No loose ends

Fans of puzzles know that solving one requires the creation of a particular kind of order, putting the pieces together in a logical way in to arrive at the correct solution.
Home health professionals perform similar tasks daily as they create orderly files made up of many different documents, from an initial referral by a physician to notes made by the nurse seeing a patient in the home. imageJust as a jigsaw puzzle is made up of interlocking pieces, with each piece depicting a small segment of the whole, the many different pieces of documentation that go into a patient’s file work together to create the larger picture of the patient’s health care experience with the agency.
And under new Centers for Medicare and Medicaid regulations that took effect this month, there can’t be any gaps in that picture.

A cohesive whole

One of the best, and simplest, ways for agencies to ensure that each step of the documentation process integrates seamlessly with all other pieces is to ask why an action is being taken or a procedure is being performed, according to J’non Griffin, owner of Home Health Solutions LLC.
Why was the care referenced in the documentation delivered? Was it medically necessary? Then agencies must show proof of that necessity.
Why was each visit made? Was it was part of the agency’s overall plan of care for the patient? Then visit notes should say so.
Approaching each piece of documentation with a goal of answering “why” will help knit together an interlocking summary of patient care and identify missing pieces that are likely to lead to costly claims denials.

Do all the pieces work in tandem?

Documentation must support the visit type and the visit type must support the plan of care. Notes made by clinicians in the home must clearly justify the visit and show the value as it relates to goals established in the plan of care.
“Quality documentation begins at the time of the patient’s initial referral to home health by a physician, and continues through each aspect of home care,” J’non says. “If each step is properly documented, the result will provide a comprehensive and cohesive file that will stand up to scrutiny.”
J’non and her team work with agencies of all sizes across the country to streamline operations, teaching agencies how to minimize compliance risk, untangle and make sense of regulatory changes and maintain quality patient care.

 Keep things realistic

Once OASIS data has been carefully collected and properly recorded, a case manager must evaluate and make use of that data to develop a realistic plan of care for a patient based on the assessment.
Clinical notes made in the field will then need to integrate seamlessly with that plan of care, not only fully supporting the visit type and acknowledging goals, but also measuring progress.
Notes will need to show clearly how the care plan is being executed with purpose at each visit.

Billing must be part of an agency’s comprehensive documentation as well. In addition to supporting all others, each piece of documentation in a file must support all related bills and claims.

Home Health Solutions team members understand the challenges facing home health care professionals as they try to adapt to the many regulatory changes implemented this month.
But implementation of the four strategies outlined in this week’s series of blog posts can make noticeable improvements in an agency’s compliance efforts and ensure that documentation will stand up to scrutiny in 2016.
“And if additional assistance is needed, we can provide the training and guidance needed to help agencies stay on track and focus on quality patient care this year,” J’non says.


The nitty-gritty of specificity

“Every picture tells a story, don’t it?” Rod Stewart sang to us in an old ’80s song based on a popular British idiom.
These days, a home health patient’s records need to tell a story, too — and it had better be a thorough one, reflecting a coordinated care plan and continuity of care, with realistic goals and outcomes, or the agency could risk costly claims denials.
imageUnder this month’s new Medicare and Medicaid regulations, home health agencies are responsible for much more detailed documentation throughout the home care delivery episode than ever before.
“Now that we’ve transitioned into IC-D10 coding, you really have to be much more specific,” says Holly Kolitz, Quality Assurance Manager for Home Health Solutions LLC. “Basically, you’re creating a little window of what happened while you were there.”
Holly and other HHS team members work with agencies of all sizes across the country to streamline operations, helping health care workers adapt to new regulatory requirements and avoid costly claims denials.
As part of that process, they train health care professionals in the mechanics of specificity: how to sift through the agency’s many, many interactions with and on behalf of a patient to glean the specific details which must be documented.

It’s a balance

Turns out there’s something of an art to capturing the nitty-gritty of patient care, especially in the notes recorded in the field by nurses and clinicians.
Too many useless details serve no real purpose, frustrating the peers, supervisors and auditors who review them. But too few details can create dreaded “black holes” of home health documentation, where failing to record what was said or done, and show cause for it, can wind up costing an agency thousands of dollars.
Finding the right balance between those two extremes is proving to be at least somewhat intimidating to most agencies. Their nurses and clinicians generally aren’t storytellers, scribes or court reporters; they’re caregivers.
And very busy caregivers, too.
“Today’s home health field is fast-paced,” Holly says. “A lot of expectations are placed on caregivers, and each home visit has to be a well-rounded visit. But proper documentation has become an imperative part of the process.”
How can caregivers identify and learn the pertinent details which must be included in their notes?

