This text-based course is a transcript of the webinar, “Documenting to Demonstrate Skilled Service and Focus on Function,” presented by Nancy B. Swigert, M.A., CCC-SLP, BCS-S.
>> Nancy Swigert: We are going to talk about healthcare changes and why we need to make sure we have our eye on function. We will discuss writing functional measurable goals, skilled versus non-skilled treatment, in particular in relation to the CMS regulation that changes the way many of us think about therapy since some therapy will be covered and progress is not required. We are going to talk about writing treatment notes to document skilled care, using a 10th treatment progress note, and if we have time at the end, we are going to practice looking at some documentation to see how to show skilled services in a better way.
Much of what I am going to share today is based on the Medicare regulations. However, even if you never see a Medicare patient, maybe you only see pediatric patients; all of this is still very applicable. What CMS puts into regulation for Medicare is often the same thing used by states for Medicaid, and often is the same thing used by many private insurers. If you are dealing more with a population of clients that use private insurance, of course you would want to check with that private insurance to see what specific requirements they have. These guidelines are good for any payer.
Accountable Care Act
Let’s start with the Accountable Care Act. Certainly healthcare is focused on quality, but the real push to focus on quality and not quantity is coming about because of the Accountable Care Act. One of the things the ACA did was to develop a national quality improvement strategy which states that we should have, “we” being healthcare, priorities to improve the delivery of healthcare services, patient health outcomes, and population health.
We have to make sure to get input from multiple stakeholders because the health care system should not be looking at how a patient does at a hospital, rehab facility or home healthcare. Rather, they should be looking at how the patient does from point A all the way to point Z as patients travel through the healthcare system for any episode of care.
There is also an increased importance on patient reported outcomes, which can be challenging when we work with individuals who have communication disorders. But it is something we have to figure out as a profession - how to include patient reported outcomes when we are describing the outcome of our services.
Value-Based Purchasing
Another term that we need to become familiar with, if we are not already, is value-based purchasing. Over the last year to two years, CMS is now rewarding hospitals that provide high-quality care. What they are doing is paying for quality, not quantity. It is really hitting hospitals first, but this same model of reimbursement will also affect every other payer in the chain, even if you are a private practice speech language pathologist. For the first time in history, hospitals are going to be paid based on the quality of the services they provide, and CMS puts out certain measures that they think should happen and how much improvement a hospital should show over a specific period of time. For example, they might have door to needle time or for a patient coming in with a stroke, what is the amount of time until they should be getting tPA, if they qualify for it? What if a person comes in with a NSTEMI, a heart attack, what are the different duties or procedures that should happen and how quickly should they happen?
Those quality measures have now been imposed on hospitals. Much of it is on the clinical process of care, not outcome, and it will get more to outcome. Many of these are process measures, such as “Was the patient supposed to get an aspirin and did he get an aspirin? Was the patient supposed to get discharge planning instruction on how to take his meds and did he get that instruction?” It is really on process now, but over the next several years, we will see it move more towards outcome.
Patient care experience is also responsible for about one-third of the payment coming into hospitals.
