Introduction to Star Measures & Timely Initiation of Care

July 11, 2016

Teresa Northcutt from Selman-Holman & Associates presents a session full of practical information you can put to work immediately. She’ll give you a solid background in the current home health star rating system: where it comes from, how it works, and why you should care about it! Teresa will also delve into the key process measure known as Timely Initiation of Care. 

You'll take away:

  • Step-by-step strategies for improving your star ratings
  • A deeper understanding of the Timely Initiation of Care process measure – including best practices for improvement
  • And more!



Welcome to the ABILITY Star Home Health Education Series. I'm Teresa Northcutt. Here is our little table of contents for today's program. Our main goal today is to make sure you understand the home health star rating system, where it comes from, how it works and why you should care about it. Then we're going to take a look at some overall strategies to improve your agency's star rating. Each webinar in the series will focus on specific measures used in home health star calculation, and we're going to review the OASIS guidance to ensure your accurate data collection, and then explore some best practices to improve performance in the outcome or process measure. The focus of this session is on the process measure for timely initiation of care.

[00:01:00] First off, why does home health need to have star ratings? Well, Home Health Compare can be too much of a good thing to many lay customers. They're faced with an urgent need to make a choice of a home health provider. There's too much information, too many measures. It's too hard to figure out what is most important. As consumers look at the Home Health Compare website, they're overwhelmed. Of the 27 measures on Home Health Compare, which should I pay attention to as I choose an agency for mom's home care? The home health star ratings give a summary of some of the more important measures, and they're represented as a star rating which customers are pretty familiar with from hotels, restaurants and other kinds of rating systems for goods and services. CMS feels customers can more easily choose a home care provider by using this star rating.

[00:02:00] There are now two types of star ratings. The New Patient Survey star ratings are based on HHCAHPS data, which comes from the home health patient responses to mail or phone survey. Some of these patient satisfaction scores have been recorded on the Home Health Compare website since 2012. The Quality of Patient Care star ratings are what we've been seeing since July 2015 based on your OASIS data for outcome, and process measures, and the Medicare claims data for acute care hospitalization.

Why do we need to add the HHCAHPS measure to the star ratings? Well, it's part of CMS's focus on "integrating the patient perspective into the service delivery process." Bottom line for home health agencies, patient satisfaction is important and you better be paying attention to your star measures.

[00:03:00] Your patient survey star rating measures are a separate rating, and it's applied to each of the three HHCAHPS composite measures that are currently reported on Home Health Compare: care of patients, communication between agencies and patients and specific care issues. I'm not going to go through all of the HHCAHPS survey questions. You should be familiar with those. If you're not, I suggest you take a look at that survey. You need to know what your patients and their families are being asked about, about the care that you provide.

The care of patients is pretty straightforward. It deals with, did you teach people what they need to know? Did you treat them with respect and courtesy? Those kind of things. Communication between agencies and patients. Did you seem like you knew what you were doing and were well-informed? In other words, were all the disciplines up on the [00:04:00] patient's plan of care and what was going on? Did you teach effectively? Did you talk to the patients and tell them about what was going to happen? Did you let them know when you were coming to make a visit? Those type of things. Specific care issues deal with how you educated the patient and treated the patient on pain, prescription medications and home safety.

There is an additional rating that's going to correspond to the global rating of care. In this case, they chose question 20, overall rating of care provided by the agency, which is where the patient and family have to rate your agency's care on a scale of 0 to 10. CMS is going to award the survey summary star. It will be an average of the ratings given for these four HHCAHPS measures.

[00:05:00] Some things to ask yourself and your quality team: Do you monitor your HHCAHPS report? What do you do with the information you get from your vendor? Do you just tell the nurses to remember to teach on meds or be sure and call your patients before you show up? That is not quality improvement. We could do a whole session on tips to improve your HHCAHPS scores. Just remember, this comes from patient surveys. In some ways, you have a little less control than over your patient's Quality of Patient Care star rating.

