1 Improving the Quality of Oral Healthcare through Case ManagementModule 4 Process and Outcome Measurement Welcome to the learning series “Improving the Quality of Oral Healthcare through Case Management”, Module 4 entitled “Process and Outcome Measurement”. Now that we’ve learned the basics of quality improvement and goal setting, we can move onto exploring how to measure the success of our achievements. Here, we’ll focus specifically on both process and outcomes measurement and how measuring both directly aligns with improving the quality of the dental services your practice delivers to it’s patients.
2 Acknowledgements Improving the Quality of Oral Healthcare through Case Management is a professional education and training program designed to advance the knowledge, skill, and competency of the dental workforce. The curricula is made up of 6 training modules which have been made available through the generous support of the following organizations and agencies: Rhode Island Department of Health Rhode Island Executive Office of Health and Human Services Rhode Island Dental Association Medicaid|Medicare|CHIP Services Dental Association Health Resources and Services Administration Since this training program was developed to advance the knowledge, competency and skills of the dental workforce, a number of state-wide entities are responsible for its creation and implementation. The curricula is made up of 6 training modules which have been made available through the generous support of the following organizations and agencies: Rhode Island Department of Health Rhode Island Executive Office of Health and Human Services Rhode Island Dental Association Medicaid|Medicare|CHIP Services Dental Association Health Resources and Services Administration
3 Goals of the Course To provide professional education and training to dental personnel in an effort to: Improve the quality oral healthcare services; Improve the oral health outcomes of all; To lower the costs of oral healthcare across the healthcare delivery system. Lets’ review the overarching goals of this series of learning modules: We want to provide professional education and training to dental personnel in an effort to: Improve the quality oral healthcare services; Improve the oral health outcomes of all; To lower the costs of oral healthcare across the healthcare delivery system.
4 Overview of the Course Introduction Learning Modules:Principles of Quality Improvement Principles of Medicaid Dental Practice Management-Part 1 Goal Setting Process and Outcome Measurement Principles of Medicaid Dental Practice Management- Part 2 Principles of Case Management Module Post-tests 1.5 Continuing Education Units (CEU) will be granted upon completion of each module and submission of the respective post-test. RI EOHHS Certification will be granted upon completion of all modules and post-tests and submission of all post-tests. Next, let’s take a look at the Overview of the Course: Introduction Learning Modules: Principles of Quality Improvement Principles of Medicaid Dental Practice Management-Part 1 Goal Setting Process and Outcome Measurement Principles of Medicaid Dental Practice Management- Part 2 Principles of Case Management Module Post-tests 1.5 Continuing Education Units (CEU) will be granted upon completion of each module and submission of the respective post-test. RI EOHHS Certification will be granted upon completion of all modules and post-tests and submission of all post-tests.
5 Advisory Team and FacultyLaurie Leonard, MS Beth Marootian Timothy Martinez, DMD Lynn Douglas Mouden, DDS, MPH Joan Pillsbury Renee Rulin, MD John Verbeyst, DMD Robert Bartro, DDS Paul Calitri, DMD Marty Dellapenna, RDH, MEd Jeff Dodge, DMD Mary Foley, RDH, MPH Deborah Fuller, DMD Mary Ann Heran, RDH, BS Marie Jones-Bridges, RDH, BS This is a list of the team that developed the on-line program. The team consists of both state-based individuals and individuals from national or federal organizations, giving the group a broad depth of expertise.
6 Module 4 Learning ObjectivesDifference between QI and QA QI Strategies for Medicaid Dental Practice Management Assessing Strategies through Measurement [Plan-Do- Study-Act] Measuring QI-Using data Data collection Dashboard development and routine data analysis The learning objectives for this session will help you understand: The difference between QI and QA QI Strategies for Medicaid Dental Practice Management Assessing Strategies through Measurement [Plan-Do-Study-Act] Measuring QI-Using data Data collection Dashboard development and routine data analysis
7 Plan-Do-Study-Act Here, you can see the Institute for Healthcare Improvement (IHI) Model of Improvement As you learned previously, the science of improvement will be integrated into the work of the Clinical Arm. We will also look at the IHI Model of Improvement for the work of the Administrative Arm related Payment Models. In testing the Payment Model and its Core Elements, we will see how the Improvement Model can support testing changes using Plan-Do-Study-Act (PDSA) cycles allowing adjustments of payment design. However, we recognized that other activities will not lend itself in using the PDSA cycles to accelerate improvements, and so we will use other evaluation strategies to guide improvement. Let’s move on from here to learn about the fundamentals of the Model for Improvement and testing changes on a small scale using Plan-Do-Study-Act (PDSA) cycles. ================== Reference: IHI uses the Model for Improvement as the framework to guide improvement work. The Model for Improvement,* developed by Associates in Process Improvement, is a simple, yet powerful tool for accelerating improvement. This model is not meant to replace change models that organizations may already be using, but rather to accelerate improvement.
