Through Qavalo’s integrated clinical staffing solutions, Real Solutions Home Health Care in Delray Beach, Florida saw an upturn in their OASIS documentation and clinician experience at work.

By outsourcing the charting of the OASIS, Real Solutions achieved significant improvements in the OASIS turnaround time while alleviating the weight of documentation duties for clinicians. Qavalo OASIS transcriptionists assumed the role of entering patient assessment data into the WellSky EMR using a specialized patient assessment form. This allowed clinicians to devote more of their time to patient care with less documentation load.

Benefits Realized

• Efficient patient assessment documentation
• Faster OASIS turnaround
• More accurate documentation
• Improved clinician work satisfaction

Clinician Charting Challenges

Ensuring the completeness and accuracy of clinical documentation can be demanding. It is an equally important task that requires the same amount of time and effort as actual patient care. 

Charting has been a major challenge for clinicians, especially in the home health setting where clinicians can spend extra hours after a long 12-hour shift to complete charts in the EMR. This has been found to cause burnout according to a study published in the Journal of the American Medical Association and Medical Care (JAMA) which discusses how the EMR system changes clinician work, productivity, and well-being.

This hurdle compromises documentation quality, especially when key patient care information is overlooked, resulting in unsubstantial clinical narratives and inaccurate OASIS item interpretations, negatively impacting reimbursements and patient outcomes.

This strenuous work nature has caused many clinicians to pursue other opportunities in other healthcare sectors. With the onset of COVID-19, healthcare demand has increased drastically, overwhelming the supply of clinicians and leaving the home health industry with major staffing challenges. Home health providers have struggled with employee retention, while recruitment has become the top challenge according to recent homecare staffing surveys.

Streamlining Patient Assessment Documentation

In an effort to boost clinician job satisfaction by reducing the charting workload, Qavalo has piloted an OASIS charting service for Real Solutions that primarily addresses patient assessment documentation and OASIS turnaround.

Qavalo designed a Quick Assessment Form that standardizes the documentation done by clinicians during patient visits. The Quick Assessment Form is a template clinicians can use to capture and gather data from patient assessments. It only covers specific areas that are vital in creating the electronic OASIS chart, thus allowing clinicians to efficiently capture information during the actual patient encounter and make sure key details are not overlooked. 

In comparison to WellSky’s OASIS form which consists of 239 items, Qavalo’s Quick Assessment Form only contains 89 items that clinicians are required to fill in, which translates into 65% less work. Using the information deduced from the Quick Assessment Form, Qavalo OASIS transcriptionists then complete the OASIS form in WellSky, including responding to the crucial functional M-items.

Improving OASIS Turnaround Time

There has been a 54% improvement in the OASIS turnaround time of Real Solutions since the electronic charting was outsourced to Qavalo in July 2021.

Figure 1 shows the monthly average OASIS turnaround time from the patient visit to QA review completion

In July 2021, the entire process took an average of 9 days to complete. When charting was outsourced, immediate improvements have been evident as the average turnaround time was reduced by 54%. By March 2022, the average turnaround time was reduced to only 4 days, which supports a faster completion of the Plan of Care (POC) and submission for Pre-Claim Review. With a shorter turnaround time of OASIS charts, the agency was able to promptly generate a POC, have it signed by the appropriate practitioner, and submit it to Medicare for Pre-Claim affirmation along with other documentation requirements.

New workflows related to observing changes in the 2022 home health payment final rule were adopted in January. This required a considerable period of adjustment in the collaboration between clinicians and the outsourced team, which was promptly resolved by the following month.

Concurrently, diagnosis coding has been initiated parallel to the electronic charting, considering all the necessary medical records references are available, hence ensuring the timely submission of the Notice of Admission (NOA) within the 5-day filing window. As soon as the electronic OASIS chart is complete and diagnosis codes are assigned, the OASIS chart is endorsed to a QA review team who returns the chart to the clinician for their signature or for further QA edits.

