Evaluating performance outcomes measurement systems: concerns and considerations.

In today's managed care healthcare environment, there is a need for hospitals and physician groups alike to know the true quality and costs of healthcare services provided to patients. As the movement toward having providers accept risk via financial capitation escalates, quality improvement professionals involved in outcomes management are increasingly being asked to investigate information sources and systems that can prove helpful in managing effectively within these limitations. As a result, there is a high degree of interest in comparative performance outcomes measurement data based on risk-adjusted and severity-adjusted data. This article explains the key features of performance outcomes measurement systems and notes concerns that should be considered when evaluating these software systems for selection.

Understanding and operationalizing subacute services.

Providers are now viewing subacute care as an opportunity to market to managed care businesses. Many existing subacute units claim they can provide quality post-acute-care hospital services for considerably less cost than traditional inpatient stays. Subacute units will have to demonstrate both cost savings and quality to be attractive to the market place. Therefore, it is important for nursing managers to understand operational and other aspects of this business.

Using case management to improve claims payment.

Payers increasingly are subjecting claims to intensive review in an attempt to control amounts paid for healthcare services. An internal case management program, however, can help providers better understand and respond to the review techniques employed by payers as well as streamline overall claims processing.

Case management can reduce costs and protect revenues.

In order to reduce costs, improve quality, and protect revenues, an integrated healthcare system should depend heavily on a case management program that provides continuity of care across all clinical settings for an entire episode of illness or injury. In addition, such a program should move homogeneous, uncomplicated groups of patients quickly and cost effectively through the healthcare delivery system and determine why other patients are not able to move through the system as quickly and effectively.

Optimizing Medicare reimbursement in skilled nursing facilities.

Effective utilization review (UR) and clear, complete clinical documentation are essential if a skilled nursing facility (SNF) is to capture charges efficiently and bill appropriately to ensure optimal Medicare reimbursement. Authors Micheletti, Shlala, and Greenfield detail how financial managers can assess UR activities and clinical documentation practices to help improve an SNF's profitability.

Home health agency reform creates new opportunities for medical record professionals.

Home health care agencies are being required by federal legislation and by accrediting agencies to comply with new, stricter regulations. By providing their expertise in interpreting regulations and establishing quality assurance programs, medical record professionals can place both the agencies and themselves in a "win-win" situation.

Quality assurance in ancillary departments.

Formalizing quality assurance programs is becoming more important in the healthcare arena. Providers are now expected to have programs in place to systematically monitor the outcomes of care delivery. This article describes how to organize and develop quality assurance activities in selected hospital ancillary areas.

New home health quality standards will trigger operational changes.

As national spending for home health services increases, concern for the quality and the effectiveness of these services grows. Provisions in the Omnibus Budget Reconciliation Act of 1987, which revised Medicare's conditions of participation for home health agencies, and recently adopted standards by the Joint Commission on Accreditation of Healthcare Organizations establish new quality assurance requirements. Home health agencies will need to consider implementing operational changes and other strategies to meet these new standards of quality. Information generated by the new quality assurance activities may be used to establish future Medicare and Medicaid reimbursement rates.

Concurrent chart analysis and DRG assignment in a prospective payment environment.

Medicare's prospective payment system and the elimination of periodic interim payments have caused dramatic changes in the day-to-day operations of most medical record departments. This article discusses one method to help hospitals expedite record completion and bill in a more timely fashion.

Restructuring quality assurance programs in HMOs and other competitive medical plans.

The Health Care Financing Administration recently established a new set of regulations for health maintenance organizations (HMOs) and other competitive medical plans (CMPs). These regulations require quality assurance (QA) programs in HMOs and CMPs to include a system for collecting data on provider performance and patient outcomes, ensuring that physicians and other health professionals review the processes involved in service delivery, and taking corrective action when inappropriate care is delivered. As a result of these new requirements, QA programs in HMOs and other CMPs have come under greater scrutiny than ever before by numerous external review organizations. This article describes a model for restructuring QA plans to meet the demands of the current regulatory environment.

New clinical documentation guidelines for long-term care.

Nursing homes are becoming subject to more stringent rules and regulations regarding documentation of care given and can expect closer monitoring of their facilities. This article discusses evolving long-term care clinical documentation initiatives, suggests guidelines and offers recommendations to help cope with the requirements.

Nursing homes must meet new requirements.

Under the Omnibus Budget Reconciliation Act of 1987, skilled nursing facilities and intermediate care facilities must meet new requirements to receive Medicare and Medicaid payments. These requirements emphasize the quality of care and quality of institutional life. The new law modifies the Medicare and Medicaid certification process and broadens the sanctions that can be applied to substandard facilities. Nursing home administrators must carefully document the additional costs, conduct comprehensive assessments, protect residents' rights, and establish or restructure a quality assurance committee.

Quality assurance in a PaCS and case-mix environment. Patient Care and Services.

Medicare/Medicaid's new long term care certification survey and case-mix payment systems have important managerial implications for quality assurance programs. These implications are explained in this article and recommendations are made to help skilled and intermediate care nursing facilities function effectively in the new environment.

Risk prevention: a market for health record services.

The purpose of this article is to identify and discuss the responsibilities of medical record practitioners in helping to minimize hospital risk. Operational programs which can be implemented to ensure integrity of the patient records are also described.

RUGs II: implications for management and quality in long term care.

Case-mix-based reimbursement could provide long term care facilities with a financial incentive to accept the more acutely ill patients who are being discharged from hospitals under Medicare's prospective payment system. But a financial incentive to maintain a complex case mix could also encourse nursing homes to provide substandard care. New York's Medicaid program has coupled a reimbursement method based on Resourse Utilizationm Groups (RUGs II) with regulatory efforts to ensure quality in a model that may be be adopted by Medicare and by Medicaid programs in other states. This article describes New York's system and discusses a number of management and quality assurance strategies that may be useful to nursing homes under RUGs II.

Case-mix adjustments require tighter documentation.

Six states currently incorporate case-mix adjustments into their payment formulas for long-term care, and Medicare is likely to follow suit in the near future. Case-mix systems require facilities to keep detailed records on patients' functional abilities, medical conditions, daily progress, and treatment plans. Much of the information required is similar to the data that the Patient Care and Services (PaCS) survey program will collect and evaluate for the new Medicare and Medicaid certification process. Long-term care facilities must establish policies and procedures to accommodate the new requirements. Recommended steps include: Redesign medical record forms so that each patient's functional limitations and medical conditions can be documented. Design care plans so that they identify the patients' disabilities and medical problems, set realistic short- and long-term treatment goals, establish appropriate interventions, and designate the care giver responsible for each intervention. Focus progress notes on problem resolution. Replace medical care evaluation processes with a quality assurance program that determines whether care plans are followed and goals reached.