Now, the agency's quality of patient care star rating measure has outcomes and process measures that are used to determine that star rating. They're listed for you here. We have six outcome measures and three process measures. Acute care hospitalization is pulled from CMS claims data for hospitalization of home health patient. Except for acute care hospitalization [00:06:00], the rest of these measures are all based on OASIS responses. If your OASIS assessment techniques aren't up-to-date and following the most current OASIS guidance, you are not generating accurate measure ratings and your star rating will be affected.

Another point to remember. When I work with agencies on quality improvement, I notice we tend to pay a lot more attention to start of care and resumption of cares and much less attention to discharges. Remember, outcome measures are determined by comparing the patient's score on the OASIS item at start of care or the most recent resumption of care to the score on the discharge OASIS for that item. If the response on either assessment is inaccurate, it skews your outcome measure. For the process measures, they're all determined by OASIS responses on start of care, resumption of care, [00:07:00] transfer and discharge assessment. Please pay attention to your accuracy on that transfer and discharge OASIS, as well as on the start of care and resumption of care.

How did CMS decide which of the 27 Home Health Compare measures would be used for star rating calculation? Well, the nine measures on the previous slide were chosen based on these criteria. They want to make sure that measure applies to most home health patients and that they have sufficient data to report it for a majority of home health agencies. The measures need to show some variation between agencies, and you should be able to take actions that are going to improve your performance on that measure. It needs to be clinically relevant and fairly stable so there's not going to be wide random variations over time.

All Medicare-certified home health agencies are potentially eligible to receive a star rating. [00:08:00]Now, if your agency is less than six months old, you will not have star ratings. Eligible agencies have to have at least 20 completed quality episodes for data on a measure to be reported on Home Health Compare. Remember, a completed quality episode means you have a start or resumption of care that can be paired with an end of care OASIS assessment. You have to have quality data reported for five of the nine quality and process measures. You must have data for 40 or more patient surveys in the reporting period. The reporting period is a 12-month period. Your eligible episodes have to have a discharge date within the 12-month reporting period.

Now, I'm not really into statistics but this gives you some info on the star rating calculation if you want to get into that. [00:09:00] The big thing to remember is each of the nine measures carries the same importance in the calculation. These star ratings will be updated quarterly in January, April, July and October when Home Health Compare updates. That's usually on or about the 17th of the month.

Now, why should I care about star ratings if I'm a nurse out there making visits to patients? Well, it's used for referrals, mergers and acquisitions, and value-based purchasing. When somebody is looking for a home health provider, they can go on Home Health Compare. Again, those 27 measures are a little overwhelming. They can simply look at a star rating. I don't know about you but I don't want to stay at a two-star hotel. I'm looking at a four or a five-star hotel. At the very least, three stars. This is a way for customers to take a look at how you do.

[00:10:00] The other thing is your referral sources may take a look at Home Health Compare and the star ratings to decide who they're going to refer their patients to. Another thing that started happening: some private insurance companies are using star ratings to adjust payment scales to agencies. They are lowering their reimbursement to agencies that do not have five stars. Now, this was not the intent of the star rating system, but it is what's happening. It's not what CMS intended it for.

We also are seeing some large agencies use star ratings to influence decisions about mergers and acquisitions. Who do we want to acquire? We want to acquire a five-star agency, not a two-star agency.

[00:11:00] Value-based purchasing. We have to think about that a little bit. Nine states are currently in the pilot project which uses ongoing performance on outcome and process measures to impact payment for those pilot states. This pilot project could be expanded to all states whenever CMS chooses to do so. There's no guarantee that we're going to have a bye until 2018 or '19.

How can we improve our star rating? Well, make sure all your OASIS responses are accurate and follow the most recent guidance. Watch those Q&As. Review all your OASIS assessments. The transfer and discharge are just as important to outcomes and process measures at the start and resumption of care. It isn't just about payment. We also have to look at these quality outcomes. In the future with value-based purchasing on the horizon, outcome measures will impact payment. Of course, it's not the only factor in choosing your target for a QAPI project. You may have infection control issues or other problems that deserve attention first, but it makes sense if I'm choosing a target measure to try to improve, I would use one that's going to impact my star rating.