8 Reviewing Weekly Data Data DashboardsThe cornerstone of the PDSA cycle calls for rapid adjustments to a process when a desired outcome is not achieved. To this end, a weekly analysis of the practice measures is a necessary step to assure the frequent evaluation required in the PDSA cycle.
9 Goal 1-Access Office Data DashboardThe first goal toward accessing improvements is in the Access area. Here’s an example of a data dashboard in an Excel format. The measures themselves are in the first column. And the rest of the page allows for weekly reporting over a period of time. Due to the precise nature of access goals as they relate to treating new population groups in your practice, it is recommended that your practice make this reporting an ongoing and regular part of data gathering. This information is vital to decision-making.
10 Goal 1- Access Team B The weekly data-gathering for Access Goal 1 was put to the test in a Medicaid adult dental Learning Collaborative. You can see the differing colored line on the graph represent the weekly fluctuation between patients scheduled and patients treated during a 12 week timeframe. Had the dental practices not gathered these specific data, this type of in-depth analysis would not have been possible.
11 Goal 2-Productivity Team AOne practice team’s results for the Productively Goal 2 over 12 weeks closely monitors both the number of all patients total vs. the number of Medicaid adult encounters. This analysis helped the practices in the Collaborative to gauge the number of Medicaid adult dental patients that could be seen week to week before the practice revenues began to shift. Weeks
12 Goal 2-Productivity Team BNo Show Rate These results show the “no-show” rate for one practice team in the RI Learning Collaborative. The first blue bar shows the significant number of no-show appts. among all payer types vs. for those adults with Medicaid. Having found this across all the Learning Collaborative practices, it really dis-spelled the notion that Medicaid patients fail appointments more often than non-Medicaid covered people. This was a very telling finding and one that could not have been reported if the practices had not collected weekly data.
13 Goal 3-Financial Team A WeeksThis graph looks at the total gross charges for the week against the total gross charges for RI Medicaid adult dental procedures. This weekly level of specificity allowed the practices to closely evaluate their gross charges by payer type, which allows for close monitoring to balance revenues, since Medicaid reimbursement rates are significantly lower than other payer types and office billed charges. Weeks
14 Goal 4 Quality and Treatment Team BFrom a quality perspective, it’s important to assess the types of procedures being performed on the Medicaid population in your practice. The needs of the adults can differ greatly than the need of children. Results from the RI Learning Collaborative show that diagnostic and restorative care was clearly to highest level of need for adults treated. Monitoring how this fluctuates as adults work through their treatment plans and become part of a regular system of care.
15 Assess Billing & Collection ProcessesAccounts receivable past 90 days broken out by payer type, i.e. Medicaid, commercial, and self pay Marker for how well the billing process is working Marker for whether the dental staff are consistently collecting co-pays If A/R is high in any payer type, assess entire billing process to determine sources(s) of problems determination eligibility process registration issues provider issues submission of claims management of denials One assessment your practice should conduct regularly is in your billing and collection processes. Monitoring your Accounts Receivable (A/R) for the past 90 days broken out by payer type,( i.e. Medicaid, commercial, and self pay) can be very revealing in that the results show: A marker for how well the billing process is working, and A marker for whether the dental staff are consistently collecting co-pays If A/R is high in any payer type, assess entire billing process to determine sources(s) of problems in such areas as: determination eligibility process registration issues provider issues submission of claims management of denials
16 Review Aging Report If A/R is high for self-pay/SFS patients, review systems and processes Review/create policy defining all aspects of payment Train staff Alert front desk staff that A/R past 90 days from self-pay/SFS patients is a measure used to evaluate their performance Educate patients about why payment is required at the time of the visit Develop scripting for staff to use in communicating with patients Set ceiling targets for A/R Monitor A/R regularly Provide feedback to staff Manage performance failures Another key report to monitor regularly is the practice Aging Report. This report provides timely information about account receivables. It can also be used to identify patients who receive a lower fee based on income, (sliding fee scale), and the timeliness of their payments. That is if A/R is high for self-pay/Sliding Fee Scale (SFS) patients, be sure to review office systems and processes, so that these payments catch up. Review/create policies defining all aspects of payments. Next, train all relevant staff as a performance improvement project for them. Alert front desk staff that A/R past 90 days from self-pay/SFS patients is a measure used to evaluate staff performance. Here are some strategies you can implement to improve point of service payments and decrease the number of encounters that end up on your Aging Report: Educate self-pay patients about why payment is required at the time of the visit. Develop scripting for staff to use consistent communication with patients Set ceiling targets for A/R Monitor A/R regularly Provide feedback to staff Manage performance failures
17 Assess Average Reimbursement by Payer Type13,018 total visits 30% Medicaid= 3,905 Visits Total Net Revenue for Medicaid= $700,000 Divide $700,000/3,905 visits- $ per visit Although Payer type total revenues are extremely important to monitor as systematic practice management approach, assessing the average reimbursement by Payer type is revealing as well. To calculate this, let’s look at a simple example you can use in your own practice with your own numbers: If there are 13,018 total patient visits in your practice, and 30% of them are Medicaid, This equals 3,905 Visits. Your practice’s annual Total Net Revenue for Medicaid is $700,000. Next, divide $700,000/3,905 visits and the result is $ per visit. This will be an important number when later compared to the per visit revenue for other Payer Types, as it helps in the Payer Mix analysis, which we will talk about next.
