Thank you. Sorry about that. So I will talk about these new measures and I thought what I would do was just start here.

Transcription

1 Event ID: WEBINAR: Review of the Transition Record with Specified Elements for the IPFQR Program Event Started: 4/24/2017 Please stand by for realtime captions. We will get started. Good afternoon. My name is Olivia Henze from the New England QIN-QIO and I will be the moderator today. WEBINAR: Review of the Transition Record with Specified Elements for the IPFQR Program. The quality innovation network works with healthcare providers and stakeholders in communities across New England on data driven qualities to engage patients families and improve clinical care at the community level. Thanks for joining us and before we get started just a few housekeeping items. This call will be recorded for training purposes. I will provide you with details on getting the recording at the end of the webinar. The phone will be on you for the duration of the presentation and we will take questions at the end and I will provide instructions on how you can ask a question over the phone or any time you can pose a question in the chat box. Just make sure you are sending to all participants. At this time I will pass it over to Jeanne who will get us started and introduce our presenter. Thank you. Charles Alexandre is the registered nurse for 30 years. You graduated from Rhode Island College with a BS in nursing and the University of Rhode Island with an MS in nursing administration. He completed his PhD in nursing and health policy at the University of Massachusetts Boston. He has been a staff nurse a nurse educator and nurse manager in inpatient settings in hospice and home care. He is the former state director of nurse registration in nursing education and chief of health profession regulation of the Rhode Island Department of Health and is currently the director of quality and regulation of Butler Hospital in Providence relied that Rhode Island. Doctor Alexander? Thank you. Sorry about that. So I will talk about these new measures and I thought what I would do was just start here. Thank you. So the agenda we will spend a little bit of time defining what the transition measures are and we will discuss the individual elements of the measure, and we will talk a little bit about some challenges to implementation of the measures, at least from our perspective here at Butler. It will be interesting to see what other folks have as far as challenges as well.

2 Our objectives today, at the conclusion of the presentation, we hope that you will be able to describe the requirements for the program transition record measure and define individual elements of the record measure and described a plan for implementation of the measure. So these are the two measures we will be talking about. The first is the transition record with specified elements received by discharged patients and then the second is the timely transmission of this transition record. So both of these measures were developed by the American Medical Association, and they were also both don't both we collected these data as of January 1 of this year. So the transition record with specified elements. The goal of this measure is to assess the percentage of patients discharged from an inpatient psychiatric facility or their caregivers receive a copy of this transition record at the time of discharge. That the record includes all of the specified elements. The rationale obviously is that hospital readmissions can be prevented by good strong patient education, thorough predischarge assessment, and appropriate aftercare. I will give a quick run through of the specified elements and then we can talk about them in a little more detail. They are broken up into four categories. The first is inpatient care. That the record should contain a reason for the inpatient care and a list of major procedures and tests performed during the inpatient stay and a summary of the results of those procedures and tests and principal diagnosis at discharge. The next section is post discharge and patient self-management. It should include a current medication list and it should include any studies or tests that are pending at discharge, and obviously patient instructions. On the advanced care plan should have some information on whether or not there is a advanced direct the or they decision-maker has been identified in that should be documented in the record. And if it's not documented there needs to be a reason as to why it's not documented so we can talk about that in a moment as well. Lastly, contact information and the plan for follow-up care. We need to have documentation of some sort of contact information for 24 hours seven days a week including the physician for emergencies related to the inpatient stay because it is generally the physician who discharges the patient or maintains responsibility for that patient generally until there is a follow-up appointment. That should include contact information for obtaining results of studies pending at discharge and it should include the plan for follow-up care and again, it should

3 include the name and contact information from the primary care physician or some other healthcare professional or site designated for follow-up care. So in order to make the measure all of the 11 elements have to be present. The numerator for the measure is the number of patients or their caregivers who receive the transition record and with whom a review of all the included information was documented at the time of discharge. The denominator again is all patients regardless of age discharged from the inpatient facility to home or any other side of care and there are a couple of exclusions. They include patients who have died while they were a patient, or left patient care AMA. Or patients who failed to return. Obviously precludes any kind of effect of discharge if the patient is in there. Thank you. So the first measure is the will get to the measures. The first one is timely transition and transmission of the transmit to the transmission record. Again the goal is to assess the percentage of patients discharged from the transition record was transmitted to the next level of care designated for follow-up within 24 hours of discharge. So the numerator is all of those patients from whom the transition record was transmitted with all 11 elements and within 24 hours of discharge. The denominator again is all patients regardless of age same as the previous one with the exclusions. The record may be transmitted via mail or fax or to your or it can be transmitted through the electronic health record or a hard copy of the record can be given to the personnel transporting the patient to the facility including ambulance drivers. It's important at the time that the method of transportation should be documented. It's also important that if the next level of care is within the hospital or hospital system that shares a medical record for example, it would be a patient leaving the patient unit and going to one of our partial hospital programs. Discharge plan [Indiscernible] in the record that the next provider has access to the medical record and this would count toward the measure. No problem. We will talk a little bit about each of the elements of the measure. So first we will talk about 24 hour seven day contact information. This measure requires that a healthcare team member with access to the medical record and other information related to the inpatient stay be available 24 hours seven days a week for the patient. This doesn't include 800 numbers or crisis lines or general emergency contact number in this measure so giving sort of a general number for the hospital would not work unless there was very specific information about how to contact someone specifically. At Butler we provide cut generally we provide the inpatient unit

