Successfully Developing and Managing an Evidence-Based Approach to Agency Management Using Key Metrics. Define the current environment for

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1 Successfully Developing and Managing an Evidence-Based Approach to Agency Management Using Key Metrics A Workshop for the 2011 NAHC Financial i Management Conference Mark P. Sharp, CPA BKD, LLP Partner F. Edward Nicolas, Jr., CPA Visiting Nurse Services of Connecticut, Inc. VP/CFO Objectives Define the current environment for Medicare home health and hospice Define evidence-based management systems and practices Describe key metrics common for success Discuss methods for integrating throughout the agency July 14, 2011 NAHC Financial Management Conference 2 1

2 The Environment Medicare in general Home health and hospice profit margins Influx of new home health and hospice providers Home health and hospice compliance concerns July 14, 2011 NAHC Financial Management Conference 3 Payment Updates July 14, 2011 NAHC Financial Management Conference 4 2

3 HHA Base Rate Updates Base PPS episode rate 2010 = $2, = $2, % Decrease July 14, 2011 NAHC Financial Management Conference 5 HHA Base Rates CBSA Base Rate Increase (Decrease) $ % New York, NY $ 2, $ 2, $ (157.53) -5.5% Houston, TX 2, , (122.47) -5.3% Los Angeles, CA 2, , (124.70) -4.6% Chicago, IL 2, , (104.85) -4.3% Dallas, TX 2, , (118.53) -5.2% San Francisco, CA 3, , (199.63) -5.9% Philadelphia, PA 2, , (117.15) 15) -4.8% Detroit, MI 2, , (123.62) -5.4% Phoenix, AZ 2, , (124.92) -5.1% July 14, 2011 NAHC Financial Management Conference 6 3

4 HHA Base Rates CBSA Base Rate Increase (Decrease) $ % Gadsden, AL $ 2, $ 1, $ (288.42) -14.3% Palm Coast, FL 2, , (319.81) -14.2% Rural North Dakota 1, , (274.64) -13.8% Auburn-Opelika, AL 1, , (263.91) -13.2% Williamsport, PA 1, , (206.23) -10.6% Rural Alaska 2, , % Danville, IL 2, , % 2.5% Racine, WI 2, , % Farmington, NM 1, , % Prescott, AZ 2, , % July 14, 2011 NAHC Financial Management Conference 7 HHA Payments Beyond 2011 The home health crystal ball 2011 = 3% to 7% decrease 2012 = 2% to 4% decrease? 2013 = 1% decrease to 1.5% increase? 2014 = Flat to 1% increase? = 1% decrease to flat? July 14, 2011 NAHC Financial Management Conference 8 4

5 Hospice Payments Beyond 2011 The hospice crystal ball 2011 = 1.8% increase 2012 = 2.3% increase? = Flat to 1% increase? 2017 = 1% to 1.5% increase? U-Shaped payment model July 14, 2011 NAHC Financial Management Conference 9 July 14, 2011 NAHC Financial Management Conference 10 5

6 The Facts Sister Irene Kraus of the Daughters of Charity, St. Vincent de Paul July 14, 2011 NAHC Financial Management Conference 11 Home Health Margins 2009 National Medicare home health margin 2009 National overall home health margin July 14, 2011 NAHC Financial Management Conference 12 6

7 Home Health Margins Can your margin sustain a 3 to 8% reduction in Medicare home health revenues? July 14, 2011 NAHC Financial Management Conference 13 Hospice Margins 2009 National Medicare hospice margin 2009 National overall hospice margin July 14, 2011 NAHC Financial Management Conference 14 7

8 The Facts Payments will be reduced Expenses will increase Payments may be delayed July 14, 2011 NAHC Financial Management Conference 15 July 14, 2011 NAHC Financial Management Conference 16 8

9 Evidence-Based Management July 14, 2011 NAHC Financial Management Conference 17 Evidence-Based Management Use the current, best evidence in management tdecision-making i Roots are from evidence-based medicine Entails managerial decisions and organizational practices informed by the best available scientific evidence July 14, 2011 NAHC Financial Management Conference 18 9

10 Business Intelligence Refers to computer-based techniques used in identifying, extracting and analyzing business data Provides historical, current and predictive views of business operations July 14, 2011 NAHC Financial Management Conference 19 Business Intelligence Aims to support better business decision- making Common functions are reporting, analytics, data mining, business performance management and benchmarking July 14, 2011 NAHC Financial Management Conference 20 10

11 Dashboards Corporate definition - a part of enterprise performance management, the dashboard provides alignment, visibility and collaboration across the organization by allowing business users to define, monitor and analyze business performance via key performance indicators July 14, 2011 NAHC Financial Management Conference 21 Performance Management Step 4 Step 1 Decide Set & Act Goals Step 3 Analyze Step 2 Monitor Dashboard July 14, 2011 NAHC Financial Management Conference 22 11

12 Key Dashboard Concepts Short and concise Drill-down capabilities Keep it simple July 14, 2011 NAHC Financial Management Conference 23 Building Your Dashboard Prioritize What s most important t to you? What key data do you need in order to manage your operations? What few indicators tell you the most about your operations? Keep as simple as possible July 14, 2011 NAHC Financial Management Conference 24 12

13 Your Dashboard Primary tool in managing performance Performance status gauge Tool to guide management focus Tool for managing decision making processes & accountability July 14, 2011 NAHC Financial Management Conference 25 Measure only what you re going to manage, manage only what matters 13

14 Benchmarking Using Metrics Performance measurement tool used in conjunction with improvement initiatives to measure comparative operating performance data & identify best practices Health Care Benchmarking Association July 14, 2011 NAHC Financial Management Conference 27 Using Metrics Develop operating targets Make targets aggressive Make targets achievable Not unrealistic Involve staff to obtain buy-in Identify & implement best practices Determine what s possible Challenge traditional thinking July 14, 2011 NAHC Financial Management Conference 28 14

A Provider s Perspective July 14, 2011 NAHC Financial Management

Non-profit Agency providing home care, hospice, hi tech and

Serve 3 counties in CT through 4 branch offices and 3 weigh stations

15 A Provider s Perspective July 14, 2011 NAHC Financial Management Conference 29 VNS - Who are we? Non-profit Agency providing home care, hospice, hi tech and telehealth services Private duty services - through an affiliate Serve 3 counties in CT through 4 branch offices and 3 weigh stations $32,000,000 in total annual revenue 260,000 annual visits 500 employees July 14, 2011 NAHC Financial Management Conference 30 15

Increased accountability from internal and external sources (board, shareholders, h debt holders, etc.

