This article is sponsored by KanTime. This article is based on a Hospice News discussion with Deanna Heath, SVP of Customer Experience at KanTime, Jennifer Hannum, Director of Learning Services at KanTime, and J’non Griffin, Principal/SVP Coding and Compliance Departments at SimiTree. This discussion took place on June 13th, 2024 during the Hospice ELEVATE Conference. The article below has been edited for length and clarity.

Deanna Heath: If your frontline people don’t like your EMR and they’re not using it doesn’t matter about your back office what they like because garbage in is garbage out.

J’non Griffin: I think that’s really important going into the HOPE tool and quality measures and all of that. Just because I’ve been in home health longer than I’ve been in hospice, we learned that in home health a long time ago that garbage in and garbage out. We got paid off of the garbage that was put into the EMR and obviously we got the garbage that was out. What I would say is make sure that whatever you’re doing for your clinicians as far as here, document this because we need it for such and such regulation.

You need to be very transparent with what those regulations are and not necessarily that a lot of times clinicians think, oh, well, this is the way this agency does it because they said so when it’s actually a regulation. I think the more transparent we can be with the regulation, whether it’s a COP or it is a payment issue, those two things sometimes they’re aligned and sometimes they’re not, that is why we have to do it.

Be very transparent with that. If you want to form a committee around what is the best way to improve that documentation again.

Jennifer Hannum: Yes, and if you do form a committee, please make sure you have some of your top clinicians on the committee because that is going to help with any process that you have is to have those that are out there in the field doing the work part of the process to help fix it to make it easier for all of them as a whole. Talk to them, ask them what their pain points are, one of the top things we hear is redundancy.

Nobody wants to write things more than one time and they really shouldn’t have to if you enter one place and it needs to go to others, then it should flow to those spots automatically. That’s also going to cut down when you have those audits and surveys on inaccurate documentation because I might’ve written it one way over here and then in another section, I thought I answered it the same but maybe there’s a little bit of a difference.

I said they were on morphine 0.25 over here and over here I said 0.5. Auditors are going to catch those discrepancies and really hone in on that and then you’re going to see it in the survey and audit scores that you end up with.

Heath: Audits are not going away, TPEs are not going away, they’re just going to get worse for hospices. In my mind, teaching those clinicians to do that right up front keeps them from having to come in in the middle of the night when you’re trying to get a TPE out the door and you need to do some documentation or whatever. It’s really important to teach them to do it right up front, do it right the first time, and you won’t have those issues. They will have a better home-life balance.

Hannum: Yes, and you can’t remember either. You’re asking when these audits come in, it’s not like I did the documentation today and they’re coming tomorrow. This is months and years ago even in some cases. It’s not going to be a true accurate picture even if you try to have them correct it.

Griffin: I’m not with KanTime, I’m with SimiTree. I am EMR agnostic, but I will tell you just from audits, it’s very important that your clinicians can see everything that’s going on with the patient. I know that some EMRs, and I’m not going to call anybody out, but some EMRs, they can only see a path. That’s great, but you can’t see what the overall picture of the patient looks like.

It’s really important that they know that. We’ll talk in a minute about the HOPE tool and why it’s so important for the entire picture.

Hospice News: Jennifer, you talked about having some of the top clinicians on those implementation committees. What other stakeholders should be on those committees?

Hannum: You want to make sure that with the clinicians it is a wide variety. You want your nurses, LPNs, aides, like everyone that clinically sees patients. Also, managerial staff, those that are doing your QA audits because sometimes there’s a miscommunication between maybe what happened in an orientation with your education staff versus who’s doing the audits for your team.

Having those key decision makers in the room is important, leadership, but then making sure that those clinicians are represented as well. That way everybody’s at the same table. Everybody’s talking about the same thing, helps to clear up maybe, again, some miscommunication that might’ve happened here and there. I would just really recommend a wide variety of a solid, your best of the best folks.

Griffin: I would add one other thing to that is you may have great documenting clinicians, but they may be what I call a negative Nancy, and everything’s terrible and everything’s awful. They may be the best documenter in the world, but you don’t want those people really on your committee if they’re negative Nancys. Now, I’m not saying that they shouldn’t challenge some things, but they don’t also need to go down the trail of being maybe Debby Downer.

Hannum: Those probably shouldn’t be your preceptors either.

Griffin: Speaking from an education point of view. They probably should not.

Hospice News: Deanna, you briefly mentioned work-life balance for clinicians. Do you think that a streamlined documentation process can aid with employee retention?

Heath: Absolutely. If I work for a job starting at seven o’clock in the morning, see my first patient at 8:00, and then go home, but have to continue to document everything, then I’m going to find another job. It’s hard to find nurses now. Nurses want to come to work, they want to be able to do their job and go home. Same thing with aides, social workers, chaplains.

