PI program targets visit frequency
Audits spur effort to ensure appropriateness
If necessity is the mother of invention, then the interim payment system (IPS) has surely spurred many agencies to change policies and procedures. Nowhere is that more evident than at Western Illinois Home Health Care in Monmouth, which implemented IPS in October 1997.
According to Anita Rutzen, RN, director of performance improvement/staff development, IPS prompted the agency to look at "everything to see where we were efficient and whether the number of visits was effective and appropriate." The subsequent audit of half the open cases at the agency showed some problems with appropriateness of visit frequency and services provided.
Rutzen and her management team instituted a program which, while not yet totally solving the problem, has certainly brought the agency a good way towards its goal of having 95% of the charts show appropriate use of services and disciplines.
Rutzen says that in January 1998, as the agency began working under IPS, the management team pulled patient charts for a close look. Team members, including Rutzen, the director of clinical services, the central intake nurse, two team managers, and the home care coordinator, were each assigned a portion of the 150 open cases and told to look at half of the selection they were given, she says. How they chose which charts to audit was left up to each team member.
Along with general compliance issues, such as whether the plan of care was signed, the team looked for several items that would justify care. The audit sheet included places to document:
• the personal care needs of the patient;
• whether the patient was bed bound, chair bound, or incontinent;
• the reason for extended duration of care over the projection was documented;
• whether there were hospitalizations, abnormal vital signs, or other reasons that might indicate a rationale for increasing visits;
• what skilled nursing was ordered and what was documented.
If the team saw the same thing documented time and again, Rutzen says that would be a signal of overutilization. "For instance, if we are there to instruct them on medication or diet, we know that teaching and training take time. But you hope new things are being taught at each visit.
The team also looked at what disciplines were used in conjunction with the diagnosis of a patient and in terms of what was being written about them. "If the nurse documented that a patient had problems obtaining medications, and there was no social worker referral," says Rutzen, "that could demonstrate evidence of underutilization of disciplines."
Something to aim for
The chart review was very time consuming, taking 15 to 20 hours per person on the team. It took about a month to complete the chart review, Rutzen says. In addition, the charts fell short of the agency’s goal of 95% appropriateness in visit frequency and discipline.
Rutzen would not disclose the actual numbers, but noted there was a statistically significant number of charts that showed both under- and overutilization of visit frequency. She also noted while there was little problem in overusing the disciplines, there was an issue in underutilizing other needed services.
The next step was to develop an action plan to correct the problem. First, the management team shared all the data with the managers. "We felt that it wasn’t just the staff in the field that had the problem, because they are conferencing on cases with their first level managers," she notes. "We felt the first area for improvement was with those managers."
Along with the data, Rutzen and her team provided managers with literature to help them better understand the appropriate frequency for various diagnoses. (For a list of the literature Rutzen used, see box, p. 41.)
At a March 1998 inservice, the data and literature was shared with the 12 nurses at Western Illinois Home Health Care, and the management team created new processes to ensure improvement. First, managers were required to start using a conference sheet that recorded discussions they had with nurses about patient care. Second, each nurse was assigned to a member of the management team. Those managers now review with their assigned staff members the visit frequency and discipline mix upon intake and recertification of each patient.
When the program was first put in place, there was some grumbling among the nurses, Rutzen admits. After all, she was adding work for them, as well as for management. "But no one wants to deliberately provide inappropriate care. And, with the threat of legal action for fraud and abuse and inappropriate care, we really had pretty good buy-in."
Because the agency is computerized, she was also able to keep the additional work to a minimum. Usually, the additional discussions between management and nurses can be handled over the telephone, and in most cases, staff members don’t spend more than an additional half hour per week on paperwork or meetings.
A sense of accomplishment
While Rutzen says the data is still being compiled, she already has a good sense that the PI program is working. "People talk more about diversifying their discipline mix on cases," she says. "In reviewing cases with the nurses, you can tell they are thinking more about the appropriateness of utilization. When a patient is hospitalized, they talk about increasing visits. When they talk about recertifying clients, they talk about if it is justifiable, or if they really need to be talking about custodial care. That is new."
The goal of 95% appropriateness is lofty, and Rutzen isn’t sure if this first go-round will get the agency all the way there. "If not, we’ll take a second look at our action plan and see if there is something missing."
"I think that in the home care climate that we are in, you have to defend whatever you are doing," says Rutzen. "If you don’t know your data, then how can you defend your actions? This is one piece of it."
There was an added bonus to the program, too, Rutzen adds. Going over the charts made the team confident that they would sail through their state survey. "Those chart audits prepared us," she says. "We knew we were ready for it."
Sources
• Anita Rutzen, RN, Director of Performance Improvement/Staff Development, Western Illinois Home Health Care, P.O. Box 856, Monmouth, IL 61462. Telephone: (309) 734-9376.
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