16 Metrics and Performance Management This always worked in the past what happened? I see declining i volume, poor outcomes & lower profits July 14, 2011 NAHC Financial Management Conference 31 VNS Measurement Metrics Why measure? Increased accountability from internal and external sources (board, shareholders, h debt holders, etc..) Boards (especially in the nonprofit arena) are becoming more active and conscious of their fiduciary role. Pressure to perform efficiently, within budget, meet benchmarks and performance standards Must align strategies and outcomes with business procedures and practices Align with mission, strategic plan, etc.. July 14, 2011 NAHC Financial Management Conference 32 16

17 VNS Measurement Metrics Issues: Metrics often not utilized Focused on projects that distract from the big picture Lack of accountability when budgets and benchmarks are not met Difficult to measure certain activities Difficult to find benchmarks/standards d for certain activities July 14, 2011 NAHC Financial Management Conference 33 VNS Measurement Metrics Characteristics: Meaningful Is the measurement meaningful to the organization? Appropriate Does it align with key strategies? Targeted Does it address the priorities? Measurable Can it be easily measured? Effective Can you develop conclusions and actions from the results? Clear Is it clear to everyone what the measurement is and means to the organization? July 14, 2011 NAHC Financial Management Conference 34 17

18 VNS Measurement Metrics Characteristics (continued): Objective Will is produce objective results? Indicator Is the measurement predictive vs. lagging? Reliable Is the error rate acceptable? Cost Is the data cost effective to collect and report? Quality Does it measure qualitative data? July 14, 2011 NAHC Financial Management Conference 35 VNS Measurement Metrics Results: Better communication Alignment of activities with strategic plan, mission, goals Maintains focus on the priorities Maximize resources for efficient operations Increase accountability and self monitoring i July 14, 2011 NAHC Financial Management Conference 36 18

19 VNS Measurement Metrics Measurement Types: Operational: Internal and External Financial Outcomes Mission/Strategic Plan Based: Typically longer term focus Helps refine organizational direction Program based July 14, 2011 NAHC Financial Management Conference 37 VNS Measurement Metrics Operational: Referrals, admissions, i sales calls, utilization, hospice days, LOS, employee/staffing ratios, case mix, payroll checks per FTE, invoices per FTE, services scheduled per FTE, financial ratios, cash flow, etc.. Mission: More Organizational specific Geared towards mission/strategic plan Program returns, community involvement, etc.. July 14, 2011 NAHC Financial Management Conference 38 19

20 VNS Measurement Metrics What do you do with it? Utilize to compare to internal and external sources Compare to budgets Tie results to individual performance The results didn t meet expectations now what? Analyze It was just a onetime blip Really?????? Take Corrective Action Re-evaluate July 14, 2011 NAHC Financial Management Conference 39 VNS Dashboard Report comes out every Monday morning Data through previous Friday Data linked and imported through clinical and financial systems. Less than 2 hours to prepare Distribution Who needs the data to perform their job function July 14, 2011 NAHC Financial Management Conference 40 20

21 VNS - Dashboard Data Covers: Typically a rolling 8 week period Referrals by location, referral source, payor mix Impact volume, profitability, staffing Referrals tracked based on referral date and projected admit date Outstanding orders, cash flow, debt Impact cash flow, profitability, A/R, leverage Case mix, utilization projections Impact profitability, staffing resources July 14, 2011 NAHC Financial Management Conference 41 VNS Dashboard Summary Referrals by Branch 4/29 5/6 5/13 5/20 5/27 6/3 6/10 6/17 BPT OXFD TORR TRUMB Referrals by Major Payor 4/29 5/6 5/13 5/20 5/27 6/3 6/10 6/17 Ins/HMO Medicaid Medicare Total Referrals by Major Referral Source /29 5/6 5/13 5/20 5/27 6/3 6/10 6/17 Ref Source A Ref Source B Ref Source C Ref Source D Ref Source E Ref Source F July 14, 2011 NAHC Financial Management Conference 42 21

VNS Dashboard Summary Hospice Referrals by Branch Hospice Referrals by Major Payor 16 14 12 10 8 6 4 2 14 12 10 8 6 4 2 4/29 5/6 5/13 5/20 5/27 6/3 6/10 6/17 OXFD TORR TRUMB Total 0 4/29 5/6 5/13

Management Conference 43 VNS Dashboard Summary Case Mix by Branch PPS Episode Count 1.550 140 1.500 120 1.450 1.400 100 1.350 80 1.300 60 1.250 40 1.200 1.150 20 1.

22 VNS Dashboard Summary Hospice Referrals by Branch Hospice Referrals by Major Payor /29 5/6 5/13 5/20 5/27 6/3 6/10 6/17 OXFD TORR TRUMB Total 0 4/29 5/6 5/13 5/20 5/27 6/3 6/10 6/17 HMO MEDICARE HOSPICE OTHER INS Hospice Top 5 Referral Source Ref Src 1 Ref Src 2 Ref Src 3 Ref Src 4 Ref Src 5 All Others July 14, 2011 NAHC Financial Management Conference 43 VNS Dashboard Summary Case Mix by Branch PPS Episode Count Bpt Oxfd Torr Trumb Total BPT OXFD TORR TRUM Cash Receipts Refused Cases 1,200, ,000, , , , , /29 5/6 5/13 5/20 5/27 6/3 6/10 6/17 Medicare Receipts Medicaid Recepts Total AR Receipts 0 4/29 5/6 5/13 5/20 5/27 6/3 6/10 6/17 July 14, 2011 NAHC Financial Management Conference 44 22