We don’t want to have to spend a lot of time doing extra stuff, so a streamlined documentation system will really effectively help that, especially with retention. I just moderated a session at Home Care 100, and we talked about AI in the nursing world. As a nurse, when I hear AI, I’m like, you’re taking my decision-making away from me. How dare you take my decision? A machine cannot tell me when somebody’s going to die. These machines can help along with the clinicians. Collaboration.

Hospice News: Could C-suite leadership prioritize switching to the newer, more intuitive clinician-friendly options?

Heath: I think they should. I think C-suite should look at all of that. I think it’s so important, again, to look at all of those things to see what works, what doesn’t work, what makes it easier. I’m not up here to sell an EMR, but there are EMRs that make it much more difficult and don’t give you the option to see the whole patient.

I think there’s lots of things that can help with that. There’s some great AI companies out there. Even Medical Dragon, and allowing them to be able to talk to text as opposed to sitting down on a keyboard and typing.

Hannum: Cost is always a factor, and you have to watch your bottom line. I would encourage everyone to look at what a change might cost you, but also what is your retention? What are your audit paybacks? What is all that costing you to see if, in the long run, an investment in a side program or a new EMR or whatever you feel like would help you and your clinicians, is that cost going to, in the end, actually save you a lot of money?

Hospice News: Taking a 360 view of the financial impact. How can healthcare leaders cultivate employee buy-in for quality documentation practices recognizing the importance of accurate record-keeping while addressing the potential concerns that staff may face in embracing these documentation standards?

Heath: I think involving the front-line staff is very important in getting that buy-in. I again asked a question the other day of someone at the Home Care 100. This is almost the same, of the Home Care 100 people because the agency specifically, and I think that agency’s in here. They do a lot of apps for their clinicians to help them do more and more.

I said, well, how do you get that buy-in? One of the ways they talked about getting this buy-in is to take the most senior nurse, not the negative Nancy nurse, but that nurse who trains everybody. If you can get that person to buy-in, then you can get your other staff to buy-in. It’s important to get those people that help train and are really revered in the agency to get that buy-in and you’ll get the buy-in from the other staff.

Griffin: I think we, as leaders, also need to be open to new ideas. I look around the room and nobody’s as senior as I am up here, but we tend to think, okay, this is the way we’ve done it. There may be new things out there that are better and more efficient for us in our operations than what we’ve always done. I hear that all the time and even where I work and I don’t record this and send it back to my boss or anything, but they live in the Excel world, and I’m like, okay, well, there are other programs out there.

There are other programs for clinicians out there. If we talk about AI or talk-to-text or anything like that to make their life easier. Now, if you happen to be from the deep south, like I am, you may want to make sure that talk-to-text is accurate, so some sort of review for that.

Hannum: Yes, and just, again, if you involve your clinicians in some of the decisions, you can’t involve them, not all of them, but the ones that they can have a say in, they’re going to feel heard, they’re going to feel like they are a part of this decision, they’re on board with things more than if you just show up one day and say, okay, today we’re doing this. Involve them as much as you can and really, if they come to the table with a solution that isn’t workable, maybe pass on it and just explain a little bit of why because sometimes people, too, need education.

Training, education, that continual learning is so key to getting just the basics done, and again, making sure that it’s not just a one-and-done with orientation or if you have to have 12 credits a year of education for your aides or whatever their discipline is, constant learning and education is so important. There are times, too, where even just a simple, 15-minute update before an IDT meeting can go a long way.

Have those discussions with the team. Ask for current pain points. If there’s a new rule that comes out and they’re having to learn a new documentation standard that’s happening for you, then talk to them about, okay, well, we implemented this last week. How is it working? What do we think we need to change or update or alter to then make it a successful program and a change in the way that you’re documenting?

Hospice News: What emerging trends or future requirements do you anticipate for hospice documentation?

Heath: The HOPE tool comes out. They’ll approve it. If anybody thinks they won’t approve it, I want your opinion on that because it’s coming, and it’ll be the Oasis for hospice. It’s starting out the wound questions even the exact same. I think it’s important that whatever EMR you use now, you get with those people, you get with that team, and you talk to them about what their preparations are for the HOPE tool.

The PECOS ORDF that just came out, what is your EMR going to do to make sure that physician PECOS or ORDF before they certify that patient? On top of that, June 6th, CMS released that you couldn’t list a nurse practitioner or a physician’s assistant as attending. What’s your EMR doing to make sure that you don’t get rejections for bills because you’ve listed that as an attending, and what have you told your staff about that? Have you educated them on that?

They can still pick the nurse practitioner or the PA as the attending, but it cannot be listed in the attending box on the claim. All of that stuff just came out, so what does your EMR do to combat that and how do they work with those trends that come out? Because it changes a lot lately.

Griffin: Yes, the things we know about the HOPE tool is it’s going to play more, place more emphasis on outcomes that are then publicly reported and so that may affect your referrals in the long run. Just simple things before we even have the HOPE tool. What is your documentation practices around changes in the patient status. What is that change in the patient status?

