Clinical Admission Process

Transcription

1

2 Clinical Admission Process 1. Entering New Referrals It is always a good idea when entering a New Referral, to perform a general Patient Name search to insure the new referral was not already a hospice patient previously. See below for more information. To Search, use the patient name search field from the Classic Dashboard or access Search from Patients tab/search: Once the New Referral patient name is confirmed as new and unique to your hospice census, click Patient Tab, click on New Referral link or Create a New Patient from the Search page. 2 P a g e

3 Complete all blue-colored information areas as directed. NOTE: All blue-colored fields MUST be completed - REQUIRED. Please note that if not performing a Name Search prior to entering the New Referral, when entering a New Referral Name, if that new Patient Name matches a name previously entered and saved in your hospice database, a Duplicate Name Warning is generated. DO NOT CREATE A DUPLICATE CHART IF THE PATIENT IS FOUND TO HAVE BEEN A PATIENT IN THE PAST a re-admission would need to occur using the original chart if the patient is already saved in the hospice database. The figure below depicts the duplicate name warning received: 3 P a g e

4 Once all required fields are entered on the new Referral, Save to create a new Patient Home Page. AFTER YOU SAVE, the New Patient Homepage displays: 2. Add Contacts/Family Members Enter new Contacts/Family Members from scratch, or select Relate Existing Family from Related Links to search your database to connect an existing family member to this patient. Then return to the Patient Homepage. 4 P a g e

5 Clicking the Contact/Family Member link bring you to this page: Creating a New Family/Contact entry by clicking New Family/Referral Source link: Saved Family/Contact entry: 5 P a g e

6 Relating Existing Family/Contact: 3. Personal Information Click the Personal Information link (originally the New Referral Screen). Clicking Personal Information link displays this page: 6 P a g e

7 Clicking the Edit icon from the homepage will open the Personal Information page directly. Complete more of the Personal Information as needed, including a Code Status, if known. If Code Status is not known on referral, a message can be typed into the text field alongside the Code Status drop-down. This is the only location in the Patient chart where Code Status information can be entered. Note the addition of Primary Caregiver and Contact fields to the bottom of the page. The Family Members that were added in step 2 above will now be available in those field drop-downs and assigned as appropriate. Once the page is completed, click Update to save the program takes the user back to the Patient Homepage. 7 P a g e

8 4. Payer Information From PATIENT Homepage, click the Payer Information link and complete as directed. Create a new Payer Group to identify insurance coverage: Complete all required fields: 8 P a g e

9 After completing the Blue required fields, Save the page. A view of the Payer information will display. From Payer Group page, click the Patient Name link (Patient Home) to return to Homepage. Note on Patient Homepage following entering a Payer Group, under the Change in Care Info section, there is now an Admit Patient link available. Complete the initial Hospice Assignment below in step 5 before officially admitting the patient to the program 9 P a g e

10 5. Hospice Assignments From the PATIENT Homepage under Administration Info section, click on the Hospice Assignment link to create a new Hospice Assignment. Note the thumbs down icon indicating nothing has been entered or completed. Click the + to go directly to the Hospice Assignment creation page: Be sure to address all informational fields at the top of the form for Medical Record Number, DME, Team, Pharmacy and Funeral Home these fields will populate their information to other areas of the chart. 10 P a g e

11 Complete the assignment table below by clicking the + symbol to Add Assignees: To add Visit Frequency information, check the box to indicate that an Assignee is primary, and then add visit frequency information. Click Create when finished; if unsure of the identity of Team members, this entry can be edited later to add them. When creating the new Hospice Assignment, you will be offered the opportunity to create a Verbal Physician Order for the visit frequencies if desired. The summary page will allow review of the new entry: After reviewing the Hospice Assignment, return to the Patient Homepage. 11 P a g e