The 5 Ws

The Home Health Solutions team often starts its specificity training with a review of one of the oldest, simplest and most reliable formats for capturing information: a basic list known as “The 5 Ws.”
Five words beginning with W — Who, What, When, Where and Why — will capture almost every detail caregivers need to include in their files. A sixth word — How — adds more important information.
Simple? Yes, but many agencies struggle with reporting each of those six aspects of information, particularly with recording WHY something is being done, and later with capturing HOW it was done.

Tell me WHY

Applying the 5Ws begins the moment a patient is referred to the agency, with the WHO and WHEN aspects covered in the on-boarding and intake process.
But the information collection system often breaks down immediately afterward, as agencies fail to record WHY they are providing services to the patient in the first place.
Failure to include documentation showing medical necessity for home health services, including the initial referral by a physician, is the No. 1 documentation error most agencies make, according to Heather Calhoun, Director of Special Appeals and Project Management at Home Health Solutions.

Care goals and 5 Ws

As managers develop comprehensive care plans for patients, coordinating services between various types of caregivers and establishing realistic goals, application of the 5 Ws can once again make significant contributions to the quality of the patient file.
In developing the comprehensive plan, be sure to include WHY and HOW each service will be provided, with specific documentation showing its medical necessity.

In the field

The 5 WS must be captured in the field, too, as caregivers actually deliver the planned treatment and services, and record doing so.
Notes should reflect not only WHO delivered each treatment or service, WHERE and WHEN, but continue to refer to WHY. Ideally, the WHY portion of the clinician’s notes will refer to the comprehensive care goals set for the patient, as well as addressing any specific goals for that particular visit.
Finally, caregivers must record WHAT they do and HOW.
It isn’t enough, for example, for a caregiver to note that she taught her patient the purpose of a particular pill and its side effects. Quality notes will reflect why she reviewed this information with the patient, what information she shared and even how the patient reacted.
“The nurse would need to summarize in a paragraph what she told the patient to educate the patient on the importance of the medication and encourage the patient to be compliant in taking it,” Heather says.

New documentation standards may seem overwhelming to agencies, but the Home Health Solutions team is encouraging. Much of the attention to detail now required of caregivers hearkens back to quality practices drilled into nursing school students, they say, and will become second nature with practice.
If your agency needs staff training to better meet new regulations, Home Health Solutions offers a comprehensive array of customized modules and on-site services.

THURSDAY: Tying up all the loose ends in your agency’s paperwork


Think like an auditor

imageSeven times on a single day last week, Home Health Solutions Director of Appeals and Special Projects Heather Calhoun opened a case file and looked for proof of medical necessity.
Six of those seven times, she couldn’t find the proof she needed anywhere in the file before her.
“This is without question the No. 1 mistake I see agencies making in their day-to-day documentation, and the ramifications are enormous,” Heather says. “Without evidence that it’s needed, any care provided to a patient is not considered medically necessary and the agency may not be reimbursed for it.”
As home health agencies scramble to shore up the quality of their documentation practices under this month’s new wave of Centers for Medicare and Medicaid Services regulations, Heather and other HHS team leaders are working with agencies across the country.
Their goal is to teach home health care professionals how to think more like auditors — a skill that could be worth many thousands of dollars to an agency’s operational costs by preventing claims denials of specific services, visits or entire home health episodes of treatment.
“Documentation is an integral piece of the regulatory compliance required for agencies to succeed in today’s home health market,” HHS Owner J’non Griffin says. “We are working with agencies of all sizes to help them develop quality initiatives for meeting their regulatory burden.”