23 VNS Dashboard Weekly Change Ref Source ADMIT 2 Week DATE 29-Apr 6-May 13-May 20-May 27-May 3-Jun 10-Jun 17-Jun TL Change REF SOURCE REF SOURCE REF SOURCE REF SOURCE REF SOURCE REF SOURCE REF SOURCE REF SOURCE REF SOURCE REF SOURCE REF SOURCE REF SOURCE (2) REF SOURCE (2) REF SOURCE (2) REF SOURCE (2) REF SOURCE (2) REF SOURCE (2) REF SOURCE (3) REF SOURCE (3) REF SOURCE (4) REF SOURCE (6) Summary ,322 5 Mdi Medicare Rf Referrals Medicare %(Adm date) 38% 46% 47% 44% 52% 54% 52% 54% 49% Insurance % (Adm date) 25% 21% 18% 26% 20% 20% 23% 20% 22% Medicaid %(Adm date) 18% 13% 12% 11% 9% 7% 11% 5% 11% No Payor Category By Referral Date--> ,290 5 Medicare Referrals Medicare %(Ref date) 43% 46% 45% 47% 53% 52% 53% 48% 48% Insurance % (Ref date) 26% 22% 19% 25% 17% 24% 21% 21% 22% Medicaid %(Ref date) 16% 8% 16% 9% 11% 7% 8% 7% 10% No Payor Category July 14, 2011 NAHC Financial Management Conference 45 VNS Dashboard Top 10 Trends 8 Week Trend - Top 10 Referral Sources (based on projected admission date): Referrals Average Ave recent Week ending ---> 29-Apr-11 6-May May May May-11 3-Jun Jun Jun-11 Prev 4 wks 4 wks Ref Source A Ref Source B Ref Source C Ref Source D Ref Source E Ref Source F Ref Source G Ref Source H Ref Source I Ref Source J All Others Total Cases Refused % refused 9% 4% 4% 6% 5% 5% 2% 8% 5% 5% July 14, 2011 NAHC Financial Management Conference 46 23

24 VNS Dashboard PPS Data Episodes Ending: End date Data Percent to Total Therapy Episodes Brnch Thpy Lvl # Eps Case Mix # Eps Case Mix # Eps Case Mix # Eps Case Mix # Eps Case Mix BPT Low % 79.0% 88.5% 97.0% 100.0% High % 10.1% 5.7% 2.0% 0.0% 20+ Over % 10.9% 5.7% 1.0% 0.0% BPT Total % 100.0% 100.0% 100.0% 100.0% OXFD Low % 84.8% 94.7% 96.7% 100.0% High % 12.7% 3.5% 3.3% 0.0% 20+ Over % 2.5% 1.8% 0.0% 0.0% OXFD Total % 100.0% 100.0% 100.0% 100.0% TORR Low % 80.2% 89.0% 94.6% 100.0% High % 12.9% 5.0% 4.3% 0.0% 20+ Over % 6.9% 6.0% 1.1% 0.0% TORR Total % 100.0% 100.0% 100.0% 100.0% TRUM Low % 83.3% 83.8% 93.0% 100.0% High % 10.8% 08% 10.8% 08% 5.6% 56% 0.0% 00% 20+ Over % 5.9% 5.4% 1.4% 0.0% TRUM Total % 100.0% 100.0% 100.0% 100.0% Grand Total Prior Week July 14, 2011 NAHC Financial Management Conference 47 VNS Dashboard PPS Data Episodes Beginning: Beg Date Data Percent to Total Therapy Episodes Brnch Thpy Lvl # Eps Case Mix # Eps Case Mix # Eps Case Mix # Eps Case Mix # Eps Case Mix BPT Low % 76.7% 85.5% 97.4% 100.0% High % 10.9% 9.1% 1.7% 0.0% 20+ Over % 12.4% 5.5% 0.9% 0.0% BPT Total % 100.0% 100.0% 100.0% 100.0% OXFD Low % 88.8% 91.1% 97.4% 100.0% High % 10.1% 6.3% 2.6% 0.0% 20+ Over % 1.1% 2.5% 0.0% 0.0% OXFD Total % 100.0% 100.0% 100.0% 100.0% TORR Low % 79.8% 83.8% 96.1% 100.0% High % 12.4% 9.4% 3.1% 0.0% 20+ Over % 7.8% 6.8% 0.8% 0.0% TORR Total % 100.0% 100.0% 100.0% 100.0% TRUM Low % 84.5% 84.5% 93.2% 100.0% High % 9.7% 10.3% 03% 5.8% 58% 0.0% 00% 20+ Over % 5.8% 5.2% 1.0% 0.0% TRUM Total % 100.0% 100.0% 100.0% 100.0% Grand Total Prior Week July 14, 2011 NAHC Financial Management Conference 48 24

25 VNS Dashboard Outcomes Data - Rolling three months reported each month DATA CHANGED JANUARY 2011 National average bench- Top 20% bench- Gold Box - VNS is at or exceeds Top 20% Nationally Green Box - VNS is at or exceeds National Average Outcomes through: mark mark 7/31/2010 / 0 8/31/2010 / 0 9/30/ /31/2010 / 0 011/30/ /31/2010 / 0 1/31/2011 / 2/28/2011 3/31/2011 / 4/30/ /31/2011 / 6/30/ How often - better at walking/ 1 moving around 47% 52% 65.0% 67.0% 64.0% 61.0% 69.0% 69.0% 70.0% 68.0% 71.0% 68.0% 69.0% 0.0% How often - better at getting in 2 and out of bed 54% 61% 52.0% 53.0% 51.0% 66.0% 64.0% 65.0% 69.0% 67.0% 68.0% 67.0% 72.0% 0.0% May 3 How often - get better at bathing 65% 72% 75.0% 72.0% 69.0% 75.0% 75.0% 75.0% 75.0% 70.0% 70.0% 69.0% 72.0% 0.0% 4 How HHTeam check for pain 96% 100% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 98.0% 97.0% 97.0% 97.0% 97.0% 0.0% 5 How HHTeam treat patient's pain 94% 100% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 99.0% 99.0% 99.0% 99.0% 98.0% 0.0% How often patient had less pain 6 when moving around 64% 73% 69.0% 67.0% 66.0% 64.0% 64.0% 64.0% 66.0% 65.0% 65.0% 64.0% 67.0% 0.0% How often HHTeam treated heart 7 failure symptoms 97% 100% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 100.0% 100.0% 98.0% 97.0% 95.0% 0.0% How often patients breathing 8 improved 60% 69% 64.0% 61.0% 60.0% 66.0% 67.0% 70.0% 74.0% 72.0% 68.0% 64.0% 70.0% 0.0% Whose wounds improved or 9 healed after an operation 80% 90% 81.0% 84.0% 82.0% 80.0% 77.0% 79.0% 84.0% 88.0% 85.0% 88.0% 86.0% 0.0% July 14, 2011 NAHC Financial Management Conference 49 VNS Cost Management Why a monthly cost report? Cost Center Management Service pricing and contract negotiations Performance evaluation globally, location, program, etc. Non-profits Grant solicitation July 14, 2011 NAHC Financial Management Conference 50 25