12 The Hospice Assignment visit frequency is based on the Medicare scheduling week of Sunday through Saturday; when assigning visit frequencies, keep this fact in mind to avoid scheduling staff to frequencies that cannot be met in a given week. For example, do not set a routine visit frequency of 3 times per week on a Friday. In that kind of scenario, an initial visit frequency of 1 time per week can be assigned then a new Hospice Assignment created on the following Sunday or Monday for the regular 3 times per week frequency. If interested in using the Scheduled Visits program feature, specific days and times must be set underneath the frequency area in the boxes provided. Once saved, Scheduled Visits link from the patient homepage will display a Scheduling calendar: 12 P a g e

13 Please access the Scheduling Guide under Training Tools/Reference Documents for more detailed information on this feature. 6. Admitting the Patient On the right upper portion of the PATIENT Homepage find the Change in Care / Location Admit / Discharge area. You will see an Admit Patient link; click the link to open the Admission Entry screen. 13 P a g e

14 Enter the date of admission (Effective Date), assign the admission to the appropriate Office, then click the Transfer tab to complete admit information: The New Admission entry appears as follows when successfully saved in the Patient Chart. Note the Start of Care Date and Level of Care now display alongside the patient name in the status bar: NOTE All patients admitted to the Consolo program are admitted initially to the Routine Level of Care (billing code 651). Be advised that the billing code 653 is used for the State of Indiana hospices only. For patients admitted directly to Respite, General In-Patient, etc., it is necessary to create the Admission to Routine Home Care then Transfer to Facility or the appropriate Level of Care. Therefore, all patients being admitted a Care Level other than Routine Home Care will require 2 entries in their Care Level Change summary. 14 P a g e

15 7. Clinical Indicators and Diagnoses From PATIENT Homepage, in the Administration Information section, click on Clinical Indicators and Diagnoses. Click on Create a New Indicator to add Local Common Determination of Terminal Disease and Diagnosis information. The Clinical Indicator page has 3 distinct sections: Diagnosis, ICD Coding and Co-morbid information all 3 sections must be completed. Complete Diagnosis information using dropdown menu to indicate qualifying Hospice diagnosis as described in the figure below. The list of Local Common Determination choices are based on information from the 4 national Fiscal Intermediaries per their directives. Palmetto intermediary has a new format for their LCD Guidelines and these are available in the list as PGBA choices: 15 P a g e

16 Once added, follow the directions under the LCD guideline to qualify this disease process as Terminal: If the diagnosis qualifies as Terminal status, there will be a Terminal Diagnosis descriptor alongside the diagnosis name. Indicator Date should match Start of Care date for this patient. Identify the ICD9 code by typing the diagnosis number or name in the search field; locate correct number from resulting dropdown and click. Diagnoses dates can be added if known or desired: 16 P a g e

17 Complete Treatment and Other Health Problems information, if known, to further support the diagnosis applied. Comorbids information is important to add to the Indicator if known to support the primary diagnosis and the LCD Guideline chosen to qualify the patient as Terminal. Co-morbidity choices are available in the drop-down and can be clicked to be added to this area. Text information may be added as well: Click Create and review resulting Summary page: 17 P a g e

18 8. Medications From the PATIENT Homepage under the Medication Information section, click on Medication Record link. PLEASE REFER TO THE MEDICATIONS GUIDE FOR SPECIFIC INSTRUCTIONS ON ADDING MEDICATIONS AND MED KITS TO PATIENT PROFILES UNDER TRAINING TOOLS/REFERENCE DOCUMENTS. From the patient Homepage: Under Related Links, find the Add Medication link and click to enter a medication. 18 P a g e

19 Basic instruction on entering patient medications: Type in the Medication Name in the search field Find and select the Medication Name/Dosage/Route required (Using the Quick Select link on the right will complete the Strength/Form/Route information for you) Complete Low Dose and Dosage Unit fields, checkbox information Complete the following: Ordering Physician Frequency Status / Delivery / Administered By fields An Infection Control Form will be displayed if you indicated the Medication was an Anti-infective This form should be completed Save Check the Medication Profile page for your entry information accuracy (edit if needed), then click Add Medication to add all other patient medications. Once completed, click Patient Name link to return to Homepage. A completed profile will appear as depicted below: NOTE: If ordered medication is not found in database search, complete a Create a New Medication Request to have it entered into the database by Consolo pharmacists. Medication Requests are added several times a day be advised the request approval may take some time before available for choice in Add Medications activity. 19 P a g e