18 Monitor Payer Mix ExampleMedicaid 70% 9,157 Self-pay/Sliding Fee 20% 2,603 Commercial insurance 8% 1,041 Unreimbursed Care 2% 260 This is a simple example you can use in your practice and plug in your own numbers. It shows several categories of Dental Reimbursement mechanisms that exist and both the percentage that the category affects the practice’s revenue next to the aw number patient visits in each.
19 Assess Payer Mix and Reimbursement ExampleMedicaid $130 9157 $1,190,410 Self-pay/Sliding Fee $50 2603 $130,150 Commercial insurance $160 1,041 $156,150 Total Annual Expenses $1,764,500 Total Projected Revenue $1,476,710 + $300,000= $1,776,710 Next, as part of the same exercise, bring in the last column on this simple example above. That is the revenue (dollar amount) per Payer type to project both annual expenses in the practice and annual revenue projected. Knowing that in most cases, Medicaid will reimburse at a lower rate, this exercise will help determine the number of patients covered by Medicaid you will be able to treat, based on both the expenses and the revenue projected.
20 Study Impact of Payer Mix on SustainabilityPlease study this example of the Payer mix on the practice’s sustainability. Determining this range for your practice is a critical step. Remember, your practice’s overarching financial goal/s to either break even or to turn a profit to expand are critical cornerstones that underlie this exercise.
21 Payer Mix, Projected Visits, Actual Visits and Actual RevenueExample This sample Excel form illustrates for you the elements from your practice systems you will need to determine your projections. And then, as you monitor your actual revenue over the weeks, the analysis will reveal how the projected and the actual align. Once you determine your payer mix, you’ll be able to tell whether you are over or under your projected estimates. We will do this in the next few slides…
22 Exercise #5: Determine Your Payer MixNext, is an useful exercise that can be done to determine your practice’s Payer Mix.
23 STOP RECORDING: Determine Your Payer Mix and CollectionsPlease stop now to complete the above worksheet, using your own practice’s data and keeping in mind the overarching goals that have been set. Work through the exercise by completing the data elements. Note: This data collection and assessment process is very similar to old “peg boards dental offices have used in the past.
24 Are you over, under, or just right?Use benchmarks and clinic data to determine weekly & potential visits Total weekly dental provider hour ___ X 1.7=___ Total weekly hygienist provider hours x ___1.2=__ Total “other” provider hours ___ X 2.0= ___ Add up each providers potential visits ___ Total weekly visits ___ x 46 weeks=___ Yearly Visits Compare! Tips: Expanded function dental assistants multiply dental provider hours by 2.0 Dental students multiply by 1.0 Low on dental assistants or support staff change to 1.5 for dentists Now, let’s walk through this example together, using your practice’s real data. Please see the TIPS above if you are considering this exercise with dental students and/or expanded function dental assistants as providers, and therefore, can bill for the services they provide. First, take your Total weekly dental provider hour ___times (X) 1.7=___ Then, take your Total weekly hygienist provider hours times (X) ___1.2=__ Then take your Total “other” provider hours ___ times (X) 2.0 = ___ Add up each provider’s potential visits ___ Total weekly visits ___ times (x) 46 weeks =___ Yearly Visits Then, compare to the revenue and expense projections you calculated initially! Ask yourself this– do the results of the comparison show you are over, under or just right?
25 Manage Success Keep it simple! Use good data to measure performanceSet realistic and achievable goals Put the goals in a plan with action steps, timelines, roles, and responsibilities Create a culture that embraces change Gain buy-in, include everyone and gather feed back Set accountability Share results! Managing your practice’s success in either bringing on or enhancing Medicaid recipients and other vulnerable population groups can be done in a number of ways. Some of these are: Keep it simple! Use good data to measure performance Set realistic and achievable goals Put the goals in a plan with action steps, timelines, roles, and responsibilities Create a culture in your practice that embraces change Gain buy-in, include everyone and gather feedback Set accountability among the dental team Share your practice’s results!