Improving OASIS Quality

Beyond improving the turnaround time, Qavalo’s OASIS charting service also contributed to increasing the quality of OASIS documentation.

A) Better QA Return Rate

Figure 2 shows the OASIS QA return rates under traditional charting and outsourced charting.

By comparing the data, a significant improvement can be seen in the volume of charts being returned with QA points from the OASIS review.

The percentage of charts that had QA issues is 64% under traditional charting and only 41% under outsourced charting. Even with the larger volume of OASIS charts completed through outsourced charting, the QA return rate was noticeably lower by 23%.

Although QA points are significantly lower in number under outsourced charting, they can still be reflected in some charts. This is because Qavalo OASIS transcriptionists only enter data deduced from information noted by clinicians in the Quick Assessment Form. A separate QA reviewer team at Qavalo checks the chart for potential improvements and consistency with supporting clinical records.

Similarly, figure 2.1 shows a quarterly comparison of the OASIS QA return rates from July 2021 to March 2022

Under the traditional charting process, QA return rates were either relatively high or fluctuating. From 66% in Q3 2021, it increased to 67% in Q4 2021, then decreased to 50% by end of Q3 2022.

On the other hand, a more consistent decline in the QA return rate can be observed when charting was outsourced to Qavalo. From 50% in Q3 2021, it continuously dropped to only 33% by Q1 2022, indicating a 17% progress.

B) Better M-item Responses

As a key area in the OASIS that impacts reimbursement values, the accuracy of responses to the 8 functional M-items is crucial.

Figure 3 above shows the quarterly average number of QA points flagged around the 8 functional M-items in OASIS charts created by Qavalo.

By the third quarter of 2021 —at the initial phase of the outsourced charting service— the average number of QA points was 38. Subsequently, by the 1st quarter of 2022, this number already dropped significantly by 75% to only 9 QA points.

Boosting Clinician Engagement

Clinicians at Real Solutions expressed their satisfaction that their workload was reduced without impacting their compensation, which can be considered positive feedback to encourage clinician retention. This is an indicator of the success of the outsourcing strategy in addressing the prevalent staffing shortage in home health. With Qavalo covering documentation, charting, and other administrative functions, Real Solutions’ in-house clinicians are able to focus on patient care.

“We were looking for a way to help our clinicians not only improve their charting and speed of submission of the OASIS but also for a way to attract new nurses and therapists and retain the ones we have. We wanted our clinicians to be able to spend less time on documentation and more time caring for their patients and for them to understand that we value their time and that this trade-off meant less time on OASIS charting, which, in turn, increased their pay per visit when you decrease the time spent on documentation.

Our nurses and therapists are very pleased with the EMR charting process of Qavalo. Once the OASIS is filled in by Qavalo, it’s returned to the clinician for review and approval. They aren’t just signing a document that they didn’t review for accuracy. Our nurses say they used to spend one to two hours at home charting on the OASIS, and now it takes about 20 minutes either at home or during the home visit to fill in the paperwork and attach it in Wellsky.”

— Angi Lupton, Director of Nursing and Clinical Services

Getting Support Where Needed

With the current staffing challenge faced by the home health industry, innovative approaches are required. Increasing wages might not be sufficient without addressing the actual challenges that clinicians experience in their work. Having a reliable partner that can provide integrated clinical staffing solutions and back-office support can truly make a difference. By leveraging strategic partnerships, agencies can delegate other functions and direct their efforts to what matters most.

Connect with us to learn more about the OASIS charting service or how you can build your own offshore back-office support team with Qavalo.

The post [CASE STUDY] Alleviating Clinician Workload by Outsourcing the OASIS Documentation first appeared on Qavalo.

*In the interest of client confidentiality, the agency name was changed for this case study.

Using efficient coding and OASIS documentation solutions, Endeavor Home Care optimized its reimbursement levels and improved the performance of its clinicians with the help of Qavalo.