20 9. CLINICAL CHARTING NURSING DOCUMENTATION Perform the patient s INITIAL NURSING VISIT DOCUMENTATION at this time. From the patient Homepage, you may click the Initial Nursing Assessment link to be taken directly to the Clinical Charting area: A Clinical Chart entry to be recognized by the program as a separate and billable Nursing Assessment AT MINIMUM is the completion of a Vital Signs Measurement section plus the addition of at least one Body Findings section. This is a necessary programming definition and not a clinical policy or recommendation. Of course, for the Comprehensive Body Assessment for new hospice patients, as much data as possible should be addressed. Each hospice should define their policies regarding what a clinician is expected to document for their specific agency to constitute an acceptable Nursing Assessment. Click the + icon to create the Admission nursing assessment. Users will access the Clinical Charting area and can add assessment sections as desired to build the admission nursing assessment. Complete the top sections to identify date of visit, discipline and user, Patient Time if applies, and Electronic Visit Verification (if used by individual hospice) when creating each Clinical Chart entry. Note that a checkmark appears by all sections when clicking into them to confirm the section is now included in the entry. 20 P a g e

21 General Clinical Chart section note the visit frequency table that displays for clinician reference; this populates from Hospice Assignments: Patient Time this section applies face to face patient time, if required or desired, to the entire Clinical Charting entry, regardless of how few or how many sections are added to the entry. Mileage and travel time to this visit are captured here as well. Clinical documentation does not occur in this section; comments box relates to information about the time entry only. Electronic Visit Verification section (optional use): 21 P a g e

22 If a section is clicked in error, to remove the checkmark from the section and subsequently from the Clinical Chart entry, click the red RESET button to clear any error data and remove the checkmark. Move on to the next desired section. Adding Clinical Chart sections Once the top sections are completed as needed, clinical charting sections to be used for the visit can be added one at a time and completed, or all desired sections added to the entry then completed. Visit the index of sections under Click to Add Section and click section choices to have the sections compile under Selected Sections as demonstrated below: 22 P a g e

23 View Button functionality: Related Links drop-down offers reference documents for Performance Scales: If Help is needed for page instruction, click the Help tab: 23 P a g e

24 No changes have been made in the assessment/observation content in each nursing-related section though the page appearance is different than in previous versions. It is not necessary to add a section and save each section by itself. Complete all chosen sections at one time in one Clinical Charting note note reminder by Save/Update button. Mini-Assessments are now part of the overall Clinical Charting Note and can be completed on Admission along with Nursing Assessment information. The following figure depicts the Mini-Nutritional Assessment: All of the current Mini-Assessments can be found in the Clinical Chart index as choices. For more detailed information on the Consolo Mini-Assessments, please refer to the 24 P a g e

25 Mini-Assessment Guide in Reference Documents. Pain Observations the old Consolo Pain Assessment is now found in the Clinical Chart index as Pain Observations. Because of the term Assessment, in the past many hospices did not desire non-nursing disciplines to use this area for scope of practice reasons. Now termed Observations, both Pain Assessments and Observations may be documented here by any discipline; the 0-10 verbal patient report scale is still used and it is possible to both identify the need of a Follow-Up Nursing Assessment and Case Manager notification: Comfortable Dying Measure program inclusion (NQF 0209) What Is the Comfortable Dying Measure? Effective October 1, 2012, all Medicare provider hospices are required to begin data collection to address this measure as authored by the National Quality Forum (NQF). To view the measure directly, visit this web address: In an effort to assist our users with this requirement, additions have been made to the program to allow documentation of the Measure particulars. The following information is a description and instruction guide of this Outcomes Measure as provided by the NHPCO: 25 P a g e

