The purpose of the demonstration was to determine if pre-claim review would ensure medical necessity was met without delaying care provided as well as determining if expenditures would decrease and outcomes would improve. It was a pre-payment review of the same medical necessity requirements which Medicare currently conducts post-payment.
Although the demonstration was paused in the spring of April 2017, home health agencies have the opportunity to learn from experiences with the demonstration and improve documentation and procedures to ensure compliance. In addition, Medicare and other insurers continue to “mine” data from assessments and claims submitted by agencies, which could influence future regulations.
Most common items that are reviewed in audits by payors:
• face to face documentation
• homebound status documentation
• proper signatures and dates
• the plan of care
Since electronic medical records have entered the scene, there has been an increased phenomenon of “click to clutter”. Clinicians are given many options when choosing a care plan. The boxes are easily checked and not personalized. This creates a care plan for patients that is not individualized and often is unattainable.
FocusChart built our system to combat “click to clutter” as well as unattainable and non-personalized care plans. We know that payors are looking for focused quality; not for quantity. FocusChart uses the format of NANDA (North American Nursing Diagnosis Association) Nursing Diagnoses, which is taught to nurses across the United States to develop appropriate nursing care plans for patients to help clinicians focus and individualize patient care plans. NANDA International uses standardized nursing terminology to communicate professional nursing judgement about patients. The evidence-based nursing diagnoses are used to determine appropriate interventions for improved patient outcomes.
FocusChart reviewed all NANDA diagnoses. After a thorough review, FocusChart customized the list for home health specifically and altered it to meet the needs of other disciplines such as physical therapy, occupational therapy, speech therapy, medical social work and dieticians.
To understand how NANDA creates a higher quality care plan there are three main elements to get familiar with: Problem, Goal, and Intervention.
The problem is a way to organize and categorize the needs of the patient.
As a clinician is reviewing the body systems (on the left side of the screen in FocusChart), when a problem that needs to be addressed in the next 60-day episode pops into the clinician’s mind, they can easily transition to the right side of the screen and add it.
The problem statement is not sent to the physician in an order and does not need to be addressed throughout the episode of care. It does not print on documents such as the discharge summary for the physician to see. It is strictly a way for clinicians to organize the care plan to ensure the care plan is focused on the patient’s specific needs.
Problems are not discipline specific. For example, if pain is chosen by the nurse at the SOC (start of care) and nursing goals and interventions are assigned, at an evaluation visit a physical therapist can see that pain is already being addressed. The physical therapist would then review what the nurse’s intervention is and choose an appropriate goal and intervention for therapy.
This helps to ensure the whole care team knows each disciplines’ care plan and decreases the risk of duplication of services between disciplines.
Problems should focus on the primary reason for care as well as any comorbid conditions that require intervention to ensure the patient has positive outcomes. A focused problem list, related to the current home care needs for this episode of care, should be created.
The goal is a specific expected outcome of nursing intervention(s). It is stated in terms of a desired, measurable change in the patient or caregiver status or behavior.
Each problem should contain a minimum of one goal specific to the patient. Goals are written in SMART format: Specific, Measurable, Achievable, Relevant, and Time-bound.
FocusChart uses mandatory fields within the creation of a goal to ensure SMART goals are written. Goals are reviewed and approved by the certifying physician. They are a part of the patient’s Plan of Care.
The intervention is a treatment, based on clinical judgment and knowledge, that a clinician performs to enhance patient outcomes.
Each goal should contain a minimum of one specific intervention. Interventions should be individualized and contain whether the intervention applies to the patient and/or a caregiver.
Interventions are reviewed and approved by the certifying physician. They are a part of the patient’s Plan of Care.
One of the four most common claim errors in the Targeted Probe and Educate by CMS was “documentation does not meet medical necessity.”
FocusChart’s use of the NANDA format has ensured that a quality care plan can be generated with a focus on the patient’s needs for that episode of care. Clinicians can then document on the care plan efficiently at each visit to ensure that skilled care is being provided every visit.
With oversight from agency management, this feature will improve the ability for the agency to ensure that documentation does meet medical necessity.
It is proven that patients have better outcomes when they have a focused, quality plan of care.
The care plan must be central to the patient, built on patient strengths and focused on the needs of the patient. It must provide a basis for quality, continuity of care and risk management.