Educate contract workers to improve clinical quality
NY agency starts special inservices for therapists
Therapy is a major part of home care services, and yet many agencies must contract for part or all of their therapists. This may lead to problems with scheduling and with quality control of documentation.
The Visiting Nurse Association of Utica and Oneida County Inc. in Utica, NY, has begun a special inservice program for all therapists who contract with the agency.
Therapists meet quarterly at the agency, so it was a simple matter to add education to the meeting’s agenda, says Jeanne Gymburch, SPHN, supervisor of special programs for the agency, which serves the Utica area of upstate New York.
Gymburch and the agency’s quality improvement coordinator Norma Swartout, RN, were concerned about documentation of the higher-income episode payments that included physical therapy, occupational therapy, and speech therapy.
"We wanted to include education for therapists at their quarterly meetings," Gymburch says. "So we began with the September meeting, where we told them about the prospective payment system [PPS] and how it would begin in October."
Gymburch told therapists how it was important under PPS to focus on the skilled needs of the client and the client’s homebound status.
Gymburch and Swartout wanted therapists to focus on making their documentation as complete as possible, Swartout says.
"It’s important that the therapists’ documentation is congruent with what the nurses are charting," Swartout adds. "We need to see the patient more holistically."
After that initial meeting with the therapists, the agency conducted a quality improvement (QI) study, Gymburch says.
The QI study looked at the therapists’ October notes to assess two main points:
1. Did the therapist document homebound status correctly?
2. Did the therapist’s notes reflect progress toward a goal?
"If the surveyor or payer pulled that note, would it stand alone as meeting those two requirements of homebound status and have a skilled need and illustrate which goals we’re working toward achieving?" Gymburch asks.
Gymburch, Swartout, and a local college student participating in leadership training together conducted the study. They took a roster of active therapy cases, randomly choosing every fifth case to review. A total of 11 charts were reviewed, including 16 therapy cases, since some clients had more than one therapy discipline in the home at the same time.
Study examined various QI indicators
"Besides the homebound and progress-toward-goals, we also looked to make sure therapy order was on the [Medicare] 485, and looked for evidence of patient care conferencing between the therapist and the nursing supervisor," Gymburch says.
A supervisor would take the therapist’s order received from the physician and document this on a load form that is sent to data entry for producing the Medicare 485 form.
The last indicator checked during the QI study was whether the client signed the service verification form, Gymburch notes.
"We’ve had that form with the nursing department for probably a year and a half, and we’ve always had it with home health aides," she explains. "We initiated it as a good thing for the client to sign as a way of documenting the visit."
The therapists had been lax on having these forms signed, so it was included as an indicator.
A target of 75% accuracy was set for the quality improvement study indicators, and the study found that three of the five goals met that target with 81% or greater compliance, Gymburch says.
The successful indicators were the orders on the Medicare 485 which had an 81% compliance rate; the evidence of communication between the therapist and supervisor had a 94% compliance rate; and progress made toward goals was documented on each note in 84% of the cases.
The areas that needed improvement included documentation of homebound status, which had only 69% compliance, and the signing of the service verification form, which had 38% compliance.
However, the last indicator had too small of a sample to be a fair representation of how well therapists were doing with having the service verification forms signed, Gymburch says.
"They keep the service verification form in their possession until they discharge the client, so we had a low number of charts that fell into that category; it was not a good representative sample," Gymburch adds. "We are focusing on that again in our next study, which will have a larger sample."
Improvement gained through inservices
After evaluating the results, the QI team decided the study demonstrated an opportunity for improvement that could be addressed through an inservice with therapists and a follow-up study.
In the meantime, the agency was sent some Medicare 488 forms, which are Medicare audit requests. Just as Gymburch had expected, these all focused on therapy.
At the next quarterly meeting with therapists, Gymburch asked them to attend either a noon meeting or a 4 p.m. meeting on a separate day. Both meetings were held during the middle of the week in February 2001.
Gymburch told therapists the agency had conducted a study and showed them the results. She said there would be a 100% note review as a follow-up study.
Therapists were given a packet of information and were told about various policies of which they might be unaware. For example, whether an episode is a start-of-care, recertification, or discharge, its documentation has to be "locked" into the computer within seven days, Gymburch explains.
"We talked to the therapists about the discharge and the therapy role and what a therapist has to do if therapy is the last skilled discipline on the case," she says.
When therapists are the ones completing the discharge Outcome and Assessment Information Set (OASIS) form, they have to document evidence of a drug regimen review at all OASIS time points, including the start of care, resumption of care, recertification, and discharge.
"So if therapy was the last skilled discipline, the therapist would be responsible for submitting to the office a drug list for nursing review," Gymburch adds.
The inservice lasted one hour, and the packet of information, which included copies of the discharge OASIS, the comprehensive discharge form, and the recertification form, reinforced the lecture.
About 40 therapists attended the two meetings, and those who were unable to attend had individual training sessions, Gymburch says.
The agency has received some positive feedback about the inservice from the therapists who attended, Swartout says. "I think it definitely assisted us in making the paperwork more complete."
During the week after the inservices, Gymburch and Swartout began the 100% chart review. It’s a time-consuming process, using about 15 hours per week between them, but it is necessary, Gymburch says.
The chart review will continue indefinitely as the agency waits for a response to their answers to the Medicare audit requests. "If Medicare doesn’t like what they read or if they deny what you do with the skill, they can deny the whole episode," Gymburch says.
After the study is completed, based on the current 100% chart review, the agency will share the results with therapists and then decide on the next QI strategy. "Well, make decisions after we have the results," Gymburch says.
• Jeanne Gymburch, SPHN, Supervisor of Special Programs, and Norma Swartout, RN, Quality Improvement Coordinator, Visiting Nurse Association of Utica and Oneida County Inc., 2608 Genesee St., Utica, NY 13502-6003. Telephone: (315) 735-8521.
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