26 Comfortable Dying Measure: Comfort Within 48 Hours of Initial Assessment after Admission Measure Specifications Description: Percentage of patients who reported being uncomfortable because of pain at the initial assessment after admission to hospice services whose pain was brought to a comfortable level, as defined/reported by the patient, within 48 hours of the initial assessment. Numerator: Number of patients who reported being uncomfortable because of pain who report pain was brought to a comfortable level within 48 hours of initial assessment after admission to hospice services. Denominator: Number of patients who reported being uncomfortable because of pain at initial assessment after admission to hospice services. Steps for Measure Administration: 1. At initial assessment after admission to hospice services, prior to beginning a clinical pain assessment, the nurse will ask the question: Are you uncomfortable because of pain? 2. If the patient responds yes and meets the eligibility criteria for the measure, the patient s response is documented and the patient is included in the measure. 3. If the patient responds no the patient s response is documented, and the patient is excluded from the measure. 4. The nurse proceeds with the clinical pain assessment, initiating intervention as clinically appropriate to improve management of patient s pain, according to the policies and procedures for pain management established by the hospice. 5. From 48 to 72 hours after the initial assessment, the hospice will contact the patient and ask the question: Was your pain brought to a comfortable level within 48 hours of the start of hospice care? The patient s response is documented. 6. If no patient response is obtained within 72 hours after the initial assessment, document the reason: a) patient no longer enrolled in hospice due to death; b) patient no longer enrolled in hospice due to discharge or revocation; c) patient unable to communicate due to deterioration in condition; d) follow-up not done within 72 hours; e) other reason with explanation. Questions regarding the Measure should be directed to NHPCO or the CMS websites. 26 P a g e

27 Addressing the Measure in the Consolo Program via Pain Observation section The measure questions are being added to the Pain Observation section in Clinical Charting. Please see the following graphic: Since the measure is specific only to verbally-reporting capable patients, the questions section will only display under the Verbal Pain scale PAINAD and FLACC scale sections remain unaffected. The New Fields Uncomfortable because of pain? - a required field. This insures that all verbally-reporting patients must be asked this question by a nurse when a Pain Observation section is being completed during the initial nursing assessment. This response becomes the first data-point for the Measure calculation. Immediately upon admission, an alert will display on the classic dashboard that a Pain Observation is Needed. No date will be associated with the initial alert. The initial alert will change to a new alert based on the assessment date when the initial Pain Observation entry is created by the RN/SN. The follow-up alert will be displayed as 48 hours following the initial Pain Observation any follow-up Pain Observation completed from 48 to 72 hours will satisfy the alert. 27 P a g e

28 Once the hour entry is made, no further Pain Observation alert will display. Data collection for the measure will only occur on a Pain Observation dated on date of admission and the entry made hours following. However, this field will remain a permanent part of the Pain Observation and must be addressed on every Pain Observation or Assessment for verbal patients thereafter; any Yes answers following admission Observations outside of the Measure period should be a prompt that the patient requires active intervention and should be managed accordingly. Reason Unable to Answer This field should be used on the 48-hour follow-up Pain Observation to document a change in the patient s Verbal ability to respond to follow-up rating of pain: The list of responses can be used to document those patients unable to report on follow-up. Other can be used for anything not met by the other listed responses. If using Other as a reason, then the user should expand on that reason in the following field: Other reason Allows an explanation of the Other reason chosen in the Unable to Answer responses drop-down. No Pain at this Time A checkbox to document patients who deny pain at the time of any Observation. Pain Under Control within 48 hours of Admission This is the second data-point of the measure calculation and should be performed 48 to 72 hours following the admission Pain Observation entry. Once the admission Pain Observation has been completed, a new alert will display on the classic dashboard: As was true with the initial dashboard alert, only a Pain Observation entry dated the date of the alert will remove this 48-hour alert. Verbal follow-up, according to the measure directions, should occur hours following the initial Pain Observation (an entry made up to 72 hours will satisfy the alert). Follow-Up Reminder This is a user-controlled feature that permits the setting up of a classic dashboard reminder alert by 28 P a g e

