The LTAC-STAC Connection: Improving Continuum of Care Through CDI

Transcription

1 The LTAC-STAC Connection: Improving Continuum of Care Through CDI Becky Slagell, BA, MHA, RHIT, CPHQ, CCDS Senior Director of Enterprise Utilization Management to Compliance Kindred Healthcare Louisville, Ky. 2 Learning Objectives Describe how to link STAC (short-term acute care) and LTAC (long-term acute care) CDI initiatives to tell each patient s story Outline process for tying in quality care metrics in real time with the CDI process Identify learning concepts that improve the safe and appropriate transition of one level of care to another I. Linking STAC and LTAC CDI Initiatives to Tell Each Patient s Story The last chapter of the STAC story helps us know where the first chapter of the LTAC story begins STAC medical record = Book 1 LTAC medical record = the sequel 3 4 For questions please contact HCPro customer service at

2 Common LTAC DRGs Often the MCC From the STAC Common LTAC DRGs (cont.) 207: Respiratory sys dx w/mv 96+ consec hrs RW SSO 26.7 GLOS : Pulmonary edema and respiratory failure RW SSO 18.3 GLOS : Septicemia or severe sepsis w/o MV 96+ consec hrs RW SSO 19.1 GLOS : Respiratory infections & inflammations w/mcc RW SSO 18.0 GLOS : Septicemia or severe sepsis with MV 96+ consec hrs RW SSO 24.7 GLOS : Skin ulcers w/mcc RW SS 21.6 GLOS : Respiratory sys DX w/mv < 96 consec hrs RW SSO 17.8 GLOS : Osteomyelitis w/mcc RW SS 25.0 GLOS : Complications of treatment w/mcc RW SSO 22.2 GLOS : Infectious & parasitic diseases with OR procedure w/mcc RW SSO 31.3 GLOS Each Character in the Book Is a Diagnosis Book One Scenario Principal diagnosis = the main character The book centers around this character In summary ( after study ), this is the individual to whom we give the most attention ( thrust of care ) Harry Potter Major comorbidities/complications = other strong characters They appear in many pages of the book and add to the complexity of the story in a major way the story would be shorter without them Ron Weasley, Hermione Granger Comorbidities/complications = characters that are further detached from the main character but do add depth to the story They are in fewer pages of the book and add dimension, but not as much time is focused on them as the major players Aunt Petunia, Dudley Patient presents in ER w/ chest pain, patient states has had indigestion for last 7 days; EKG changes noted w/elevated cardiac enzymes. Admitted and H&P documents possible AMI. Patient also anemic and malnourished. 7 8 For questions please contact HCPro customer service at

3 Book One Scenario (cont.) Book One (STAC) DRG: 233 RW=7.2292; GMLOS=11.9; AMLOS=13.4; Actual LOS=13 Days Hospital course: Confirmed as new AMI, anterior wall Comorbidities POA protein-calorie malnutrition and anemia Procedures based on conditions POA: R & L cardiac catheterization CABG to four arteries Postoperative course becomes complicated: Respiratory failure, placed on vent Purulent drainage at postop wound site Develops severe sepsis Develops decubitus ulcer to the sacrum, Stage 4 Principal diagnosis: AMI, anterior wall, first episode of care MCCs: Decubitus ulcer, Stage , (not POA) Severe sepsis, organism NOS 038.9, (not POA) Respiratory failure NOS (not POA) CCs: Protein-calorie malnutrition (POA) 9 10 Book One (STAC) DRG: 233 (cont.) Book One (STAC) DRG: 233 (cont.) Other diagnoses: Anemia (POA) Procedures: R & L cardiac catheterization CABG Insertion of endotracheal tube Mechanical ventilation > 96 consecutive hrs Query opportunities: Cause of sepsis/organism Specify skin condition at postop site Specify cause of respiratory failure For questions please contact HCPro customer service at