I’ve seen some records that the documentation is not very good about what that change is. Be specific about that change, pain level of four, and they have a five today. Is that considered a change in status that you’re going to have to then do an update to your HOPE tool?

Hannum: Yes, and, we’re looking at October 25 for the HOPE tool to be implemented. You need to start talking to your employees well in advance of October 25. There needs to be a strategy in place of how they’re going to need to document anything that’s changing. Again, get with your EMR. Make sure that they’re prepared for the tool when it comes out. See if you can look up mock-up screens and get those to your employees early.

Also try to put the practices in place that it’s going to take to get the HOPE tool accomplished, all that reporting and all those measures done, so that it’s not just next October that we’re all struggling because it’s going to be a massive change for every single organization in this room. If you get that information to them early, let them know what may need to be changed in their day-to-day practices and go ahead and just start getting it into place, you’re going to be in a much better place on October 25.

You don’t just show up at the softball game to play. Everybody’s got to practice ahead of time, so go ahead and just get those things in there before the game.

Heath: That ESAS, your Edmonton scale is going to be huge. If they’re a point above anything on the ESAS scale, they’re going to require a follow-up visit. Now, they haven’t said if it’s going to be a phone call or a physical visit, but go ahead and put that in practice now because that is going to be the biggest change for clinicians, is having to either call or see that patient the next day when they’re one point above.

We do it for pain now, but we don’t usually do it for nausea or depression, or those other symptoms. That’s a big thing you can start now.

Hospice News: Are there other ways that organizations can proactively prepare to meet those needs while ensuring continued excellence in care?

Heath: Again, I think it’s putting those practices in place, looking at the solutions that are out there that help them manage that better, but especially, going ahead and getting ready to be able to meet the needs of what the HOPE tool is going to require, which is the biggest thing, the biggest change for us, other than the questions that they’ve added, is going to be that follow-up visit. Whether it’s a phone or whether it’s a physical visit. They haven’t said yet, I don’t think.

Hospice News: Hospice physicians are often not mentioned when the EMR documentation burden issue comes up. Most have their own practices and need efficiency. How do you get the physicians on board with these changes or these opportunities?

Heath: I think you need something very easy for physicians to do. Something that pushes the workflow to the physician and doesn’t necessarily make them go look for it. Anything that will push that workflow out to them is important. If you and your staff are on board, you have a better likelihood of getting a physician on board. Physicians are hard.

Hannum: Yes, and really just talk to them and let them know how important their documentation is and how it can cause a denial quicker than probably almost anybody else. They really need to be part of the team. They need to be on board with it. One of the best physician practices that I ever saw was this physician who was an excellent teacher. Now, they’re not all great teachers. We know that. He was a great teacher.

In IDT meetings, as we all sat around and talked, he actively did his narrative at that point in time and then read it back to the room. That was a great practice because not only did I, as the manager, know what he was writing without having to look over his shoulder at the time to see and make sure that, yes, everything was covered. It also helped to teach the rest of the room that was in there, the social workers, the chaplains, the nurses, to see, okay, so if he wrote that down in a narrative, which is proving why they’re on hospice or why they’re getting resorted, that’s good for me to know to make sure that I’m hitting all those key bullet points that he made.

If you can get your physician’s buy-in, just let them know how important they are and that the rest of the team is really looking to them for guidance on these narratives and decision-making for eligibility, I think that’s going to go a long way.

Heath: The money factor, too. Let the physicians know how much money, when they don’t do what they’re supposed to do, it’s going to cost them. That check that they’re getting from the hospice, probably paying for the pool boy or the cabana, or the vacation. Not that it does for everybody, but that’s important. I wouldn’t have taken this job if I didn’t want to make the money.

Griffin: I’ll say one more thing, especially around physicians, is understanding the regulations and because I’m over-coding, I’m going to throw coding in there, that if your physician says the terminal diagnosis is CKD stage 3, they better have some explanation around that because I’ll just tell you, my husband’s had CKD stage 3 for about five years.

Hospice News: Can you discuss any future developments or trends in technology that hospices may leverage to further reduce this documentation?

Heath: AI, I think, is big, and I can’t say AI enough. If you had asked me three weeks ago about AI, I would have been like, no. I think there are companies that will help agencies with OASIS, and now they’re looking to get into hospice because of the HOPE and they’ll listen to a narrative and based on that narrative, they’ll fill that out for you and the nurse just has to double check it the key is getting the nurse to double check.

Then any talk to text application that’s secure helps because I would much rather talk and I can get my stuff done a lot quicker if I can talk as opposed to typing.

KanTime streamlines all aspects of your agency from beginning to end. From patient intake to scheduling, billing, and payments, our solutions allow you to do what you do best – deliver quality care to your patients. To learn more, visit: https://kantime.com/.