26 VNS Monthly Cost Analysis Total preparation time Approximately 1.5 hours per month Invest the time in building the process Report Format: Excel Access Links and data imported from Access through: Clinical System General Ledger July 14, 2011 NAHC Financial Management Conference 51 VNS Monthly Cost Analysis Medicare Methodology No Allocations based on costs, volume, personnel, etc. Input code table provides for allocation, expense type, etc..: Branch Dept Acct Description Code Exp Type Group 1 Group 2 Expense Category Acct Description nurses rn 14 Variable Dir Svc - SN Dir Svc - RN Wages nurses rn nurses uses lpn 14b Variable abe Dir Svc Sc- SN Dir Svc Sc- LPN Wages nurses uses lpn revenue services 11 Fixed Spprt - Office Spprt - Rev Wages revenue services clerical 10 Semi Var Spprt - Office Spprt - Office Wages clerical Account detail assigned in general ledger July 14, 2011 NAHC Financial Management Conference 52 26

27 VNS Monthly Cost Analysis VNS of CT, Inc - Monthly Cost Report Summary Total Cost Data; For illustrative purposes only SN PT OT ST MS HA HOSPICE May 31, 2011 TELE HEALTH NU Total All Services Total 6 Core Services Total Costs Direct 8,000,000 2,700, ,000 90, ,000 3,000,000 1,500, ,000 8,500 16,478,500 14,810,000 Clinical Other Overhead ,456, , , ,000 76, , ,000 29, ,000 2,999, ,695,000 Clinical Direct Overhead 777, ,000 58,000 9,000 41, , ,000 16,000 1,000 1,601,000 1,438,000 Therapy Overhead - 341,000 72,000 11, , , ,000 A&G Overhead 2,767, , ,000 31, ,000 1,038, ,000 55,000 3,000 5,701,000 5,124,000 Visit Data: Total Visits 98,428 33,140 7,003 1,129 5,938 95, ,071 Hospice Visits 5, ,238 5,218 12,057-1 Allocated Visits 93,000 33,000 7,000 1,100 4,700 90, ,900 Cost per Visit: Direct Cost Visits O/H Allocation Clinical Other O/H Allocation Clinical Direct O/H Allocation Therapy O/H Allocation Office Total Cost Visits Direct Cost Breakdown Variable Semi Variable Fixed Total July May 14, 26, 2011 NAHC New Financial England Home Management Care Conference 53 VNS Monthly Cost Analysis Hospice Program Cost Analysis For illustrative purposes only As of: 5/31/2011 Average Visits per Admission Net Rev Per Admission Direct Cost per Admission Direct Operating Margin Overhead Cost per Admission Net Operating Profit or (Loss) per Admission Fiscal Year to Date Admissions Net Operating Profit (Loss) by Payor Hospice Program 33.7 $ 6,364 $ 3,886 $ 2,478 $ 2,435 $ $ 16,413 Contributions 65,095 Net $ 81,508 Fiscal Year to Date Service Days Revenue Direct Cost Direct Operating Margin Net Profit (Loss) by Payor Per Day Data: Overhead Cost Contracts Free Care Patient Insurance HMO ,642 36,836 22,806 23,084 (278) Medicaid Medicaid Hospice Benefit ,084 34,175 30,909 21,416 9,493 Medicare Medicare Hospice Benefit 10,203 2,331,746 1,429, , ,517 7,197 Network Other Non Govt Other Government Public Funding Self pay ,710 2,456,473 1,500, , ,017 16,413 Per day basis Selected Per Day Detail Data: Equipment 6.76 Pharmacy Costs 7.73 Team Meetings 1.85 Physician Costs - Hospital Costs Child Bereavement Group - Ambulance Costs 0.62 Lab/Outpatient 0.01 Teen Bereavement Group - Supply Costs 1.28 Respite Care - Adult Bereavement Group 0.16 July May 14, 26, 2011 NAHC New Financial England Home Management Care Conference 54 27

28 VNS Performance by Payor Know your performance by payor Direct cost vs. fully loaded d cost Is a contract worth it if the rates fall between your direct cost and full cost? VNS: Medicare helps to support Medicaid business Insurance difficult to manage with low reimbursement rates Charity care Limits? July May 14, 26, 2011 NAHC New Financial England Home Management Care Conference 55 VNS Performance by Payor Profit and Loss Analysis by Payer Category For illustrative purposes only As of 5/31/2011 Average Visits per Admission Net Revenue Per Admission Direct Cost per Admission Direct Operating Margin Overhead Cost per Admission Net Operating Fiscal Year to Net Operating Profit or (Loss) per Admission Date Admissions Profit or (Loss) by Payor Charity/Public Fndg 11.2 $ 1,285 $ 919 $ 366 $ 586 $ (220) 15 $ (3,300) Contracts ,870 1, ,203 Insurance/HMO ,308 1, (119) 1,821 (216,699) Medicare ,085 2,118 1,967 1, ,014 1,669,756 Medicaid ,381 5,590 2,791 3,517 (726) 922 (669,372) Hospice Program ,364 3,886 2,478 2, ,413 Other Non Gov't ,121 (181) 700 (881) 9 (7,929) Network ,966 2, ,458 (704) 20 (14,080) Other Government Free Care 24.3 (1) 1,924 (1,925) 1,216 (3,141) 40 (125,640) Private pay ,934 1,624 1,310 1, ,552 Total 36.2 $ 4,164 $ 2,459 $ 1,705 $ 1,601 $ 104 6, ,904 Reconciling Items to Financial Statement Public Support 200,000 Other revenue (Int, Inv Inc, FMV Appr/Depr, Other Revenue, Retroactive Adjustments) 250,000 Other (Prior Revenue Adjustments, Retro Rate Adjustments, etc.) (84,904) Net Surplus(Deficit) per Financial Statement $ 1,050,000 July 14, 2011 NAHC Financial Management Conference 56 28