4 number because staff, they are there 24 seven and they wouldn't have access to the information the patient would be requesting and they could contact the attending physician for them as well. Contact information and plan for follow-up care. So patients discharged at home copy 11 elements must be shared with the patients and the caregiver and for patients discharged to an inpatient facility, the record can indicate that these for specific elements can be discussed between the discharge unaccepting facility. So the 24-hour contact information for obtaining results and plan for follow-up care and primary physician can be discussed between the two facilities if the patient is not going home. So there also needs to be contact for healthcare professionals that the patient can call to receive information about studies not concluded by the time of discharge. We use the same number here that we would to contact the position. The type of studies that may be addressed could be bloodwork primarily and any radiological imaging that may have happened and that would pretty much be it for us here at Butler. We talk about advanced directives and surrogate decision-makers. The transition record should indicate whether or not there is a written signed statement that details the patient's preferences for treatment should the patient be unable to make decisions for themselves due to psychiatrically medical reasons. The statement should inform others about what treatment the patient would or would not want to receive from psychiatrists or other professional concerning both psychiatric and nonpsychiatric care. It must be compliant with state laws in which the patient receives care. The measure doesn't require that all patients have advanced directives. There must be a reason documented in the transition record if the patient does not have an advanced directive or has a surrogate decision-maker. It must provide patients with an opportunity to complete the advanced directive is nonexistent and also a copy of that does not have to be transmitted to the follow-up provided. There are a few very specific reasons why there may not be an advanced directive or why one was not provided for them. We need to document that reason to successfully complete the venture and so we would document the advanced directive or surrogate decision-maker and make sure it was discussed with the patient but the patient didn't wish to have one or wasn't able to provide an advanced directive or surrogate decision-maker. And or that document that the patient's cultural or spiritual beliefs preclude such a discussion and would be viewed as harmful to the patient and the relationship. Those are the only two acceptable reasons why there wouldn't be an advanced directive or surrogate decision-maker on the record.

5 Another element in the transition record is the current medication list. And so this list has to include prescription medication and over-the-counter medication and any herbal products. It has to include medications that are to be taken by the patient after discharge and the medications not to be taken by the patient after discharge. Under medications to be taken by the patient, it should include medications used by the patient prior to hospitalization that will be continued after discharge and it should include any new medications starting during the hospitalization and to be continued after discharge and also any newly prescribed a recommended medications to be taken after discharge. For the list of medications needs to include recommended dosage and any special instructions with consideration and the intended duration for each medication listed. They will accept a blank statement indicating that routine medication should be taken until told to stop. Medications not to be taken by the patient. These have to include everything the patient may have been on at one time like prescriptions over the product is counter herbal. These are taken before the inpatient stay in they should be discontinued or withheld after discharge. So it's a pretty extensive list of medications that we will send home with the patient. We also need to identify any major tests or procedures that may have taken place while the patient was in the hospital and we should include a summary of the results of any of those tests and procedures and they don't have to be everything or may affect the discharge in any way. So again some of those examples are mostly complete blood counts and metabolic panels and certainly that they require some sort of follow up after discharge and any radiologic imaging and certainly we would want to include ECT in that if they had it will they were here and whether or not they will continue to receive that in the outpatient basis. These are directions for the patient and caregiver to follow upon discharge. They should be appropriate for the patient and they should include the use of language services as appropriate. Again, it's medication information and activity restrictions and what to do if symptoms recur in those kind of things and we need to document somewhere in there that any sort of language service was used, either an interpreter or language line or whatever, should be documented in that record as well. We need to document the primary care physician and any healthcare professionals or site of care designated for follow-up and these can include the PCP or psychologist or psychiatrist or therapist or specialist that the patient may be seen and really any healthcare professional at all. It may be a site or health center or community health center for practice specific to the psychiatric care be measured. Again hotlines or