What auditors look for

To stand up to scrutiny, an agency’s documentation must be thorough. It will need to establish cause and intent for each aspect of care. That means agencies must record their delivery of patient care in clear and brief detail, beginning with the initial referral by a physician.
It isn’t enough just to note each pill, each dressing and each service provided to the patient; documentation must also show a comprehensive care plan coordinated among caregivers, with care goals specific to the patient.
But many agencies aren’t meeting all those requirements. Staffs busy with the delivery of patient care can get distracted from properly completing files — and HHS team members find that some of the same errors, omissions and inconsistencies show up routinely in the records of agencies of all sizes.

“Proper documentation is imperative for agencies,”  HHS Quality Assurance Manager Holly Kolitz says.  Even with time constraints and many competing demands,  agencies will need self-policing to  avoid costly errors and make sure documentation makes the grade.


Red Flag Checklist

     The HHS team has compiled the following checklist of some of the most common red flags almost guaranteed to catch the attention of auditors:
— Missing physician orders
(Agencies need physician orders for each service, medication and treatment, including each change made to a patient’s medicine or treatment.)
— No evidence face-to-face physician requirement met
— No evidence of coordination of services
— No evidence of routine re-evaluation of patient care needs
— No explanation included for missed visits
— No documentation showing the physician was notified of a missed visit and why
– Careless mistakes due to lack of adequate proofreading 
– OASIS, clinical notes, progress summaries, etc. fail to align, or in some cases even directly contradict each other.
— Clinicians provide conflicting information in their reports

“If a wound starts out being identified as one type of wound at the beginning of treatment, but is repeatedly identified in later documents as a different type of wound, auditors are certainly going to notice,” Holly says. “The legitimate question to be raised is whether we even know what kind of wound we’re dealing with.”
Agencies must provide documentation showing the initial diagnosis was changed or maintain uniformity throughout the treatment records, cross-checking to make certain later records support the wound identification in OASIS.
One of the most common mistakes Heather sees agencies make involves discrepancies in reporting between nurses and therapists.  A nurse, for example, may provide a highly functional score for a patient, because the nurse isn’t necessarily evaluating the same criteria as a  therapist. When a therapist evaluates the quality of the same patient’s gait,  stride or ease of transition from chair to walker, and reports lower functionality, the resulting discrepancy can become a red flag.

“Sometimes, it’s the simple mistakes that bog things down,” Holly adds. “Agencies can sometimes miss the obvious in recording details, and the results can create real issues.”
From copying a medical code wrong to identifying the wrong site for an injection or mistakenly substituting “right” for “left” on a record of a limb amputation, careless errors can sometimes cost an agency thousands of dollars.
The HHS team strongly recommends self-evaluation  in agencies, with frequent reviews of all documentation for accuracy.

One other area likely to generate red flags in an agency’s documentation is a lack of specificity. Tomorrow’s post will focus on strategies to better capture the important details needed for quality documentation.

Wednesday: The Mechanics Of Specificity 

Did you see our companion post on the four elements of quality documentation?  Read it here


Will your agency’s documentation stand up to scrutiny?

imageHome health agencies are heading into 2016 with some degree of apprehension about how well their documentation will stand up to scrutiny in a health market rife with regulatory risk.
Flawed documentation could threaten agencies with everything from legal issues to claims denials, and the compliance burden fattened up this month as new G Codes for home health and hospice took effect.
Curtailing risk requires not only an eagle eye approach to all records, but ongoing training efforts for staff whose notes are a crucial component in demonstrating quality care, according to J’non Griffin, owner of Home Health Solutions LLC.
“Agencies must sharpen their documentation skills, making certain their staff really understands how to capture critical information and integrate it with a cohesive, justifiable and well-defined care plan,” she says.
“At the same time, they’ll need to avoid the inconsistencies, omissions and errors that create red flags for auditors.”
Easier said than done? Maybe not. With the right focus on achieving quality, some guidance and a bit of practice, J’non believes, most agencies will successfully navigate these new complexities.
Home Health Solutions works with agencies of varying sizes to streamline operations and shore up bottom lines by identifying and improving weaknesses. Documentation is one of the areas where weaknesses are most likely to occur.
“Our clients often have unique needs and face different challenges, but when it comes to documentation errors, many of the same mistakes show up no matter how large or how small an agency is,” J’non says.