29 VNS Staffing Ratios Managing Staff: What are the right staffing levels for each department? I need more staff to run my Department!!!!!!!!!!!!!!!!!!!!! Department Managers often want more staff Need to do more with less How do you measure it? Direct Service Staff: Clinical productivity visits per day (weighted, non-weighted), paid time per visit, cases per case manager, etc. Support Staff: Clinical Managers Clinical FTEs, patient census, etc.. Scheduling patients and/or certification periods Revenue staff monthly bills, managed care patients, etc.. July 14, 2011 NAHC Financial Management Conference 57 VNS Staffing Ratios Direct Service Staff Paid time per visit RN Paid Time Per Visit - Benefited Staff RN Staffing Requirement Total work weeks Number of episodes of care 9,750 Less: Visits per episode Benefit time (6.20) Total required visits 100,425 Non-productive time (2.00) Less: Visits done by PV staff (9,000) Net productive weeks Net Visits 91,425 Visits per week Paid time per visit 1.90 Annual visits per FTE 1, Required hours 173,666 Annual FTE hours 2, Required FTE Annual visits per FTE 1, Actual FTE Paid time per visit 1.90 Variance 0.48 Calculation actually done by payor to capture For illustrative purposes only accurate episodes and utilization July 14, 2011 NAHC Financial Management Conference 58 29

30 VNS Staffing Ratios Bpt Oxfd Torr Trumb Total Clinical Services Clinical Director Clinical Manager Clinical i l Manager Weekend Clinical Manager Wknd/Afthrs HHA Supervisor Clinical Scheduling Coord Scheduler - Nursing Scheduler - HHA Weekend Support Total Clinical Services Ratios: FTE Nurses per C Mgr FTE Nurses per C Mgr&Nsg Schdlr FTE Clin Staff per C Mgr FTE Nsg/HHA per CMgr/H Spvs TL Pats Svcd per C Mgr TL Pats Svcd per CMgr/H Spvs HHA patients per Scheduler For illustrative purposes only July 14, 2011 NAHC Financial Management Conference 59 Key Home Health Metrics July 14, 2011 NAHC Financial Management Conference 60 30

31 BKD Home Health Metrics Cost reports with 2009 year ends 9,016 total agencies 7,649 (85%) freestanding, 1,367 (15%) provider-based 7,463 (83%) urban, 1,553 (17%) rural SHP Benchmark Leader peer group Identified as a 2010 SHP Benchmark Leader Quality, compliance and patient satisfaction Combined with financial success 71 total agencies 59 (83%) freestanding, 12 (17%) provider-based 61 (86%) urban, 10 (14%) rural July 14, 2011 NAHC Financial Management Conference 61 BKD Home Health Metrics OCS Elite100 peer group 93 total agencies 86 (93%) freestanding, 7 (7%) provider-based 85 (91%) urban, 8 (9%) rural July 14, 2011 NAHC Financial Management Conference 62 31

32 Net Profit Margins OCS Elite 100 All Other Median Best 25% Median Best 25% Median Best 25% Medicare (all) 27% 34% 26% 35% 13% 26% Medicare (freestanding) 29% 36% 26% 35% 15% 27% Medicare (provider-based) 7% 17% 9% 20% -6% 10% Overall (freestanding) 12% 18% 21% 28% 5% 14% July 14, 2011 NAHC Financial Management Conference 63 Medicare Payments OCS Elite 100 All Other Median Best 25% Median Best 25% Median Best 25% Payment per episode $ 3,002 $ 3,315 $ 3,287 $ 4,012 $ 2,743 $ 3,319 Case-mix weight Therapy visits per episode July 14, 2011 NAHC Financial Management Conference 64 32

33 Payment Adjustment Mix OCS Elite 100 All Other Median Best 25% Median Best 25% Median Best 25% LUPA s 7.6% 5.0% 3.8% 1.8% 6.5% 3.1% PEP s 2.1% 1.2% 1.4% 0.8% 1.8% 0.9% Outliers 0.3% 0.2% 0.2% 0.0% 0.6% 0.0% July 14, 2011 NAHC Financial Management Conference 65 Other Payment Indicators Median Best 25% OCS Elite 100 Median Best 25% All Other Median Best 25% Medicare payer mix 81% 94% 91% 99% 85% 100% Episodes per Medicare patient July 14, 2011 NAHC Financial Management Conference 66 33

34 Episode Costs Median Best 25% OCS Elite 100 Median Best 25% All Other Median Best 25% Direct costs $ 1,207 $ 1,016 $ 1,248 $ 1,005 $ 1,262 $ 1,008 Indirect agency costs , , Overhead allocations (provider-based only) Total costs 2,127 1,766 2,406 1,906 2,419 1,943 July 14, 2011 NAHC Financial Management Conference 67 Visits per Episode Median Best 25% OCS Elite 100 Median Best 25% All Other Median Best 25% Skilled nursing Physical therapy Occupational therapy Speech therapy Medical social services Home health aide Total visits July 14, 2011 NAHC Financial Management Conference 68 34

35 Cost per Visit - SN Median Best 25% OCS Elite 100 Median Best 25% All Other Median Best 25% Direct cost $ $ $ $ $ $ Indirect agency cost Overhead allocation (provider-based only) Total cost July 14, 2011 NAHC Financial Management Conference 69 Cost per Visit - PT Median Best 25% OCS Elite 100 Median Best 25% All Other Median Best 25% Direct cost $ $ $ $ $ $ Indirect agency cost Overhead allocation (provider-based only) Total cost July 14, 2011 NAHC Financial Management Conference 70 35

36 Cost per Visit - Aide Median Best 25% OCS Elite 100 Median Best 25% All Other Median Best 25% Direct cost $ $ $ $ $ $ Indirect agency cost Overhead allocation (provider-based only) Total cost July 14, 2011 NAHC Financial Management Conference 71 Productivity Median Best 25% OCS Elite 100 Median Best 25% All Other Median Best 25% A&G hours per visit Total hours per visit Hours per visit SN (nursing only) Aide (aide only) July 14, 2011 NAHC Financial Management Conference 72 36

37 Other Cost Indicators Median Best 25% OCS Elite 100 Median Best 25% All Other Median Best 25% Employee benefit % 16.1% 14.0% 14.3% 10.0% 15.1% 10.8% Labor as a % of revenue 68.4% 58.1% 58.6% 53.6% 72.9% 62.6% A&G as a % of cost 38.4% 31.3% 46.5% 35.9% 41.5% 32.3% Capital as a % of cost 3.3% 2.2% 3.5% 2.7% 3.3% 2.1% July 14, 2011 NAHC Financial Management Conference 73 Financial Indicators OCS Elite 100 All Other Median Best 25% Median Best 25% Median Best 25% Days in AR Current ratio Quick ratio Gross profit 51% 62% 61% 68% 51% 60% Return on equity 23.8% 103.6% 100.1% 294.8% 21.6% 87.5% Return on assets 21.2% 84.5% 78.6% 164.6% 15.9% 62.3% July 14, 2011 NAHC Financial Management Conference 74 37

