Managing Outcomes
Learning Objective
As a result of this session, the participant will:
 Identify areas of clinical performance that relate to positive
patient outcomes.
 Have strategies for drilling down to uncover performance
issues.
Data Analysis
Why do we do it?
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Accurate outcome data is a powerful tool that can be used
to educate key decision makers in the hospital, potential
patients, payers, and the community at large.
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Marketing efforts are enhanced when outcome information
is used during direct marketing calls.
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The team benefits from use of outcome information by
being able to see where they are the most effective and also
by being able to focus improvement efforts.
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Breaking down your performance may reveal opportunities
to capture the burden of care and yield greater
reimbursement.
Data Analysis
When conducting data analysis, ask yourself:
•
Does the data look real?
It is important to validate that the data that you are
analyzing is reliable.
Can you identify any inaccuracies in your sample?
•
Do the outcomes meet your expectations?
Compare your outcomes to your goals and industry
benchmarks.
How do you stack up?
•
What impact would change make?
Would there be a positive impact on your patient
care services if you improved your performance in
this area?
Data Analysis
• Selecting Indicators:
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Review outcomes
Determine what is below benchmark
Figure out what is meaningful to your facility
Determine what is attainable for your facility
Facility Report
• Case Mix Index
 Are you getting paid for the work that you do?
 Does it seem like your CMI is lower than your burden of
care?
• Capturing the proper CMI is essential to enable you to
staff appropriately.
• Since many of us predict staffing ratios based on patient
acuity as realized through the CMI, it is important to
capture what most closely reflects the care being
rendered on the unit.
Facility Report
• Case Mix Index:
 Benchmark against the nation and the region.
 Investigate the components• Rehabilitation Impairment Classification
• Motor Functional Independence Measure Subscale
Weighted Score at Admission
• Age
• Tier Assigning Co-morbid Conditions
 Investigate the distribution of impairment groups,
CMG, or RIC.
 Investigate the components for the most common
groups.
Facility Report
• Average Medicare Expected Reimbursement:
 Based on Medicare reimbursement
 Adjusted for your facility pricer as updated through
eRehabData
 Includes calculations for transfer payments and short
stay reductions
Facility Report
• Transfer Patients:
 Percentage of patients that are discharged to another
Medicare bed
• Acute care
• SNF
• LTACH
• Another IRF
• Discharge Destination:
 Breakdown of discharge locations for the patient’s
served
 Skilled nursing and subacute designation errors
Facility Report
• Averages:
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Two benchmarks: Weighted and unweighted
Onset days: Different instructions by RIC
Length of stay considerations
Functional Independence Measure scoring data• Admission Totals
• Discharge Totals
• Functional Independence Measure Change
• Motor subscale at admission
Facility Report
• Individual Functional Independence Measure
Items:
 Admission, discharge, change, and follow-up
 Explains difference between facility totals and
benchmark totals
 First glance at isolating Functional Independence
Measure scoring errors
Breaking Down the CMI
Tips:
• Evaluate your admission Functional Independence
Measure scores
• How does your admission Functional Independence
Measure score compare to those in your region and
across the nation?
Breaking Down the CMI
• Determine what percentage of the time you are scoring
a tiering comorbidity
Breaking Down the CMI
• Pay attention to the most commonly used comorbidity
lists
Breaking Down the CMI
• Pull reports to show your CMG breakdown
• Are you missing high acuity patients, low acuity patients?
Breaking Down the CMI
• Pay attention to the warnings to tell you when there is a
mismatch between IGC and Etiologic diagnosis
Drill-Down
• Reimbursement:
 Determine which populations have the greatest transfer
payment percentages.
 Evaluate length of stay by RIC, IGC, CMG.
 Review discharge destinations by group.
 Use the patient report to identify outliers.
Drill-Down
• Averages:
 Onset days should be evaluated on a RIC basis to ensure you
are hitting your targets given the definition stated in the IRFPAI Training Manual.
• RIC Report
• Referral date to admission date
 Length of Stay should be evaluated to ensure you are hitting
your targets.