6 general contact numbers don't generally suffice when they want specific information on how to contact each of these. And then any plan for follow-up care. So we should be able to describe the treatment and supportive services that the patient will require optimal health according to the patient's goals and it should include contact information and dates for any follow-up appointments or any therapy or equipment needed and any outpatient resources that are available for support for self-care and instructions. So that is an overview of the measures and I would like to bend some of the time talking about how this is implemented and challenges that we have and I would like to hear any challenges that anyone in the audience would have and how you overcame that challenge and suggestions for those who are struggling. Obviously, we started this by doing an analysis and we did this over a year ago and this measure was supposed to have started last year and it got extended and postponed to January of this year. So we had to look at our electronic medical records for the required data elements. We had to map the data elements to the discharge report so we had all of these things, but certainly are patient care instructions didn't necessarily include everything that is included in this measure. One of the unique challenges, I think unique challenges to us is that we use two different electronic medical records. At Butler right now. We have used avatar for a number of years for documentation and initially we are using just the clinical documentation and our own physician orders and medication. A few years ago part of the system the rest of the system so we implemented that force POE and the electronic medication administration record. Supposition and nurses are using to records every day which complicate our implementation of this because the medication list and any tests or procedures that were done and anything else comes out of avatar so everything has to be done twice for the patient for discharge. Unfortunately at this moment the two don't speak to each other. So it doubles the documentation to be done on some level. So we dealt with that. And we began working in figuring out how we will do this. We collaborated with IT folks with our clinical and schematics people and certainly groups of nurses and physicians and social service and our health information management staff and we were all involved in the implementation of this measure because it truly affected everyone. Across the board. So our EMR, it required some revision in Avatar which is our clinical documentation records so we had to do some revisions to our discharge summaries and we had to revise or aftercare instructions to make sure we included all of the measures and elements because again not all of them were in their. And then we had to actually create a new home medication list through Cerner that included all of the different meds that will be continued and the new medicines and any stopped and any of our labs and test results. So it took, as I'm sure all of you know, months to get through that. To be honest, we are still having some struggles with this along the way.

7 We've got a fair amount of training with staff and nurses and social services and knowing what information we have them put in the record and also where they can find that information and where they can put that information to make sure it moves itself into the report at the time of discharge. And then we had to work with our health information management staff to work with them to make sure that record would get out within 24 hours. We were under the five day rule for a long time and so we had that down pat and then moved to get things out in 24 hours required a fair amount of revision to the staffing out there to their workload out there because it's 24 hours a day seven days a week so if it's 24 hours and includes weekends and holidays and we don't have a lot of discharges over the weekends but we do have some and we need to make sure we get that information out. So they were able to successfully do that and they get information out now in the high 80% range within 24 hours. I think that is pretty remarkable. I think our biggest struggles right now has to do with our electronic record. We have done all of the revisions that need to be done. Unfortunately we're having some trouble getting some of those elements to our discharge and the transmission record itself is going home with the patient and being transmitted to the next level of care our numbers are not good at the moment. So I would like to cut if we could, I would like to hear from other people questions or comments about how things went with them and how it went view. We can learn from each other and try to make this go smoothly. Thank you. If you would like to ask a question or talk over the phone you can press pound and the number 6 to unmute yourselves you can also write in the chat box as well just make sure you're sending it to all participants. This is Eric, in Bridgeport Connecticut at St. Vincent's medical center. Can everybody have a? Yes. I am on the Cerner one chart standard model that is fairly new. I don't know that there is us and Christie on it. It's a standard model. We struggle with getting all these elements since the electronic standard model. But I am not sure why because it is regulatory so we just struggle with the new Cerner model and getting stuff pushed through to meet egulatory requirements. We struggle as well. From our perspective it is regulatory and it's not like we have a choice. It seems to me it's not like Cerner is a tiny program that few hospitals are using.