26 Key Practice Data and ReportsProfit and Loss Statement Gross Charges Net Revenue Total Expenses Transaction or Productivity by Procedure Report Procedures by ADA code- scope of service # of sealants (D1351) #of completed treatments (Dummy Code) New patients (D0150) ER rate (D0140 or dummy code) Aging Report Total outstanding money owed to practice by payer type past 90 days It’s important to recognize the value of the practice’s data reporting systems as a tool to determine what data elements are most useful in measuring the goals your practice has determined. Doing so is a critical step to monitoring your success. These are some of the key practice data and reports to refer to as part of this analysis: Profit and Loss Statement Gross Charges Net Revenue Total Expenses Transaction or Productivity by Procedure Report Procedures by ADA code- scope of service # of sealants (D1351) #of completed treatments (Dummy Code) New patients (D0150) ER rate (D0140 or dummy code) Aging Report Total outstanding money owed to practice by payer type past 90 days
27 Key Practice Data and Reports (Continued)Additional Reports (vary on PMS) No-Show rate Emergency rate Unduplicated patients New Patients Number of visits Number of FTE Providers Payer Patient Mix These are some additional practice reports that do vary, depending on the practice management system your office currently uses: Review the list above…
28 Key Takeaways Capacity is based on staffing, # of operatories, and clinic hours Capacity should determine the productivity goals Not achieving maximum capacity reduces productivity and negatively impacts your dental program Program goals (both financial & productivity) should be determined using key data reports Program performance should be monitored regularly using a pro forma Please review the following takeaways to summarize the critical points in this Session: Capacity is based on staffing, # of operatories, and clinic hours Capacity should determine the productivity goals Not achieving maximum capacity reduces productivity and negatively impacts your dental program Program goals (both financial & productivity) should be determined using key data reports Program performance should be monitored regularly using a pro forma
29 Process and Outcome MeasurementTake Module 4 Post-Test Now Please Stop here to take the Post-test for this Module. Simply cut and paste the blue link above into a browser address line and the Post-test will open for you in Survey Monkey. Thanks for your participation!
30 Faculty Marty Dellapenna, RDH, MEdMs. Martha Dellapenna is the MSDA Center Director. In this role, Ms. Dellapenna provides oversight to the projects and activities of each the five divisions within the Center. She is the former Project Manager for the Rhode Island Oral Health Access Project. Ms. Dellapenna joined the RI Department of Human Services in the Center for Child and Family Health in 2003 through its project management contractor, Xerox. Ms. Dellapenna’s primary role at that time was to manage the development of RIte Smiles, the state’s first managed care dental program for young children. Ms. Dellapenna is also the current Chair of the Center for Medicare and Medicaid Services (CMS) Oral Health Technical Advisory Group.
31 Faculty Mary E. Foley, RDH, MPHMs. Mary E. Foley is the Executive Director of the Medicaid|Medicare|CHIP Services Dental Association (MSDA). Ms. Foley is a dental hygienist and holds a Masters Degree in Public Health with a concentration in Epidemiology and Biostatistics from the University of Massachusetts School of Public Health and Health Policy. Earlier in her career, she served as the Director of the Massachusetts Department of Public Health, Office of Oral Health. In this role she had oversight of state dental public health programs addressing surveillance; access; prevention; and education. Just prior to her current position, Ms. Foley served as the Dean of the Forsyth School of Dental Hygiene at the Massachusetts College of Pharmacy and Health Sciences in Boston, Massachusetts. Since joining the Medicaid|Medicare|CHIP Services Dental Association, Ms. Foley has been instrumental in broadening national stakeholder collaboration, and advancing state program policy and protocols to improve the health, health care and costs for all Medicaid programs and their beneficiaries.
32 Faculty Timothy S. Martinez, D.M.D.Timothy S. Martinez, DMD, is the Associate Dean of Community Partnerships and Access to Care at the UNE College of Dental Medicine. Dr. Martinez recently relocated to the New England area after spending six and a half years developing the community-based dental programs for Western University of Health Sciences College of Dental Medicine in Pomona, California. He served as program evaluator at the Forsyth Institute from 2010 to 2011; state dental Medicaid director at the Commonwealth of Massachusetts, Executive Office of Health and Human Services from 2006 to 2009; and dental consultant at the Office of Public Protection, Board of Registration in Dentistry, Massachusetts Department of Public Health from 2005 to Dr. Martinez also served as dental director for Harbor Health Services Inc. from 1999 to 2003 and dental director at Boston Healthcare for the Homeless from 1994 to He earned a Doctor of Dental Medicine degree from the Harvard School of Dental Medicine.