29 specific date. It can be used at any time and its use can managed by any hospice per their clinical policies. To remove the alert, enter a Pain Observation entry dated the date of alert. Other Follow-Up Pain Observations (past hour) Pain assessment follow-up functionality is included under the Pain Observation in Clinical Charting and can be done at any time per individual Hospice policy. In the past, the program has alerted for Pain Observations according to a hour timeframe. With the addition of the Comfortable Dying Measure functionality and changes in clinical recommendations (JCAHO PC ), the alerting for follow-up is now user-controlled and can be managed by internal hospice policies. Automatic program Pain Observation dashboard alerting is now reserved for the Comfortable Dying Measure functionality. TAGGING THE INITIAL COMPREHENSIVE NURSING ASSESSMENT - the Clinical Chart entry standing for the Initial Comprehensive Body Assessment can be tagged as such by viewing that Note under Clinical Charts list, clicking Related Links menu, and clicking the Tag as Comprehensive link (if the Note is completed, don t forget to e-sign to prevent any future editing): 29 P a g e

30 From the Clinical Charts page, a small Flag icon will now display next to the Note component description as having been tagged as Comprehensive: If the Tag needs to be moved to a different Note, simply View the Note that should be tagged and click on the Tag as Comprehensive link under Related Links the Flag icon will move to the new Note. Currently, the tagging feature is only used on Initial Admissions. It is not necessary to re-tag any Notes for re-certifications or re-admissions. 30 P a g e

31 10. Hospice Plan of Care Click on the Hospice Plan of Care link from the Homepage: The thumbs up icon will display once any problem has been added to the Care Plan this should not be construed as the Plan of Care being fully complete. The icon means that enough was done in the POC to allow access to the Certification page. The Hospice Plan of Care page is where you may select Care Plan issues to be addressed for the patient and/or family. You may wish to review the Admission Care Plan template as well for intervention information by problem; the Template content is controlled by each individual hospice site. Enter the Effective Date of your Care Plan (use SOC date on admission) and select the listed Problems by Discipline desired. Select as few or as many Care Plans Problems as appropriate for care of the patient and click on Save at the bottom of the page. (Care Plans can be added to and edited at any time to add more Problems to be addressed). 31 P a g e

32 Adding a completed Plan of Care to the Certification is optional. The Care Plan Summary page will be displayed with the Care Plans listed noted with an INCOMP (for incomplete). It is always best to complete the Problems selected as soon as possible to allow other disciplines to add associated Problems after the Admission. 32 P a g e

33 To build your care plan, simply click the Care Plan Name link. A new page opens where you can complete Expected Outcomes and individual Interventions, then identify the Start Date for the Plan and add Evaluation information as desired. Once completed, click Save at the bottom of the page. The Care Plan will display and you may confirm what you just entered; from this page you can either click on Edit this Plan under Related Links to add or correct the information in the plan or you can click on View Entire Plan of Care from the above taskbar to return to the History page. You will note that INCOMP will now read as COMPL, confirming that you have addressed the care plan. Follow the above procedure and address each Problem until all of the Status headers read COMPL. 33 P a g e

34 Return to the Patient Homepage once finished. NOTE: The Care Plan area is used by the entire interdisciplinary team. The Problems available for use by the interdisciplinary staff will be populated by Care Plan Templates that are developed by your Clinical Management Team of your Hospice prior to using Consolo as a charting tool. Please refer to your Management Team if needing additional interventions added to existing Problems or Problems not available for use. 34 P a g e