[00:12:00] Just telling your staff to do it better really isn't a quality or performance improvement plan. A quality improvement plan addresses systems, processes and tools for more than just individual performance.

How can we make it easier for staff to do things "the right way" and harder for them to do it the wrong way? Do you have protocols for medication education? Do you have standardized teaching tools for staff to use? How do you evaluate your patient's understanding of their meds? Do you consider this a one-time teaching shot? Do you come back and see if the patient remembers the instruction on some of the key meds before discharge? That's more like a quality improvement plan.

[00:13:00] Now, the steps for improvement. If you don't have an active QAPI program, here are the key steps for improvement. Involve all your staff when you're choosing a target for improvement. This isn't just some QA manager's decision. Use all the resources available to you. It doesn't have to be costly. There are a lot of vendors out there who do charge quite a bit for their quality information and report, but you can use CASPER and PEPPER reports, which are free. Don't forget to consider survey problems, patient complaints, incident reports for falls or infection control monitoring as potential targets for improvement. One of the requirements of the new COPs is that QAPI targets and activities must be data-driven. You need to document why you chose a specific target.

[00:14:00] Have your staff brainstorm best practices to improve the target outcome or the process measure. If you need a little help here, go check the HHQI website and those best practice information packets for list of best practices.

Do some chart auditing. Which of these best practices am I doing now and on what percentage of patients? It may not be quite as high as you think. Develop your action plan. Use things like rapid-cycle improvement, the Plan-Do-Study-Act. Don't get bogged down here. You don't have to have a perfect plan to get started. When I used to work with the QIO, my favorite question was what can you do by next week? Do small things. Put them all together. You'll show big improvement.

Be sure and evaluate your changes. Did I accomplish what I expected with this new process? Did it generate any new problems? If changes are effective, then you need to look at incorporating them into your agency's policy and procedure and get all the staff to follow those new processes.

[00:15:00] Let's take a look now specifically at timely initiation of care. The Conditions of Participation require that the initial assessment to determine the patient's eligibility for home care services and immediate care needs has to be conducted either within 48 hours of the date of referral or within 48 hours of the patient's return home from an inpatient facility or on the physician-ordered start of care date.

Now the initial assessment is usually done at start of care and resumption of care. You're looking at eligibility for home health services. Is the patient meeting the Medicare criteria for care? Are they homebound? Do they have a skilled need? Is there a physician willing to sign the plan of care and so on? It doesn't mean you have to complete the entire OASIS comprehensive assessment at that time.

[00:16:00] Let's take a look at the specific OASIS items that are used to calculate timely initiation of care process measure. It's M0102, 104 and M1005. Let's take a look at these specific OASIS items. This is M0102 date of physician-ordered start or resumption of care. This is asked at start of care and resumption of care. If you have a specific date ordered by the physician to start home care services, then the date goes in this item. If you don't, you mark NA. Most of the time, we end up marking NA for here.

Remember, it does have to be a single date, not a range of dates. If the originally ordered start of care date is delayed due to a patient condition, maybe they stayed in a hospital longer, or a physician request, they change the date, then make sure you revise or update your referral information with that new date because the [00:17:00] State Operations Manual requires a visit for resumption of care within 48 hours following hospitalization. We need to mark NA if the physician orders a resumption of care date that extends beyond two calendar days of the inpatient facility discharge date. Now, the State Operations Manual is the surveyor's guidance, and so even if the physician tells you that it's okay to delay that resumption of care until Monday, if that takes it beyond two calendar days, you are out of compliance.