8 In order to meet all the 11 elements we have to print out two different copies. We have to print out the patient clinical summary on the inpatient clinical summary and give both to the patient and the provider because we can pull all the data elements into one or the other. We have a big challenge one chart model. I am not feeling bad about having to post the reports at this point if it's happening with Cerner as well. Frustrating. How are you doing now? We are 0% compliant only because we have a few other things that aren't being completed on the transition records. Currently having the metabolic panel with the HCM LBL we have to make more specifications on that actually meet the requirements I don't think we will be making any compliance for a few months down the road. We have the duration on all the medications because there is a lot of defaulting that goes on in the one chart and it's not very intuitive. Anything that is a new prescription they have to fill in the duration but for meds they came and on it is not a required field and there's nothing for them to remember. There is no pop-up or anything. We fall out on meds that the patients come in on because on discharge there's nothing sufficient for the duration. So we did have them put that statement in that they should just take them until they are told to stop. Sort of a blanket they did say that was acceptable for we have managed to do that but like you certainly we are at 0% as well because it's just a matter of getting everything where it needs to be. It has been frustrating. It looks like we have a question in chat from Matt Doyle. We had some pushback from our providers about including the reasons for inpatient admissions and can't be a simple diagnosis. Joint counter the same thing and how did you address that? Yes we did. So what we have done is we've tried to look at different areas so we can pull some information to see the formulation and we try to look at the initial psychology evaluation that was done but from position to position and practitioner to practitioner, we didn't always want to share everything to be honest what was written there with the patient at discharge so we have asked the position and this was sort of a work around at the moment, every physician does in every attending does an assessment that day that they are in and so we have asked them on that in the first paragraph of that assessment we asked them to write a brief sentence for hospitalization and we are actually pulling that into that one paragraph into the discharge summary. So far it seems to be working fairly well. It looks like we have about three questions in the question-and-answer. Lori asked what is a patient comes in on no beds and is discharged on no medicines.

9 You do have to document that. This is in the discharge record. You have to say that there were no meds on admission or discharge. Suzanne asks what elements are you still struggling on. To be honest, our biggest problem right now is I think we have our elements there. Our IT folks are struggling in getting the reports done to get things moved into Avatar. So primarily it's that advanced directive measure element that I think is the most difficult we are having trouble with. The rest of them we have the information there and we always had troubles to be honest with specific language not having advanced directives and probably the one that is giving us the biggest trouble and we have not always put in major tests and procedures in the patient information we have given out so getting all that that is easy enough for the patient to understand has been a struggle for us as well. If the provider is in the same system and is able to use electronic record besides documenting this is the record, how do you meet the need to notify the provider's office that the patient had a recent the recent admission. We don't have a lot of providers here. Date mostly go from inpatient to partial hospital and our social service clinicians actually handle that before the patient's discharge and they actually set up that first encounter for them before they leave. Lori has a follow-up question from when a patient comes than on no meds with no discharge checking to make sure does not have to be a mad list that states no meds or can this be any discharge summary? I am not entirely sure the answer to that. It seems silly to have a medicine must with nothing on it. I would imagine as long as it's documented somewhere you would meet the measure. Lori if you would like to ask him any more questions specifically you can press the # and number six. Again, if you would like to follow up over the phone line, it is pound plus the six. This is Lori. We were struggling with that if it needed to be specifically in the transition record or documented on a medicine must because that has been a challenge and it doesn't happen a lot but it happens occasionally.

10 It tends to happen with the small adolescent unit with them. So the way our record works if there are no medicines there is no med list to print out so we would just document somewhere in that transition record that there were no medications. A few more questions. One from Suzanne. Knowing all these measures are captured on the patient discharge paperwork, has there been a negative feedback from patient and or family regarding all this detailed information? Not the information specifically. I think it's the number of pages. One of the things I found with the new med list is it also includes information about the medication so we print out the information about the medicines and we're doing that with the new meds primarily. For a number of patients we have had some of these things printouts 30+ pages so I think it's not so much they been actually happy with the information they're getting but not so happy with the amount of paper that comes along with that. Okay. It looks like we have one more question here. Barbara asks our hospital users if patient given the ABS after visit summary while the next level of care will receive a report that includes all 11 measures are pulled in both for the same and communicate with each other and the only issue we are having is if one or the other is printed before all discharge information is documented. So that is a problem. We have had that with us and that came up the other day. We had the information where the patient was discharged at 1230 in the afternoon and the secretary printed out all the paperwork and the aftercare instructions listed the appointment the patient was scheduled for in the patient didn't leave for a few hours and then the meantime the patient talk to the social worker and new a new plan was made for aftercare and the patient was actually gonna go to one of our partial hospital programs. The social worker documented that in the record but unfortunately no one knew it had changed and the patient ended up going home with partial information and it was caught later and we were trying to figure out a good way to communicate that information on the unit to make sure both had the information. Does that answer your question? Within that we were able to provide two forms one for the patient that goes on for providers enable talk to each other which is very nice. Very nice.