35 11. Face to Face Visit If the patient has Medicare, and is entering your hospice in their third or later Benefit Period, complete a Face-to-Face Visit using the Clinical Charting link from the Patient Homepage. The availability of the Face to Face Visit documentation choice is determined by permissions set in each user Role. If this documentation choice is not seen in the Clinical Charting index, please see your office administrator. For more information, please refer to the Face to Face Guide in Training Tools/Reference Documents. 12. Miscellaneous Patient Home Care Links Please click any of the following links on the Patient Home Page, if needed: Add DME Orders by using Order Durable Medical Equipment (this data will flow to the Hospice Certification) Write necessary Physician Orders Add Custom Patient Alerts to communicate to other Team Members Document Training provided in the Teaching/Learning Assessment Document your Explanation of Services File a Complementary Alternative Medicine Add a Volunteer Request to inform the Volunteer Coordinator that the Patient and/or Family would like Volunteer Services (this will become a Dashboard Alert) Click on the Link of any of the above areas and complete the pages They are self-explanatory. When completed, click Save at the bottom of each screen. 35 P a g e

36 13. Hospice Certification Click the Hospice Certification and Plan of Treatment link from the Patient Homepage, if it is your responsibility in your facility/agency to complete the Certification. Note: The Certification should be done AFTER all of the above steps, to ensure that the Certification will capture all of the necessary information. For example, if you create the Certification BEFORE entering Medications, the Certification will NOT capture the Medications. It is best to do the Certification last. Click the link from the Homepage for the Hospice Certification and Plan of Treatment: 36 P a g e

37 Clicking the + icon will open a new Certification page, then Edit This Certification under Related Links: Verify the SOC date is entered in the Benefit Period Start Date and Certification Start Date (these dates will be different, if the patient is a Transfer). The Benefit Period and Benefit Period End date will be completed automatically based on Medicare Certification Periods Select other Certification Lengths only if needed. Complete the text fields for Orders for Clinical Disciplines and Treatments and Goals / Rehabilitation Potential / Discharge Plans. Be advised that Consolo has information already 37 P a g e

38 in these two areas as a starting point (canned text). You can delete these statements and write your own, or you can edit or add text to them as you desire. Be sure to individualize your patient s certification information to fit their particular care needs! Do not leave canned text as is for every patient! If a Medicare patient is entering hospice in their third or later Benefit Period, select the appropriate Face-to-Face Visit to attach to this Certification. Select the Initial Nursing Assessment (Comprehensive) from the Associated Nursing Assessment area. Select a Care Plan to attach to this Certification. Attaching a Care Plan is not required, but may be done if you desire. Click Update to Save the Certification. Once you click Update, you will be brought to the Certification Display page where you can review the information that you just entered; click Related Links to add, delete or correct information or apply electronic signatures. Click Certifications to see a listing of all Certifications or return to the Homepage. 38 P a g e

39 14. Hospice Aide Assignment If the patient is going to be assigned Hospice Aide Services, a Hospice Aide Assignment (or Care Plan) may be written at this time. A visit frequency for the Hospice Aide should be added in Hospice Assignments before creating the Hospice Aide Assignment and a Case Manager role assigned for the nurse professional that will be managing Supervisory Visits. See figure below for Hospice Assignment appearance when applying Hospice Aide service: Once saved, click the Hospice Aide Assignment under the Clinical Charting area from the Patient Homepage: 39 P a g e

40 Create a New Hospice Aide Assignment: Complete all required fields (blue) and check off all of the Aide Tasks you want to assign to the Hospice Aide. It is important to add the Hospice Aide visit frequency into the Hospice Assignment before creating a new Hospice Aide Assignment. Once you have selected the tasks to be assigned, click Save at the bottom of the page P a g e

41 2-3 Tasks not used or understood by specific hospices can be ignored assign only the tasks according to internal policy: The saved Hospice Aide Assignment (Care Plan) will be displayed so that the information entered may be reviewed. Under Related Links, you can choose to return to the Assignment to add, delete or correct information (Edit), go to the Hospice Aide Summary page (where your Hospice Aide can now document their visits) or simply return to the Homepage. Hospice Aides can access their Hospice Aide Visit Note in Clinical Charting + or via the Hospice Aide Assignment link as depicted below: 41 P a g e

42 GENERAL NOTE: Clicking the Help menu tab will provide a Help Screen for further guidance on the associated page. In other areas outside of Clinical Charting, clicking on the? icon in the right upper-hand corner of every page will provide instructions on the page being visited. 42 P a g e