M0104 is the date of referral. This seems pretty straightforward but a lot of questions and errors come up with this item. It is the referral date, the most recent date that verbal, written or electronic authorization to begin home care was received by the agency. [00:18:00] The problem we have is, what's a valid referral and what happens when there's a delay? "Mom broke her hip and she's in the hospital. We want you to do home care." "That's great. How long do you think she'll be in the hospital?" "Probably a couple of weeks. The doctor said he thought she would be ... It'll take her a while to get over this." "Who's the doctor?" At that point in time, you have information but you do not have a valid referral. The other thing to remember is your referral date is not the date you get payer authorization.

When an agency gets an initial referral or contact about a patient who needs services, you have to make sure the physician that calls you or another physician is going to provide the plan of care and ongoing orders. If you get a referral from a hospitalist, that may not be the case. A valid referral is when you have a physician who's willing to follow the patient. [00:19:00] He provides adequate information regarding the patient. That's your valid referral. If that physician or that entity is not going to follow the patient, it's not a valid referral for M0104.

Now, the little number down here in the corner, 3rd Q 2014, that little notation is the CMS OASIS Q&A that this guidance comes from. In this case, it's from the third quarter Q&As in 2014.

In the example of a hospitalist who is not going to provide an ongoing plan of care for that patient, you will need to contact an alternate or usually the primary care physician, and upon agreement from this physician, to follow the patient for referral and further orders, then that becomes your valid referral date.

[00:20:00] A general order to evaluate for home care services, there's no disciplines, but the physician that gives you that order will follow the patient, that's a valid order. That initial assessment has to be conducted to determine the immediate care and support needs and eligibility for the Medicare program within your 48-hour window.

We do have a new Q&A that just came out in January 2016. If you have a situation where you have a late face-to-face encounter and you're going to have to generate a new start of care date, a new OASIS, the date of physician-ordered start of care for M0102 will be marked NA and you will report M0104, the date of referral, as the day prior to the new start of care date.

[00:21:00] Now, why is M1005 included in this? Remember, your COPs. One requirement is that the initial assessment visit for start or resumption of care must be within 48 hours of the patient's return home from an inpatient facility. The date they are discharged from that inpatient facility is part of the calculation.

Let's take a look at a couple of examples so this makes sense. The agency gets a referral from the hospital on Mr. Smith on January 1st with an anticipated discharge date of January 3rd. The agency checks the hospital's census report daily. They see Mr. Smith is still in the hospital at end of day on January 3rd and there's no answer at his home phone number. They contact the hospital, learn that the patient has a UTI. They're keeping him another couple of days to make sure he responds to his antibiotic. The patient is actually discharged from the hospital to home on January 7th. The agency does their initial assessment and their start of care visit on the 8th.

[00:22:00] Now, M0102 is going to be marked NA. We do not have a specific start of care date that the physician told us to go see the patient. M0104 is going to be January 3rd. That's when I contacted the hospital and learned there was a problem and he's going to be kept a little longer. M1005, the day the patient was discharged from the hospital, January 7th. My start of care date is January 8th so that's my M0030 date.

The way that process measure for timely initiation of care is calculated, it looks at these three OASIS items. Is there a date in M0102? If there is, does that match the start of care date at M0030? If it matches, the agency gets credit for this process measure. If it doesn't match the date, then you do not get credit. If it's NA, then the software skips down to M0104. [00:23:00] What's the date in M0104? Is the start of care date in M0030 within two days of the date in M0104? If yes, that's a good answer. The agency gets credit for the process measure. If it's not within two days, then the software goes and looks at M1005. What is the date in M1005? Is the start of care date in M0030 within two days of the date in M1005? If it is, that's a good answer. The agency gets credit for the process measure. If it's not, then you do not get positive credit for the timely initiation of care process measure. You're outside the 48-hour window.