38 Key Hospice Metrics July 14, 2011 NAHC Financial Management Conference 75 BKD Hospice Benchmarks Cost reports with 2009 year ends 2,172 total agencies All freestanding 1,670 (77%) urban, 502 (23%) rural Elite agency peer group Overall margins of 20% and greater 394 total agencies All freestanding 299 (76%) urban, 95 (24%) rural July 14, 2011 NAHC Financial Management Conference 76 38

39 Net Profit Margins Elite Agencies Median Best 25% All Others Median Best 25% Medicare 26% 35% 3% 17% Overall 28% 40% 2% 9% July 14, 2011 NAHC Financial Management Conference 77 Payments Elite Agencies Median Best 25% All Others Median Best 25% Average Medicare rate $ 140 $ 150 $ 143 $ 163 Medicare revenue per Medicare patient $12,147 $14,522 $10,584 $13,185 Average revenue per day $ 144 $ 165 $ 155 $ 188 July 14, 2011 NAHC Financial Management Conference 78 39

40 Service Mix Elite Agencies Median Best 25% All Others Median Best 25% Continuous 0.00% 0.05% 0.01% 0.15% Routine 99.53% 98.67% 99.21% 96.70% Inpatient respite 0.07% 0.22% 0.09% 0.27% General inpatient 0.14% 0.63% 0.38% 1.57% July 14, 2011 NAHC Financial Management Conference 79 Other Payment Indicators Elite Agencies Median Best 25% All Others Median Best 25% Medicare ALOS Overall ALOS Average daily census Medicare payer mix 94% 98% 92% 95% July 14, 2011 NAHC Financial Management Conference 80 40

41 Cost Per Day Elite Agencies Median Best 25% All Others Median Best 25% Direct costs $ $ $ $ Indirect agency costs Total costs July 14, 2011 NAHC Financial Management Conference 81 Direct Cost Per Day Elite Agencies Median Best 25% Nursing care $ $ Medical social services Spiritual counseling Aide and homemaker Drugs and biologicals DME and oxygen Medical supplies All Others Median Best 25% $ $ July 14, 2011 NAHC Financial Management Conference 82 41

42 Other Cost Indicators Elite Agencies Median Best 25% All Others Median Best 25% Direct labor as a % of revenue 34.5% 26.1% 39.9% 29.1% Direct nonlabor cost as a % of revenue 9.8% 4.8% 14.1% 7.4% Total labor as a % of revenue 48.9% 39.3% 62.9% 51.6% Employee benefit as a % of salaries 17.2% 12.1% 18.4% 12.9% Indirect costs as a % of revenue 25.2% 18.4% 34.3% 24.4% July 14, 2011 NAHC Financial Management Conference 83 Financial Indicators Elite 100 Median Best 25% All Others Median Best 25% Days in AR Current ratio Quick ratio Gross profit 53.5% 61.7% Return on equity 70% 155% Return on assets 61% 124% % 53.6% 12% 46% 4% 23% July 14, 2011 NAHC Financial Management Conference 84 42

43 Questions? Mark Sharp Ed Nicolas National Association for Home Care & Hospice Financial Management Conference 43

44 Attachment A

45 Visiting Nurse Services of Connecticut, Inc. Sample Weekly Dashboard Report Data provided for illustrative purposes only Report Date Week Ending June 20, 2011 June 17, 2011

46 Visiting Nurse Services of Connecticut, Inc. Referrals by Branch Through: Referrals by Major Payor June 17, /29 5/6 5/13 5/20 5/27 6/3 6/10 6/17 BPT OXFD TORR TRUMB /29 5/6 5/13 5/20 5/27 6/3 6/10 6/17 Ins/HMO Medicaid Medicare Total Referrals by Major Referral Source 4/29 5/6 5/13 5/20 5/27 6/3 6/10 6/17 Ref Source A Ref Source B Ref Source C Ref Source D Ref Source E Ref Source F Hospice Referrals by Branch Hospice Referrals by Major Payor /29 5/6 5/13 5/20 5/27 6/3 6/10 6/17 OXFD TORR TRUMB Total /29 5/6 5/13 5/20 5/27 6/3 6/10 6/17 INS HMO MEDICARE HOSPICE OTHER Hospice Top 5 Referral Source /29 5/1 5/3 5/5 5/7 5/9 5/11 5/13 5/15 5/17 5/19 5/21 5/23 5/25 5/27 5/29 5/31 6/2 6/4 6/6 6/8 6/10 6/12 6/14 6/16 Ref Src 1 Ref Src 2 Ref Src 3 Ref Src 4 Ref Src 5 All Others

Visiting Nurse Services of Connecticut, Inc. Through: June 17, 2011 Case Mix by Branch PPS Episode Count 1.550 140 1.500 120 1.450 1.400 100 1.350 80 1.300 60 1.250 1.200 1.150 40 20 1.

47 Visiting Nurse Services of Connecticut, Inc. Through: June 17, 2011 Case Mix by Branch PPS Episode Count Bpt Oxfd Torr Trumb Total BPT OXFD TORR TRUM Cash Receipts Refused Cases 1,200, ,000, , , , , /29 5/6 5/13 5/20 5/27 6/3 6/10 6/17 Medicare Receipts Medicaid Recepts Total AR Receipts 2 0 4/29 5/6 5/13 5/20 5/27 6/3 6/10 6/17 Oustanding Physician Orders > 21 Days Medicare and Medicaid Bills on Hold Current Last week 2 weeks ago 3 weeks ago Bpt Oxfd Torr Trumb 4 weeks ago5 weeks ago Current Last week 2 weeks ago 3 weeks ago Bpt Oxfd Torr Trumb 4 weeks ago5 weeks ago