• RIC, IGC, CMG, Patient Report
Drill-Down
• Averages:
 Functional Independence Measure Scores
• Total Admission Functional Independence Measure shows
patient’s overall burden of care and potentially indicates barriers
to progress or expected rate of progress.
• Total Discharge Functional Independence Measure shows
patient’s achieved performance. Scores are gathered across the
last 3-days of the stay. Facility identifies patient’s best
performing 24-hour period and the lowest scores from that day
are reported on the IRF-PAI.
• Functional Independence Measure Change is the amount of gain
from admission to discharge and is also reported on a per day
gain basis.
Considerations:
Totals reviewed for total population
Totals reviewed by RIC, IGC, CMG
Items reviewed in for total population
Items reviewed by RIC, IGC, CMG
Functional Independence Measure Scoring Comparison Graph
Time-Series Graph
Metrics
Strategies
• Averages:
 Evaluate screening and admission process to determine if
patients are being admitted at the right time in their
recovery.
 Evaluate initial IRF-PAI scores for proper scoring
• Be sure that the lowest score is taken from the
documentation
• Be sure that a full set of scores is captured daily
• Set the stage for accuracy through communication
among team members
 Evaluate the effect of the volume factor.
 Start an ADL program, ambulation group, cognitive group,
etc to focus on enrichment of skills learned in 1:1 sessions.
Functional Gain
Functional Gain: The Functional Independence Measure
change between admission and discharge measures
the degree of functional improvement demonstrated by
patients.
 Effectiveness: Ensuring patients obtain sufficient gain
to be able to return to their prior level of function.
• What are the problems?
Outcomes are too high
Outcomes are too low
Discrepancy between the scoring of items within the
same category
Functional Gain
Why would outcomes that are too high be a problem?
 Admission Functional Independence Measure scores were too
low during the assessment period.
 Failure to assess areas of the Functional Independence
Measure (i.e., bathing, stairs) can lead to gains above the
benchmark.
Functional Gain
Tip: Focus on Gain Above Benchmark
• Look at the number of 0’s on particular Functional
Independence Measure items
Remember 0 is not a score and there are only three
reasons that justify the use of 0.
1. The clinician determines it is not safe.
2. Medical condition or treatment
3. Patient refusal
• Look at reliability of the scoring for items that exceed
benchmark.
• Look at facilitators within the environment that enable
gains to exceed benchmarks to explain the outcomes.
Functional Gain
Why don’t we want gains that are too low?
 Why gains are less than the benchmark:
• Patients are not admitted from acute in a timely manner
• Therapy protocols or techniques need to be examined
• Lengths of stay are not sufficient
• Functional Independence Measure scoring during the
admission process may be delayed
Functional Gain
Tip: Focus on Gain Below Benchmark
• Look at the average length of stay
• Look at interdisciplinary treatment processes
• Look at patient mix
• Look at volume
Functional Gain
• Look at admission scores for individual Functional Independence
Measure items
• Look at point at which Functional Independence Measure scores
are collected (early within 3 day look back or on day 3)
• Look at LOS on acute
Functional Gains
• Look at returns to acute
• Look at discharges to settings other than home
Goal Attainment
• Goal setting is important!
 Patient metrics page reports admit, discharge, goal, and
gain.
 Review again goal at team and following discharge for
success with goal attainment.
Strategies
Goal Attainment:
 Emphasize goal revision on the plan of care.
 Inservice on goal setting to include proper goal setting and
progression of treatment through incremental goal achievement.
 Begin reviewing long term goals in the weekly team conference.
 Determine a method to communicate current status and goals
regularly through a functional status board, stand-up meetings,
and/or team conference.