[00:24:00] Here's another scenario that is all too common. A referral is received by the agency from a physician office on January 1st. The agency calls the patient to set up the initial visit and the patient requests a delay in the start of care visit to January 4. Maybe they're overwhelmed with the family all being in when they come home from the hospital, or they want to wait until a family member can get off work to be present for the visit, or sometimes the agency may not have staff to do a start of care within a 48-hour time period, especially if it's a therapy-only case. The problem is January 4th is outside the 48-hour time period allowed for the initial assessment visit. How you deal with any of these situations will determine whether you have a positive or negative impact on this process measure. The key point here is going to be informing the physician.

[00:25:00] If I have a patient who tells me when I call her on the evening of January 1st, my date of referral, I call the patient and say, "I need to come for home care," and she says, "No, I don't want you coming tomorrow. Wait until January 4th." I say, "Okay. No problem. I'll put you on the schedule for January 4th." I go out and do my visit, my start of care visit January 4th. M0030, January 4th. M0102 is NA. I did not have a specific start of care date. What's my date of referral? January 1st. In this case, the patient came from a physician office referral. I do not have M1005 answered. I had no inpatient discharge in the past 14 days. In this case, I have a negative score for this process measure. I am not compliant with my timely initiation of care.

[00:26:00] However, if on January 1st when I get my referral, I call the patient, she says, "Nope. Don't want you to come until January 4th." I turned back around, called the physician office and say, "The patient does not want me to come until January 4th when her daughter can make arrangements to be off work. Is it okay if we schedule that start of care date for January 4th?" The physician office says, "Sure, that's fine." I now have a specific start of care date approved for this patient. M0102 is January 4th. That matches my M0030 date. I am good on this process measure.

[00:27:00] Now, let's take a look at some best practices for timely initiation of care. First off, how do I know if I'm doing a good job with this outcome measure? As of January 2016, the national average score for timely initiation of care is 91.9%. In other words, 91.9% of home health episodes in the 12-month measurement period on Home Health Compare had the initial assessment visit done within 48 hours of referral or 48 hours of the patient's return home from an inpatient stay or on the physician-ordered start of care date. Take a look at your CASPER report for process-based quality improvement. That's your PBQI report or go to Home Health Compare and check your score. If you aren't higher than the national average and your state average, this might be something to work on, especially since it also has survey implications. You don't want to be out of compliance with a Condition of Participation.

Take a look at your referral process. Now, sometimes when I ask an agency, "What's your referral process?" I get a confused look from staff. They aren't sure what I mean by a process. It's a series of steps in receiving a referral and getting from that point to the initial visit, so start at the beginning. [00:28:00]

When the phone rings or the fax machine starts spitting out paper or an email shows up, however you get your referrals. For discussion, we're going to go with a phone call. The phone rings. It's Dr. Jones' office with the referral. What are your steps in your process to handle this referral? Who takes that initial call? Do you have an intake, or referral form, or an intake screen in your computer software, or do you just grab the closest blank sheet of paper and write the information down? Do you date the referral form? [00:29:00] Obviously, that's absolutely essential to have a date on it, but I do see undated forms sometimes when I'm auditing. Do you just take the information you're given or do you some ask some questions? Do you have an intake tool that cues you to ask for the information you need about diagnoses so you get good specific coding in ICD-10? Have you ever had a referral with a patient phone number that ends up being a wrong number and it takes a day or two to track down the patient? Now, you’re past your 48-hour time period. It's a good practice to get a contact number for someone outside the patient's home like a family member or a neighbor as part of your referral process.

If you receive a referral from an inpatient facility, do you track the patient on your daily or twice daily inpatient census checks to make sure you don't miss the date of patient's discharge? If that patient leaves late in the day, it may take an extra day for the facility to notify you about the discharge and you've lost that time to get the visit made. If the patient's anticipated discharge date passes and the patient is still in the facility, check in with that discharge planner or social worker and get updated information. Then make sure you update the date on your referral form with any new information. It's a good practice to verify the date on the referral form when the visit goes on the clinician's daily schedule. Double check that it's within that 48 hours or if there's documentation to explain why it's late. [00:30:00]

