Mary Jones is the health information supervisor at Somewhere Home Care, which is Medicare-certified. As required by Medicare, her agency and staff members have been completing and submitting OASIS-C1 data. The staff has been accessing patient data through the OASIS-C1 reports, as well as monitoring and documenting visit patterns and frequency by the agency. In addition, the personnel have been monitoring the cost of supplies utilized per patient. In reviewing the financial data, Mary’s director has indicated that the agency has performed marginally un-der the Medicare prospective payment system. The staff would like to improve financial performance and has met with the leadership team of the agency to discuss a possible plan of action. Although some insurers still pay by the visit, Medicare patients are the largest group in the agency’s payer mix, and Medicare pays a set amount of money for providing care over a 60-day period rather than a per-visit fee. Mary has some statistics available to her to assist the director with formulating a plan. These include:

·        The number of patients the agency has had in each HHRG classification over the past 3 years.

·        The number of visits (by clinician type, i.e., RN, LPN, HHA, PT, OT, SLP) made to each patient for each 60-day episode of care.

·        The average number of visits to patients in each HHRG classification

·        Financial data, including reimbursement amounts for each HHRG and the agency-specific costs per each type of visit.

·        Primary diagnosis for each patient

·        OASIS C1 outcome reports printed for OBQI/OBQM, showing how the agency has performed in outcomes, compared to other agencies in the country.

·        Payers mix report, showing the percentage of patients the agency has in each payer source (i.e., Medicare, Medicaid, commercial insurance, private pay, etc.). At Somewhere Home Care, 65% of the patients are covered by Medicare.

Investigation into care plans and visit patterns indicate wide fluctuation in visit patterns among clinicians. Patients within the same HHRG category—who basically should be similar—have widely varying visit ranges. Based on the above information and scenario, answer the following questions:

1. What are some significant factors that Mary and her director should consider about their payment sources as they evaluate their financial performance?

2. What statistical data available to Mary would be most helpful in developing an action plan?

3. Where should Mary focus her clinical and medical record expertise?

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