Other Views
• Time Series Graphs:
 Look at performance over time
 Multiple indicators can be viewed simultaneously
 Data tables are useful tools for report preparation
Other Views
• Functional Independence Measure Scoring
Comparison Graph:
 Graphs admission, discharge, and change scores for
the facility and region/nation
 Review weighted and unweighted comparisons
 Helps identify items that may require special attention
in order to accurately represent the burden of care
Other Views
• Percentile Ranking Report:
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Allows comparison of your facility’s performance with other units
Ranks your performance by report item
States your facility ranking among all units for that time period
Offers benchmarks of what performance level you would need to
reach your desired percentile ranking
• Case Mix Index Example:
Facility CMI = 1.1180
National average CMI = 1.2686
Facility Percentile Rank = 16.48%
Facility desires to be ranked at 60% of database, so their target
CMI = 1.2849
Other Views
• 60% Rule Report:
 Know how you will report your compliance to the FI:
admissions or discharge
 Know your cost report year and look back periods
 Manage conditionally compliance closely
Other Views
• 60% Rule Report:
 Confirm the final IRF-PAI with the patient’s status on
the compliance report
• Presumptive or conditional?
• In order to appear on this report correctly, you will
answer questions on the eRD tab to determine if
the patient is 60% compliant or not.
• Review the detailed assessment to determine what
makes the patient compliant.
Other Views
• 60% Rule Compliance Threshold:
 Provided that each patient is properly identified on
your 60% report, the compliance threshold established
for your current reporting period is adequate.
 Every patient that meets the criteria for inpatient
rehabilitation deserves to receive that level of care.
• Therefore, operating at a higher compliance while beds
are empty is essentially denying a patient an opportunity
to regain independence.
 The key is to be sure that you capture the 60% status
of each patient correctly.
Other Views
• Dashboard:
 Great tool for daily census update
 Offers a 14-day projection of census decline for current
case mix
 Provides 30-day analysis of several indicators: CMI,
60% rule compliance, RIC distribution, and payor
source breakdown
 In order to provide data, your bed configuration and
pricer need to be up to date
Referral Tracking
• Referrals Outcomes:
 Designed to trend referral sources, referring
physicians, and conversion rates.
 Offers information on reasons for denied admission.
 You can filter the information to drill down on
physician, referral source, internal vs. external fill, and
reason for denied admission.
Other Views
• Referrals Outcomes:
 Use information to determine referral trends by• Referral source
• Referring physician
• Internal versus external fill
• Zip code breakdown
• Payor source breakdown
• Conversion rates
• Reasons for denial
 Drill down by RIC, CMG, and Patient
• Patient reports list patients denied
Conducting a Non-Admission Review
• Non-admission review:
The review of all patients that have not been admitted to
rehab unit. This is done by reviewing the pre-admission
forms and reviewing the section that notes the reason for
not admitting to the rehab unit to help identify trends and
changes that occur over a quarter.
• Common Reasons
Too impaired
Too functional
No bed available
Physician did not agree
Patient or family refused
Insurance did not authorize
Not 60% rule compliant
Conducting a Non-Admission Review
• What can we do about the “too impaired”
category?
 Determine if the admission denial was based on
objective criteria
 Identify if the denial was based on staff’s lack of
competency
 Clarify with Medical Director his/her comfort level with
the staff managing a patient with that diagnosis or at
that level of acuity
Conducting a Non-Admission Review
• Denial because “Too Functional”
 Review the referral date against the actual date of the
screen
 Would reducing the number of onset days have
resulted in a decision to admit?
 Determine what the patient’s deficits really were and if
they could have benefited from a stay in an IRF.
Optional Items
• Patient Satisfaction Instrument:
 3-Step Satisfaction Tools specific to rehab
• Service Recovery
• Discharge
• Follow-Up
 Feedback from Stakeholders:
• Reported with demographics
• Item by item averages of responses for each item
• Same drill-down capabilities as facility reports
Optional Items
• Patient Satisfaction Instrument:
 Graphs responses to questions from each survey type
for selected time period
 Graphs historical trends for each question asked on the
surveys
 Time Series Graphs available to drill-down by patient
type or demographic profile
 Stores and reports narrative comments provided by
patients
Putting It All Together
• Best Practices in Performance Improvement –
 Communicate
 Inservice
 Peer Auditing
 Use Case Studies to facilitate learning
 Select a manageable number for performance
indicators to work on
 Report change and what worked to facilitate change
 Don’t fear it!
Questions?
Contact:
Lbazemore@erehabdata.com
202-588-1766