Next, who assigns the opening to a clinician? How is that done? Is it by phone, voicemail, email, text, communication, note in an agency software system? How do you know the clinician got the message? Is there a confirmation response? Does someone from the office contact the patient on the day they go home to set the date for the initial visit, or is it left to the clinician to make that first contact? If the patient or family refuses to allow the initial visit within the first two days, whose job is it to notify the referring physician and inform him or her of the delay? [00:31:00] You have to get approval to delay that start of care visit and that must be documented in the medical record either as an order or as updated notation on the referral form. Another thing to consider, does the clinical manager make sure that clinician doesn't already have seven visits for the day and makes some schedule changes to allow time for the initial assessment visit to be conducted?

Brainstorm with your office staff, your field staff and your clinical managers. What types of problems do they encounter in taking referrals and setting up timely initial visits? How can you modify your process of obtaining referral information to minimize those problems?

Now, let's take a look at field staff practices that help ensure the initial visit takes place within the 48-hour time period after referral for start of care and also within that 48 hours of inpatient discharge for all resumption of care. That's where field staff action really play an important role. [00:32:00] Hopefully, the family will contact the agency to let them know if or when a patient is admitted to the hospital. Do clinicians teach patient/families to call the office in case of hospitalizations or ER visits? If the clinician herself sends the patient to the hospital, he or she needs to inform the office so the patient goes on the inpatient list for tracking to make sure you know whether to do a transfer OASIS and you know when the patient is discharged back home.

From the date of discharge from the inpatient facility, you have two days to do that resumption of care visit in order to comply with the Condition of Participation for timely initiation of care. Does a nurse or therapist have access to the referral information before her visit? If a patient goes to dialysis three days a week, that will affect the clinician trying to schedule the visit. [00:33:00] It could cost a day's delay. Does the clinician call the day or evening before to arrange the visit time or wait until the morning she's planning to see the patient? It's better to give a little notice, especially if there are issues like the caregiver being present, other appointments like a dialysis scheduled visit or something like that.

If the patient or family refuses the visit or doesn't answer the door when the clinician arrives, does a nurse or therapist immediately notify the office so the visit can be rescheduled for the next day? If you're already on the second day after referral for inpatient discharge, the physician needs to be notified of the delay. Who's responsible for that? The clinician or the manager in the office? When completing those OASIS items on the start or resumption of care, watch your dates on the OASIS assessment.

[00:34:00] Field clinicians. When you're filling out that OASIS, check the referral form. Was there a specific date for the start of care? That's M0102. Is that the same date you're putting on M0030? Great. If there is no date, then M0102 is NA. You go on down to M0104. The date on the referral goes in M0104. Take a look. Is it more than two days before the M0030 start of care date or the M0060 resumption of care date? If it is, investigate to see if there was updated or revised information from the referral source about a delay or a change in plan that didn't get documented on the referral form. Does a physician need to be contacted to inform him of the circumstances of the delayed start of care? Document all this communication regarding delays in your start of care or resumption of care visit. [00:35:00] You got to have that documentation. Remember, a resumption of care visit can't be delayed past 48 hours after the inpatient discharge or you are out of compliance with those COPs.

Finally, let's consider some ways the QA staff can improve this process measure. Review all your start and resumption of care assessments for compliance with that 48-hour requirement. For all assessments with greater than two days between the start and resumption of care date, investigate the circumstances and get any omitted documentation from your office or clinical field staff. If the initial start of care visit was delayed beyond the required time period, identify that case for focus auditing. Audit charts for patients that didn't get opened within 48 hours. Identify any possible causes for the delay. What did you at your agency do right? Those are the best practices you want to keep doing. What could have been done better to get the initial visit done more timely? [00:36:00] Those additional best practices could be added to your process to make it more effective. Remember, when you make a process change, test it to see if you get the results you want. If it works, then go ahead and implement that change.

This concludes our presentation on improving your process measure scores on timely initiation of care. For additional help with quality and process improvement, coding and OASIS education, and auditing or consulting services, please check out the Selman-Holman website.

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