48 VNS of CT, Inc. Weekly Referral Report Major Changes Last Two Weeks as of: June 20, 2011 Ref Source ADMIT DATE 29-Apr 6-May 13-May 20-May 27-May 3-Jun 10-Jun 17-Jun TL 2 Week Change REF SOURCE REF SOURCE REF SOURCE REF SOURCE REF SOURCE REF SOURCE REF SOURCE REF SOURCE REF SOURCE REF SOURCE REF SOURCE REF SOURCE (2) REF SOURCE (2) REF SOURCE (2) REF SOURCE (2) REF SOURCE (2) REF SOURCE (2) REF SOURCE (3) REF SOURCE (3) REF SOURCE (4) REF SOURCE (6) Summary ,322 5 Medicare Referrals Medicare %(Adm date) 38% 46% 47% 44% 52% 54% 52% 54% 49% Insurance % (Adm date) 25% 21% 18% 26% 20% 20% 23% 20% 22% Medicaid %(Adm date) 18% 13% 12% 11% 9% 7% 11% 5% 11% No Payor Category By Referral Date--> ,290 5 Medicare Referrals Medicare %(Ref date) 43% 46% 45% 47% 53% 52% 53% 48% 48% Insurance % (Ref date) 26% 22% 19% 25% 17% 24% 21% 21% 22% Medicaid %(Ref date) 16% 8% 16% 9% 11% 7% 8% 7% 10% No Payor Category Based on Referral Date: Ref Source A Ref Source B Ref Source C Ref Source D Refused: Refused - Capacity Refused - Ins Part

49 Attachment B

50 Visiting Nurse Services of Connecticut, Inc. Sample Dashboard Supplemental Data Data provided for illustrative purposes only

51 Visiting Nurse Services of Connecticut, Inc. Weekly Summary Date: Week Ending: Admissions May June Not Admitted Pending Admitted TL P&A Budget Not Admitted Pending Admitted TL P&A Budget Bpt Bpt Oxfd Oxfd Torr Torr Trumb Trumb Total Total Closed with 578 Projected Same Month Previous Year 633 Same Month Previous Year Week Trend - Top 10 Referral Sources (based on projected admission date): Referrals Average Ave recent Week ending ---> 29-Apr-11 6-May May May May-11 3-Jun Jun Jun-11 Prev 4 wks 4 wks Ref Source A Ref Source B Ref Source C Ref Source D Ref Source E Ref Source F Ref Source G Ref Source H Ref Source I Ref Source J All Others Total Cases Refused % refused 9% 4% 4% 6% 5% 5% 2% 8% 5% 5% Outstanding 485s: June 20, 2011 June 17, 2011 Cert Periods Beginning: 7/1/2005 Bpt Oxfd Torr Trumb Total Last Week 2 wks ago 3 wks ago 4 wks ago 5 wks ago Days Outstanding: 0-21 days Days Days Days Days > 61 Days Total Outstanding Greater than 21 Days Trending: Medicare & Medicaid Claims on Hold Trending: Bpt Oxfd Torr Trumb Total Bpt Oxfd Torr Trumb Total Current Last week weeks ago weeks ago weeks ago weeks ago Cash: 3rd Prev 2nd Prev 1st Prev Current Line of Credit Activity: Cash Balance 595, , , ,584 Balance 1,050,000 TPL cash in above 573, , , ,570 Current Cash Receipts: 29-Apr 6-May 13-May 20-May 27-May 3-Jun 10-Jun 17-Jun 4 wk Ave 8 wk Ave Medicare Receipts 563, , , , , , , , , ,555 Medicaid Recepts 408, , , , , ,082 Total AR Receipts 1,025, , , , , , , , , ,015 2,732,370 2,091,749

52 Visiting Nurse Services of Connecticut, Inc. Referrals by Program and Branch Week Ending: June 17, 2011 Based on Admission Date Program Branch 4/29/2011 5/6/2011 5/13/2011 5/20/2011 5/27/2011 6/3/2011 6/10/2011 6/17/2011 Total ADMISSION DATE: CARE OF SICK BPT CARE OF SICK OXFD CARE OF SICK TORR CARE OF SICK TRUMB Subtotal ,192 HOSPICE OXFD HOSPICE TORR HOSPICE TRUMB Subtotal Total IVCONTRACT OXFD IVCONTRACT TORR IVCONTRACT TRUMB Subtotal PALLIATIVE OXFD PALLIATIVE TORR PALLIATIVE TRUMB Subtotal PROBLEM TORR Subtotal Summary ,322 Less H Promo Net Non Hpromo ,322 REFERRAL DATE: CARE OF SICK BPT CARE OF SICK OXFD CARE OF SICK TORR CARE OF SICK TRUMB Subtotal ,173 HOSPICE OXFD HOSPICE TORR HOSPICE TRUMB Subtotal IVCONTRACT OXFD IVCONTRACT TORR IVCONTRACT TRUMB Subtotal PALLIATIVE OXFD PALLIATIVE TORR PALLIATIVE TRUMB Subtotal PROBLEM TORR Subtotal Summary ,290 Less H Promo Net Non Hpromo ,290

53 VNS of CT, Inc. Medicare Data Report Date Data as of June 20, 2011 June 17, 2011 Episodes Ending: End date Data Percent to Total Therapy Episodes Brnch Thpy Lvl # Eps Case Mix # Eps Case Mix # Eps Case Mix # Eps Case Mix # Eps Case Mix BPT Low % 79.0% 88.5% 97.0% 100.0% High % 10.1% 5.7% 2.0% 0.0% 20+ Over % 10.9% 5.7% 1.0% 0.0% BPT Total % 100.0% 100.0% 100.0% 100.0% OXFD Low % 84.8% 94.7% 96.7% 100.0% High % 12.7% 3.5% 3.3% 0.0% 20+ Over % 2.5% 1.8% 0.0% 0.0% OXFD Total % 100.0% 100.0% 100.0% 100.0% TORR Low % 80.2% 89.0% 94.6% 100.0% High % 12.9% 5.0% 4.3% 0.0% 20+ Over % 6.9% 6.0% 1.1% 0.0% TORR Total % 100.0% 100.0% 100.0% 100.0% TRUM Low % 83.3% 83.8% 93.0% 100.0% High % 10.8% 10.8% 5.6% 0.0% 20+ Over % 5.9% 5.4% 1.4% 0.0% TRUM Total % 100.0% 100.0% 100.0% 100.0% Grand Total Prior Week