4 The Sequel Scenario: Day of Transition to LTAC Patient presents to LTAC as a direct transfer from the STAC Received medical record from STAC LTAC attending physician reviewed key elements: Patient assessments from clinical liaisons H&P Consultative reports Operative reports Transfer/discharge summary MAR Most recent x-ray reports Most current labs Last 4 5 days of progress notes 13 The Sequel Scenario: Day of Transition to LTAC (cont.) Patient presents with the following modalities (the whats ): Full ventilator support 3 IV antibiotics IV fluids Thrombolytic therapy Beta-blockers TPN NPWT, dressing changes 3x wk, specialty mattress Vitamin B12 Iron supplements 14 The Sequel Scenario: Day of Transition to LTAC (cont.) Recent diagnostics ( clinical dots ): Culture noted 6 days prior to LTAC admit showing presence of staph aureus from incision site Clinical findings on cxr 6 days prior to admit acute respiratory failure Blood culture negative per results 4 days prior to admit Bone MRI results pending Hgb 7.0 three days prior to admit Albumin 1.9 three days prior to admit BSs The Sequel Scenario: Day of Transition to LTAC (cont.) Present signs/symptoms as stated in LTAC H&P (more clinical dots ): Respiratory insufficiency S/p CABG Wounds Hx of sepsis, currently afebrile Malnutrition Bone exposure to the sacrum For questions please contact HCPro customer service at

5 Linking the STAC s Last Chapter to the LTAC s First Chapter For every what (treatment/procedure), there is a why (diagnosis) A what without a why is free (and perhaps inappropriate) care For every test result and symptom, there is an opportunity to query for further specificity (ICD ) We need to connect the clinical dots The Sequel (LTAC) DRG: 3 RW=4.1537; SSO=50.1; GMLOS=60.1; Actual LOS=55 Days The principal diagnosis after study : Acute postop respiratory failure MCCs: Stage 4 decubitus ulcer to the sacrum , (POA) Severe protein-calorie malnutrition 262 (POA) CCs: Postoperative wound infection (POA) Acute osteomyelitis to the sacrum (POA) The Sequel (LTAC) DRG: 3 (cont.) Other conditions: AMI, anterior wall, subsequent episode of care (POA) Anemia (POA) Procedures: Temporary percutaneous tracheostomy 31.1 Excisional debridement through the sacral bone Continuous mechanical ventilation > 96 consecutive hrs Multiple blood transfusions of PRBCs The Sequel Scenario: Day of Transition to LTAC (cont.) Query opportunities Specify severity level of anemia/ why transfusion (acute blood loss anemia CC) Blood sugars check values how high? Diabetes? Manifestations? (osteo d/t diabetes or pressure ulcer?) On steroids? For questions please contact HCPro customer service at

6 The Presence of Clinical Dots Supporting the Thrust of Care Are Time Sensitive The Presence of Clinical Dots Supporting the Thrust of Care Are Time Sensitive (cont.) PRINCIPAL REASON FOR ADMISSION DRG 5/6 LOS GLOS RW Admit for ventilator management and antibiotic therapy W/o CC or MCC W/CC W/MCC Admit for ventilator management and antibiotic therapy for stage 3 / 4 decubitus wounds W/o CC or MCC W/CC W/MCC Admit for respiratory failure on a vent (<96 hrs consec) and antibiotic therapy for stage 3 / 4 decubitus wounds W/o CC or MCC W/CC W/MCC PRINCIPAL REASON FOR ADMISSION DRG 5/6 GLOS RW LOS Admit for respiratory failure on a vent (>96 hrs consec) and antibiotic therapy for stage 3 / 4 decubitus wounds W/o CC or MCC W/CC W/MCC Admit for respiratory failure on a vent (<96 OR >96 hrs consec) and antibiotic therapy for stage 3 / 4 decubitus wounds - patient has tracheostomy W/o CC or MCC W/CC W/MCC Admit for respiratory failure on a vent (<96 OR >96 hrs consec) and antibiotic therapy for stage 3 / 4 decubitus wounds - patient undergoes excisional debridement W/o CC or MCC W/CC W/MCC II. Tying in Quality Care Metrics in Real Time With the CDI Process Interdisciplinary Team (IDT) Identifies Opportunities for Improvement With: Using an interdisciplinary approach Identifying quality care and risks in real time together Can aggregate and identify root causes for unexpected outcomes/changes in condition/untoward events The interdisciplinary team should be a beautiful orchestra just one player out of tune can destroy the music and disengage the rest of the team, causing an incomplete story and missed care Clinical/quality care processes Appropriateness Efficacy Efficiency Risk/safety management processes Reduction Prevention Documentation Specificity Accuracy Timeliness Goal/care plan identification Prioritization of goals Anticipated completion of care date Discharge barriers Internal External Team engagement Attendance Participation Preparation For questions please contact HCPro customer service at