Qavalo’s expert coders were able to capture all diagnosis codes deduced from medical records in successful collaboration with Endeavor’s in-house team. Meanwhile, Qavalo’s comprehensive quality assurance (QA) program not only improved the OASIS M item scoring, but also helped clinicians better their patient assessment skills.

Benefits Realized

• Higher reimbursement values from comorbidity adjustment
• Higher reimbursement values from the OASIS M item data (Functional Impairment Level)
• Successful collaboration between the in-house team and outsourced team
• Improved clinician-patient assessment skills
• Areas that need further improvement are identified

Challenges in Coding and OASIS Documentation

Diagnosis coding and functional M items or activities of daily living (ADL) data are two (2) significant areas that can be reinforced to optimize reimbursements. These two factors create a significant impact under the Patient-Driven Groupings Model (PDGM), not only in the calculation of the case-mix weight and reimbursement, but also in helping to support the medical necessity of the care to be provided to the patient in the documentation. Let us take a closer look at the elements that affect these two factors.

Comorbidity Adjustments

There are four (4) steps in the grouping of a patient into the PDGM Home Health Resource Group (HHRG), which establishes the case-mix weight and eventual payment. ICD-10 coding makes up 50% of that process. 

While the primary diagnosis (from the claim) of the patient is the sole determinant of the Clinical Grouping of the patient, the comorbidity adjustment is based on the secondary or other diagnoses that are found on the claim. The comorbidity adjustment has three levels:

1. No Comorbidity Adjustment – No secondary codes meet criteria for higher resource use.
2. Low Comorbidity Adjustment – Only one secondary code meets the criteria for higher resource use.
3. High Comorbidity Adjustment – Two or more secondary codes meet the criteria for higher resource use.

The case-mix weight is increased by 6.01% with a Low Comorbidity adjustment and an additional 12.95% if a High Comorbidity adjustment applies.  

Often, comorbidities are not clearly outlined in the documentation received from the referral source. In some cases, only symptom codes or ‘R Codes’ (which are symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified) are indicated in the documentation; these are not allowed to be assigned as secondary diagnosis.

Functional Impairment Level

The functional impairment level is based on the responses to eight (8) OASIS-D1 items for ADL. The responses from all M items based on a point system determine the functional impairment level depending on the clinical category. 

The Centers for Medicare & Medicaid Services (CMS) looks at the above OASIS assessment items and related resource usage over a 30-day period and assigns a point value to each item.

Points reflect relative resource use. OASIS item responses that indicate higher functional impairment and a higher risk of hospitalization are assigned higher points. OASIS points are then summed up to determine an overall functional score. After, this score is compared with the PDGM clinical grouping thresholds to determine whether the 30-day period is assigned a low, medium, or high functional impairment level.

The accuracy of responses to the M items relies on the clinicians’ judgment and their patient assessment skills, which is often a challenge due to the complexity of M items. Each one involves different time considerations and requires different levels of assessment for different aspects of a patient’s ability to perform activities.

The Qavalo Method

To help address the above challenges and improve reimbursement levels, the following coding and QA review solutions are applied by Qavalo:

• Accurate diagnosis sequencing
• Proactive query for additional information for coding
• Comprehensive QA review with focus on the M items
• Supporting of reeducation of clinicians
• Efficient OASIS review for accurate M item scoring

Let us take a closer look at the impact of Qavalo’s solutions in numbers using claims data from e Endeavor from May to June 2021:

Expert and Proactive Coding

Out of 250 charts coded, 79 or 32% realized an increase in reimbursement value after secondary diagnoses have been assigned.

For the 79 charts, secondary diagnoses triggered a comorbidity adjustment which increased the total reimbursement value by 6%.

The positive results prove how Qavalo’s team of coders are well accustomed to coding conventions and guidelines, medical terminologies, and disease processes. To ensure all comorbidities are captured, Qavalo coders thoroughly analyze all relevant patient medical records, such as history and physical (H&P) examination, discharge summaries, operative reports, and progress notes.