11 Just another quick question. Will there be a chance for an distribution list for the attendees so we can attend -- touch base with each other and ask questions and those who wish not to participate can opt out of something like that That would probably be a question for gene We will pull together all of the attendees. I know in a Massachusetts we do have inpatient and listserv along with the acute-care so I certainly have no problem pulling not together and to your point we can have people that want to opt out can let me know. Thank you. You are welcome. It looks like we have one more question from Kathy. How did you determine what are the major tests and procedures that need to be resulted in documented in the discharge record for the patient? We don't do a lot of tests here. It is primarily bloodwork. We pretty much include most of the labs. The only time patients really have any other tests or x-rays are things like that is if they have a medical problem or issue that comes up while they are here we have to send them up for evaluation and treatment so certainly anything we are pretty much including everything. Has anyone had a problem with their psychiatric advance directives and if they are recognized in their state? Well, they are not in Rhode Island that I am aware of yet. Not in New Hampshire either. This is Megan. We have the same problem. We don't have advanced psychiatric directives. Nobody is familiar with them and nobody uses them. Joanna, I didn't know if you wanted to elaborate at all. If so you can press pound and then the number six on your phone. If not that is fine as well. We got a hold of our state Atty. General. and we can't really find that it is in the statute, the Connecticut statute, and that he is not really giving us a straightforward answer on it. So we are kind of up in the air at this point with that particular element. I was just asking if anybody else was having that issue.

12 We ask if they have advanced directives. So even the medical advance directives. We do that already. I know in one of the webinars on the quality reporting site there was something about if your state doesn't recognize them, you are not obligated -- you can just I guess have it documented in the record that it's just not recognized. Actually got you would go through the same thing with a probate if they don't have them just like the advanced directives if they don't have that. The medical advanced directives. That was my question. Just wondering if anyone else had an issue with that. Rhode Island and New Hampshire are pretty straightforward and they know they are not recognized in those states. We are kind of up in the air at that point. Paula Duffy did put in chat in Rhode Island those are not allowable. We added a statement on our paperwork that stated Rhode Island can't execute psychiatric advance directives. We do have to comply with the medical advanced care plan. Okay. Thank you. We have that issue which we can put it in there like you did. Thank you very much. Charlie, have you noticed a delay in your discharge process where you can't get patients out as quickly as you did previously? Is that causing any type of backlog for you? It doesn't seem to. We have an issue going on to try to get patients out earlier in the day but to be honest it's been a chronic problem getting them out. It's hard to say if it has had much of an impact. Thank you. I have a question about timely transmission. Patients refused to have the record faxed to anyone. So I have to say that it is not transmitted. They don't even offer a solution to say that there isn't an option to say that the patient has refused to allow the information to be transmitted. There is not. That is actually a fail to measure. Right. Does anyone run into this? We run into it fairly regularly. Especially on our substance abuse unit. Right.

13 In that case we have run into that as well. In psychiatry you know you need to have a separate release to be able to send out that sensitive information. I don't see why you couldn't put the patient refused any referred them to the ER if they needed to seek immediate care and I think that would meet the measure. I don't know if it would meet the measure. I don't know that that would. We have been advised by our legal department that actually that falls under the continuum of care for the privacy act. And so you have to notify the patient especially with the new privacy regulations that were enacted in 2012 or 2013 I guess that you have to notify the patient that you are translating is transmitting information but for continuum of care of does as long as it's to the next level provider that it fits under that level of care as part of the regulation. You know purse states that that wouldn't be a HIPAA violation because I know on any of the consent forms it does say specifically that you have to consent for release of psychiatric information separately. Substance information is separate from that. Yes I was including that in the bundle. Dr. Alexandre, do you have anything else to add before we wrap up today? Another question. Back to the psychiatric advance directives One chart requires that behavioral health patients are asked if they had psychiatric advance directives so we are able to capture this information on admission. That is more of a Comment. That is when we asked them about the directives general and we do Sure that on admission as well. We would also Sure if there is a decision-maker or a guardian or something like that and we would Sure that as well. Anything else to add, Dr. Alexandre? Anyone else? Last chance for a question or comment. Thank you and it's good to hear that you are not alone going through some of these things and implementing these and what seems like a straightforward measure is much more complicated once you start working on it so it is good to hear from other people going through it.

14 I just wanted to thank Doctor Alexander for a great discussion. I had a few last-minute announcements before we and the today when you close out of this webinar the evaluation will automatically pop-up on your computer. If you can fill that out we would appreciate that. If you don't have time to fill it out right now or you are currently sharing the computer with somebody else you will receive an tomorrow morning with the linked with the evaluation as well to the link on our website. The PowerPoint presentation was in your and it's posted on a website. Within the next two business days a recording and transcript of the webinar will also be added. Thank you again to everyone and I hope everyone has a great day. Thank you Doctor. Thank you. Goodbye. [Event concluded]