7 IDT Focuses on Quality Care Through Coordinated Efforts WHO Comprises the IDT? Non-specificity Pneumonia - Renal insufficiency - Wounds Anemia - Malnutrition - Respiratory failure Whats without whys - IV antibiotics - Hemodialysis - IV narcotics - Multiple blood transfusions - TPN - O2 therapy Whys without whats - Aspiration pneumonia - ESRD - Stage 4 sacral decub - Acute blood loss anemia - SPKM - Acute respiratory failure Change in condition At risk for HAC - Red flag /risk for return to acute What is vs. what was Does the patient STILL need treatment for? Chief clinical officer Director of case management Director of quality management Nursing representative Infection control practitioner Pharmacist Respiratory therapist Wound care nurse Dietitian Rehab therapist WHAT Are Their Roles in IDT? WHAT Are Their Roles in IDT? (cont.) General goals for everyone Attendance & engagement Routinely attends and is on time Homework is done (Knows patient s current situation? Follow-up completed from last week?) Knows the status of last week s goals met vs. not met Knows the why behind goal not met Presents any new changes in condition positive or negative Sets new goals based on patient s progress and his/her own involvement/wishes Discusses any barriers to meeting goal Establishes completion of care dates by which to meet the goals Identifies quality care/risk prevention opportunities (it happened/it s going to happen) examples: New GI bleed why? (quality care negative outcome/change in condition) Severely contracted, noncompliant with turns, malnourished (risk for wound breakdown/hac) Has clear ownership of query opportunities in his/her area of expertise Matches the whats with the whys Prioritizes goals discussed and determined as a team Clarifies the top 3 short-term goals (for the week) Clarifies most appropriate next level of care for patient Agrees upon educational and other discharge preparation needs to ensure a safe transition to the next level of care For questions please contact HCPro customer service at

8 Together the Team Exhausts the WHYs Each discipline owns their area of expertise, queries and all example: Nursing goal : Pain management What medications is patient taking? (IV narcotics, PRN) Why is patient in pain? (wounds) Wound care nurse goal : Improve wounds Why is patient still on IV narcotics? (dressing changes painful) When is patient receiving meds? (1 hr before dressing changes) What type of wounds? Together the Team Exhausts the WHYs (cont.) Dietitian goal : Improve protein stores Why? (wound healing, protein malnutrition) Pharmacist goal : Change IV to PO meds PRN but dispensing q 4 6 hrsiv Why is patient still on IV narcotics? Rehab goal : Improve compliance refuses therapy When does patient receive therapy? (3 hrs after dressing changes) Why is patient refusing? Together the Team Exhausts the WHYs (cont.) Team discussion of patient s coordination of care Rehab noncompliance d/t pain Query opportunities regarding: Wound type Severity level of malnutrition Together the Team Exhausts the WHYs (cont.) Recommendations Revisit time of pain medication administration with rehab therapy Wound care nurse to query MD re: etiology of wounds while ensuring appropriate treatment in her area of expertise presenting the what (wound care) and clarifying the why (wound type) to ensure appropriateness and an accurate story Dietitian to query MD re: nutritional status while ensuring appropriate treatment in his area of expertise presenting the what (current diet) and clarifying the why (severity level of malnutrition) to ensure appropriateness and an accurate story For questions please contact HCPro customer service at