Furthermore, Qavalo coders coordinate queries to in-house teams about missing information in the documentation that can substantiate coding assignments. The in-house team, especially the intake team, communicates these queries to referral sources so they can then provide the necessary information.

Accurate Functional M Item Scoring through OASIS QA Review

Out of 250 charts reviewed from May to June 2021, 22% had an increase in the reimbursement level. By analyzing the patient assessments, QA reviewers found more opportunities to improve the M item scoring, which resulted in an increase in the reimbursement level.

It can also be noted that after OASIS review, 11% of the charts had a decrease in its initially coded reimbursement value. Comprehensive QA review caught inconsistencies in some functional M item documentation which had to be corrected in order to accurately reflect the patient’s condition in compliance with CMS standards.

Nonetheless, a 15.8% increase in the reimbursement value was realized for 22% of the  charts after OASIS M item scoring was improved.

On the other hand, we also recognized that a considerable number of charts did not have any change in the functional impairment level (or reimbursement amount per se) even after the OASIS QA review. This is because Endeavor clinicians have improved in patient assessment and learned to accurately score the M items through continued education from the QA program. This is evident in the declining number of QA points flagged for the OASIS M items during the QA review.

The data shows that on most M items, the rate of revisions continued to drop despite the increase in total number of charts reviewed. This signifies the improved accuracy of clinicians’ scoring of the M items.

Moreover, leveraging on data insights from Qavalo, Endeavor was also able to identify their clinicians’ areas of improvement. Table 2.3 also shows that clinicians may have challenges responding to M1840: Toilet transferring. This is evident in the significant increase in the rate of revision on the said area. Therefore, this can then be Endeavor’s focus for further clinician education and process improvement.

Targeting Areas of Concern with Precision 

As reflected in the data, Endeavor improved their reimbursement levels by optimizing their HHRG through the help of accurate coding and efficient OASIS QA review. In addition, proactive and knowledgeable coders maintained effective collaboration with the in-house team to secure substantial documentation and to find opportunities to optimize code assignment. A sustainable QA program also supported clinician reeducation through the use of data analytics to target areas of improvement in clinicians’ patient assessment and OASIS documentation skills. Continued implementation of these best practices and effective solutions will lead to lucrative progress in many aspects of the home health business.

The post How Proactive Coding and a Comprehensive OASIS QA Program Can Help Optimize Reimbursements first appeared on Qavalo.

When OASIS submission, coding, and QA review were streamlined, Qavalo’s client agencies saw significant improvements in their OASIS turnaround time and realized better compliance and profitability.

With the right outsourcing partner, Qavalo clients have been able to get the support their in-house teams need to find efficiencies in their documentation workflow and seize big picture process improvement opportunities.

Benefits Realized

• Consistent OASIS submission-to-completion process
• Faster OASIS submission time
• Shorter OASIS turnaround time
• Declining LUPA rates
• Optimized reimbursement values

PDGM Turnaround Time Challenges

The Patient-Driven Groupings Model (PDGM) overhauled the entire home health reimbursement system with new case-mix weight calculations, new LUPA thresholds, new Request for Anticipated Payment (RAP) requirements, and shorter payment periods, among other big changes.

Request for Anticipated Payment (RAP)
In 2020, CMS introduced RAP, requiring agencies to submit initial documentation to authorize care under a home health agency and establish the care episode. Though a complete OASIS is no longer a requirement to file a No-Pay RAP this year, it is still best for agencies to complete the OASIS within the 5-day window period.

HHRG and HIPPS codes
Based on an OASIS assessment, 30-day periods under PDGM are classified under a variety of patient information and other clinical characteristics, such as admission source, timing, clinical grouping, functional impairment, and comorbidity. This results in a Home Health Resource Group (HHRG) combination for which CMS will generate a PDGM case-mix weight represented as a Health Insurance Prospective Payment System (HIPPS) code on Medicare claims.