54 VNS of CT, Inc. Medicare Data Report Date Data as of Episodes Beginning: Beg Date Data Percent to Total Therapy Episodes June 20, 2011 June 17, 2011 Brnch Thpy Lvl # Eps Case Mix # Eps Case Mix # Eps Case Mix # Eps Case Mix # Eps Case Mix BPT Low % 76.7% 85.5% 97.4% 100.0% High % 10.9% 9.1% 1.7% 0.0% 20+ Over % 12.4% 5.5% 0.9% 0.0% BPT Total % 100.0% 100.0% 100.0% 100.0% OXFD Low % 88.8% 91.1% 97.4% 100.0% High % 10.1% 6.3% 2.6% 0.0% 20+ Over % 1.1% 2.5% 0.0% 0.0% OXFD Total % 100.0% 100.0% 100.0% 100.0% TORR Low % 79.8% 83.8% 96.1% 100.0% High % 12.4% 9.4% 3.1% 0.0% 20+ Over % 7.8% 6.8% 0.8% 0.0% TORR Total % 100.0% 100.0% 100.0% 100.0% TRUM Low % 84.5% 84.5% 93.2% 100.0% High % 9.7% 10.3% 5.8% 0.0% 20+ Over % 5.8% 5.2% 1.0% 0.0% TRUM Total % 100.0% 100.0% 100.0% 100.0% Grand Total Prior Week

55 VNS of CT, Inc. Weekly Referral Trends by Source and Payor Through: June 20, 2011 (Based on Admission Date) Payor Category 04/29/11 05/06/11 05/13/11 05/20/11 05/27/11 06/03/11 06/10/11 06/17/11 Total 04/29/11 05/06/11 05/13/11 05/20/11 05/27/11 06/03/11 06/10/11 06/17/11 Total Agency Total Agency Total Ins/HMO % 31% 28% 34% 27% 26% 26% 26% 28% Agency Total Medicaid % 13% 12% 11% 9% 7% 11% 5% 11% Agency Total Medicare % 46% 47% 44% 52% 54% 52% 54% 49% Agency Total Medicare Hospice % 5% 7% 4% 6% 6% 5% 6% 5% Agency Total Medicaid Hospice % 1% 0% 0% 1% 1% 1% 1% 1% Agency Total Other % 5% 7% 7% 6% 7% 5% 8% 7% Total All Total , % 100% 100% 100% 100% 100% 100% 100% 100% Ref Source Ref Source 1 Ins/HMO % 30% 31% 52% 26% 33% 39% 31% 33% Ref Source 1 Medicaid % 7% 10% 7% 12% 3% 11% 4% 9% Ref Source 1 Medicare % 57% 51% 38% 48% 53% 43% 58% 47% Ref Source 1 Medicare Hospice % 0% 0% 0% 7% 3% 4% 0% 2% Ref Source 1 Other % 7% 8% 3% 7% 10% 4% 8% 8% Subtotal % 100% 100% 100% 100% 100% 100% 100% 100% Ref Source 2 Ins/HMO % 35% 38% 25% 40% 15% 42% 36% 34% Ref Source 2 Medicaid % 26% 23% 16% 13% 8% 5% 12% 14% Ref Source 2 Medicaid Hospice % 0% 0% 0% 0% 0% 5% 4% 1% Ref Source 2 Medicare % 35% 23% 38% 27% 62% 32% 36% 36% Ref Source 2 Medicare Hospice % 0% 0% 6% 7% 8% 11% 4% 5% Ref Source 2 Other % 4% 15% 16% 13% 8% 5% 8% 9% Subtotal % 100% 100% 100% 100% 100% 100% 100% 100% Ref Source 3 Ins/HMO % 0% 0% 29% 13% 25% 6% 10% 13% Ref Source 3 Medicaid % 0% 6% 0% 13% 13% 13% 0% 9% Ref Source 3 Medicare % 63% 71% 64% 67% 44% 75% 90% 65% Ref Source 3 Medicare Hospice % 38% 12% 7% 7% 19% 6% 0% 11% Ref Source 3 Other % 0% 12% 0% 0% 0% 0% 0% 2% Subtotal % 100% 100% 100% 100% 100% 100% 100% 100% Ref Source 4 Ins/HMO % 46% 38% 56% 29% 22% 30% 43% 37% Ref Source 4 Medicaid % 0% 50% 11% 14% 22% 30% 14% 19% Ref Source 4 Medicaid Hospice % 8% 0% 0% 0% 0% 0% 0% 1% Ref Source 4 Medicare % 38% 13% 22% 29% 33% 30% 36% 30% Ref Source 4 Other % 8% 0% 11% 29% 22% 10% 7% 12% Subtotal % 100% 100% 100% 100% 100% 100% 100% 100% Ref Source 5 Ins/HMO % 22% 25% 43% 33% 50% 40% 29% 31% Ref Source 5 Medicaid % 11% 0% 0% 0% 13% 0% 0% 8% Ref Source 5 Medicare % 67% 75% 43% 67% 38% 60% 43% 52% Ref Source 5 Medicare Hospice % 0% 0% 0% 0% 0% 0% 0% 2% Ref Source 5 Other % 0% 0% 14% 0% 0% 0% 29% 6% Subtotal % 100% 100% 100% 100% 100% 100% 100% 100% Ref Source 6 Ins/HMO % 80% 100% 100% 100% 80% 100% 100% 94% Ref Source 6 Other % 20% 0% 0% 0% 20% 0% 0% 6% Subtotal % 100% 100% 100% 100% 100% 100% 100% 100% Ref Source 7 Ins/HMO % 0% 0% 0% 33% 0% 0% 50% 9% Ref Source 7 Medicaid % 0% 0% 0% 0% 17% 0% 0% 5% Ref Source 7 Medicare % 100% 100% 67% 33% 67% 33% 0% 55% Ref Source 7 Other % 0% 0% 33% 33% 17% 67% 50% 32% Subtotal % 100% 100% 100% 100% 100% 100% 100% 100% Ref Source 8 Ins/HMO % 0% 0% 0% 33% 50% 0% 0% 11% Ref Source 8 Medicare % 100% 100% 100% 33% 50% 60% 100% 72%

Leadership in Home Health: Elevating Everyone s Role to Stay Afloat

Leadership in Home Health: Elevating Everyone s Role to Stay Afloat CPAs & ADVISORS experience clarity // 2014 MAHC Annual Conference Mark P. Sharp, CPA Objectives Identify how to drive accountability