Four ways to clean up your documentation

With those recurring trends in mind, J’non and her HHS team members have identified four primary goals which any agency can use as a checklist in the pursuit of quality documentation:

1. Be defensive.

Your documentation is a legal record, and must stand up to examination by many sets of eyes.
“The quality of your documentation is the quality of care delivered to your patient,” says HHS Director of Appeals and Special a Projects  Heather Calhoun. “What is written there becomes the indisputable record of whether something was done, and why.”
The record will grow as your team members work from it and with it to develop and deliver patient care; each addition must not only be accurate and complete, for its integrity to be maintained, but must build on the other parts.
Eventually this record may well be seen not just by by auditors, but by licensing, accreditation and government reviewers — and could, in a case involving legal proceedings, even be viewed by judges or juries.
“It must be able to defend itself to each new pair of eyes as an error-free, easy-to-understand, complete record with all parts in place to show exactly how and why your agency provided quality patient care,” J’non says.

2. Be specific.

With auditors now able to pull out records of visits by type and ask specific questions, details have become more important than ever before.
Vague areas in records are the black holes of the home health field, costing agencies thousands of dollars, and must be bridged with clear, concise summaries showing cause, goals and intent as well as all specific actions taken.
“And the need for specificity begins at the very start of all care,” Heather says. Agencies must start each case by first establishing the medical necessity for care and continue to document each step in the process through the filter of why it was necessary.

3. Be realistic.

One of the most important skills agencies must master to meet new documentation requirements is goal-setting. Determining a realistic course of patient improvement within a 60-day window requires consideration of comorbidity and a comprehensive approach across all home health disciplines.
Holly Kolitz, HHS Quality Assurance Manager, describes the right approach as a careful balance of common sense and measurable achievement.
“Goal-setting is a very patient-specific process,” she says. “It’s very important to be realistic about what you can expect a particular patient to fully understand and achieve, as well as in selecting the parts of that process which must be captured in documentation.”

4. Be comprehensive.

Does your documentation work together to tell a comprehensive story about a patient, with each piece fitting together like an interlocking puzzle? The pieces must match on multiple levels, with each document both standing on its own merit AND integrating seamlessly with each of the other documents.
“This is critical to demonstrating cohesive continuity of care,” Heather says. “Inconsistencies in documentation can potentially cost agencies a great deal of money.”
In addition to supporting all others, each piece of documentation in a file must support all related bills and claims.

All this may sound like a tall order, but focusing on these four fundamental goals really can make a marked difference in the quality of your agency’s documentation procedures.
“And if your agency needs additional help to untangle new documentation requirements, HHS can provide the customized services you need to transition successfully into 2016,” J’non says.

Beginning tomorrow, the HHS team will take documentation practices a step further, breaking down each of the four fundamentals covered here with some specific strategies for each.

TUESDAY:  Think Like An Auditor (A Checklist of Common Mistakes)

What are your agency’s 2016 goals?

January is the month traditionally littered with good goals gone bad.
You know the drill. We resolve to eat less and exercise more, avoid sugary desserts, get to bed earlier, spend more time researching or completing that next certification and less time on social media. And we do exactly that, for a few days.
Then somebody brings a big box of doughnuts to work and POOF. Just like that, our ambitions for 2016 are nothing more than sweet, sticky memories we’re licking from our fingers.
Business goals, of course, are a little different.
“We can’t afford to treat our business goals for 2016 as cavalierly as we sometimes treat our waistline goals,” Home Health Care Solutions LLC Owner J’non Griffin says. “It’s more important than ever before for those of us in the field of home health care to set and follow strategic goals designed to ensure quality patient care and bottom line performance.”
One of the crucial components in goal-setting for 2016, she says, should be developing long-term solutions rather than focusing on short-term fixes.
“Is your goal just to make money today?,” J’non asks. “Or is it to position your agency or organization for the future by putting into place the quality initiatives necessary to continue moving forward in a fluid and challenging home health care market?”
J’non will join a panel of industry leading experts at the HCAF Winter Gathering in Ft. Lauderdale next week to address many of the most critical issues facing home health professionals, guiding them in establishing quality initiatives.
The event runs from noon Monday, Jan. 11, until noon Wednesday, Jan. 13, and is being billed as a”crash course” in must-know info for more effective management strategy in 2016. J’non’s presentation will be: “Monitoring Quality Outcomes for the Future.”
Continue reading What are your agency’s 2016 goals?