Completion of the OASIS in time for RAP filing allows agencies to determine the claim’s HHRG classification and a HIPPS code that is more reflective of the actual patient case. This is important so that the assigned HIPPS code in the RAP would be more consistent with the HIPPS code in the final claim, thus lowering the chance of the agency being flagged for an Additional Development Request (ADR).

Low Utilization Payment Adjustments (LUPA)
With PDGM, LUPA thresholds vary per HHRG over a 30-day period, which means agencies should closely monitor different LUPA thresholds and visit intensities for each patient. Early identification of the LUPA threshold though the HHRG and HIPPS code will help agencies plot and schedule visits accordingly to prevent claims falling under LUPA.

These changes underscore the need for home health agencies to fast-track their process, improve documentation turnaround, and observe strict OASIS completion timelines in order to address key functions that affect claims approvals and reimbursement values. This is no easy task since an OASIS needs to undergo a number of processes, including coding and QA review, before being completed. In many cases, this can take up to 10 days—or ⅓ of the care period—if processes are not streamlined.

Qavalo Solutions in Numbers

To address the abovementioned challenges, Qavalo applies several workarounds and best practices to help agencies achieve the ideal workflow and succeed in timely submissions. 

• Timely coding and OASIS review to allow agencies to identify LUPA thresholds ahead of time, and generate a HIPPS code that is reflective of the actual patient case.
• Coding is done as soon as the OASIS is available in the QA manager.
• Coders are available seven (7) days a week.
• OASIS QA review is completed within 48 hours after coding.
• There is efficient resolution of escalations of OASIS quality issues.
• Qavalo proactively notifies agencies of trends on late submissions of OASIS by the clinicians.

Figure 1.1 shows the average OASIS submission time of clinicians across all home health agency clients of Qavalo. In January 2021, average OASIS submission was at 2.52 days, and by May 2021, this decreased to only 1.41 days.

More importantly, figure 1.2 below shows the average OASIS turnaround time from clinician submission to final approval. From January to May of 2021, Qavalo home health agency clients were able to realize completion of the OASIS within an average of 3.16 days.

Though a complete OASIS is not required to submit No-Pay RAPs since January 2021, clinicians were able to maintain early submission of OASIS, allowing other OASIS processes,  such as coding and QA review, to be accomplished in a timely manner. In addition, Qavalo’s QA review program supports clinician reeducation, helping them improve their charting skills overtime. This resulted in an efficient end-to-end average OASIS turnaround time of 3.16 days, which falls within the 5-day RAP filing window.

Due to efficiencies in the OASIS completion timeline, LUPA thresholds were identified early on in the payment period, allowing agencies to properly plot visit schedules, and anticipate and address missed or cancelled visits, thus avoiding LUPAs.

Figure 2 below shows sample data from one of Qavalo’s clients, Palmeria Home Health in Arizona and Nevada. The graph shows the percentage of Palmeira’s LUPA episodes from the fourth quarter of 2020 to the second quarter of 2021.

In Q4 of 2020, only 7% of all episodes fell under LUPA. Even with the implementation of No-Pay RAPs in 2021, when the OASIS is no longer required to be completed within 5 days, LUPA rates continued to drop at 6% by Q1 and down to only 4% by Q2.

While early identification of LUPA thresholds greatly helped agencies, LUPAs were not completely avoided because of some uncontrollable factors such as cancelled visits due to patients’ anxiety towards COVID-19.

The Right Partner for the Job 

Based on data, Qavalo’s home health agency clients realized a better OASIS turnaround time. Beyond the scope of documentation review and coding, Qavalo maintains ongoing collaboration with in-house teams and leverages data to help agencies have a comprehensive view of their documentation workflow and properly address gaps. This path of progress will only lead to more streamlined processes, resulting in better patient outcomes and business profitability.

The post PDGM Challenges: Optimizing Profitability Through Efficient OASIS Turnaround first appeared on Qavalo.