9 Each Discipline Is a CDI Specialist in His/Her Area of Expertise III. Improving the Safe and Appropriate Transition of Care Wound nurse to query for Performed at the bedside Worsening Stage 4 decubitus ulcer Wound debridement Procedure performed yesterday Technique: excisional Site: sacrum Instrument: scalpel Nature of tissue: nonviable Appearance & size of tissue removed: down to viable, bleeding tissue 8 cm x 10 cm Depth: down through subcutaneous tissue and through the fascia & into the muscle 33 Reduce the risk of return to the STAC by monitoring and discussing all conditions and risks in real time (IDT) How many conditions were not present on admission? How many clinical dots (signs/symptoms, whats w/o whys) are disconnected? d? How many avoidable days (inefficient and/or ineffective delivery of service/care) and what are they? *Consult delay *Delay in test results *Delay in surgery *Delay in discharge planning *Delay in ancillary service *Unrelated workup for condition *Medication omission *Delay in progressing treatment plan 34 IDT Can Perform RCAs Then Identify in Real Time Any Other Patients at Risk Who witnessed the fall? Where did it happen? Why did patient fall? What was the outcome of the patient? When/what time did it occur? How did it happen? Risks? Based on these findings, who else TODAY, IN IDT is at risk? 35 What Conditions Are the Current Focus for Readmission Penalties? Conditions measured in FY 2013: Acute myocardial infarction Heart failure Pneumonia Additional conditions measured beginning FY 2015: Chronic obstructive pulmonary disease Coronary artery bypass graft Percutaneous transluminal coronary angioplasty Other vascular conditions 36 For questions please contact HCPro customer service at

10 Collecting Data and Identifying Trends First: Did we have the information we needed from the STAC to make informed decisions in care from the very beginning? Is there a current diagnosis or history of for one of the focus readmission conditions? (AMI, CHF, pneumonia) Remember: The H&P from the STAC does not equal the H&P for the LTAC LTAC does not start over LTAC continues where the STAC left off Collecting Data and Identifying Trends Second: Do we have a clear picture of the patient s story page by page (routinely documented in progress notes)? Who is our main character? Does it remain clear? (principal dx) Who are our other major players? (MCCs) Who else can we not forget? (CCs) Any unexpected villains we need to be paying attention to? (HACs) Collecting Data and Identifying Trends Third: Is the patient safe to transition to the next level of care? Have the goals set out by the patient, family, and IDT been met? Has the patient/family been given the necessary education to safely transition to the next level of care? What are the barriers to discharge? What Have Our Data/Trends Shown Us? Documentation deficiency trends What percent showed lack of key documents from STAC at time of admission? Example: Sending patients out for new postop complication (sepsis, wound dehiscence, infection) when that is why they came to the LTAC to begin with to continue the care. Why send them back? Specific tests/procedures Lack of equipment to perform certain procedure? Lack of availability of clinician to perform procedure at specific time? For questions please contact HCPro customer service at

11 What Have Our Data/Trends Shown Us? Discharge disposition trends What percent of top DRGs discharge back to STAC or expire? Why? Instability at time of admit? Lack of/poor use of protocols (ex: weaning protocol DRGs 207, 208 sepsis DRGs 870, 871, 872) Inadequate resources to treat patient population Lack of necessary specialist? Inadequate information from STAC Unconnected clinical dots What Have Our Data/Trends Shown Us? Specific MCC/CC What MCC/CC has high rate of not present on admission? Time of day/week Weekends? Nights? Physician trends Convenience? Communication issue? When We Know the Why Discharge Dispositions We can take action to eliminate or at least reduce the risk of a poor outcome: Perform ROI on equipment needs based on send-outs Develop necessary protocols (weaning, sepsis, DVT prophylaxis, diabetic management) Improve information flow from STAC to LTAC Improve infection control practices to reduce nosocomial infections Improve OR scheduling process to reduce procedural delays Listen to the orchestra and be a part of the music Kindred LTACH Discharge Dispostions for 2012 n=61,150 Other 1.17% Expired 14.47% Other LTAC 0.89% STACH 11.19% Hospice 2.26% Lower Level Care 70.03% For questions please contact HCPro customer service at

12 Strong Clinical Documentation Initiatives Used Throughout the Continuum Result In Improving patient outcomes and discharge disposition when we do it together Thank you. Questions? Cell: / Office: In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the workbook For questions please contact HCPro customer service at