Standardized Performance Measures for Advanced Certification in Heart Failure

Transcription

1 Standardized Performance Measures for Advanced Certification in Heart Failure Karen Kolbusz, RN, BSN, MBA Associate Project Director Division of Healthcare Quality Evaluation The Joint Commission

2 Objectives Discuss the six inpatient ACHF measures and related data elements Review associated measure algorithms Provide opportunity for questions

3 Performance Measure Requirements for ACHF Effective January 1, 2014, data collection for 6 inpatient ACHF measures (mandatory) Continue data collection for HF core measures HF-2 Evaluation of LVS Function and HF-3 ACEI/ARB for LVSD (mandatory) Data collection for 7 outpatient ACHFOP measures is strongly encouraged for healthcare organizations with access to outpatient data but not required

4 ACHF Measure Specifications performance_measures/ Copyright, The Joint Commission

5 Initial ACHF Patient Population Discharges with ICD-9-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1

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8 Excluded Populations ALL ACHF Measures Patients who had a LVAD or heart transplantation procedure during the hospital stay Age < 18 years Inpatient Discharges > 120 days

9 ACHF-01 Beta-Blocker Therapy for LVSD Prescribed at Discharge Denominator: Heart failure patients with current or prior documentation of left ventricular ejection fraction (LVSD) < 40% Numerator: Patients who are prescribed bisoprolol, carvedilol, or sustained-release metoprolol succinate for LVSD at hospital discharge

10 ACHF-01 Excluded Populations Patients with Comfort Measures Only documented Patients enrolled in a Clinical Trial Patients discharged to another hospital Patients who left against medical advice Patients who expired

11 ACHF-01 Excluded Populations Patients discharged to home for hospice care Patients discharged to a healthcare facility for hospice care Patients with a documented Reason for No Bisoprolol, Carvedilol, or Sustained- Release Metoprolol Succinate Prescribed for LVSD at Discharge

12 ACHF-01 Data Elements Denominator: Admission Date Birthdate Clinical Trial Comfort Measures Only Discharge Disposition ICD-9-CM Other Procedure Codes ICD-9-CM Principal Diagnosis Code

13 ACHF-01 Data Elements Denominator: ICD-9-CM Principal Procedure Code ICD-9-CM Principal Procedure Date LVSD < 40% Reason for No Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Prescribed for LVSD at Discharge

14 ACHF-01 Data Elements Numerator: Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Prescribed for LVSD at Discharge

15 Only Acceptable Beta-Blockers Inclusion Bisoprolol Bisoprolol/fumarate Bisoprolol/HCTZ Carvedilol Carvedilol phosphate Coreg Coreg CR Metoprolol succinate Toprol-XL Zebeta Ziac Exclusion All other betablocker medications other than those listed as inclusions

16 LVSD < 40% Use the lowest ejection fraction (EF) Calculated or estimated EF is acceptable Use the worst narrative description of severity (Inclusion List A) Moderate/severe inclusion term counts Mild/moderate excluded Use narrative description without severity specified (Inclusion List B) Abnormal, compromised, decreased

17 Reason for No Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Beta-blocker allergy Second or third-degree heart block on ECG on arrival or during Other reasons documented by the physician/apn/pa or pharmacist

18 ACHF-01 Algorithm Highlights Copyright, The Joint Commission

19 ACHF-02 Post-Discharge Appointment for HF Patients Denominator: All heart failure patients discharged from a hospital inpatient setting to home or home care Numerator: Patients for whom a follow-up appointment for an office or home health visit for management of heart failure was scheduled within 7 days post-discharge and documented including location, date, and time.

20 ACHF-02 Excluded Populations Patients with Comfort Measures Only documented Patients enrolled in a Clinical Trial Patients discharged to locations other than home, home care, or law enforcement Patients with a documented Reason for No Post-Discharge Appointment Within 7 Days

21 ACHF-02 Data Elements Denominator: Admission Date Birthdate Clinical Trial Comfort Measures Only Discharge Disposition ICD-9-CM Other Procedure Codes ICD-9-CM Principal Diagnosis Code

22 ACHF-02 Data Elements Denominator: ICD-9-CM Principal Procedure Code ICD-9-CM Principal Procedure Date Reason for No Post-Discharge Appointment Within 7 Days

23 ACHF-02 Data Elements Numerator: Post-Discharge Appointment Scheduled Within 7 Days

24 Post-Discharge Appointment Scheduled Within 7 Days Follow-up appointment with a physician/apn/pa in a physician office or ambulatory care clinic that occurs within 7 days of discharge Home health visit with a RN/APN that occurs within 7 days of discharge telemedicine/teleconference to assess the patient in the home setting Appointment must include location, date, and time

25 Reason for No Post-Discharge Appointment Within 7 Days Reasons must be documented by MD/APN/PA in the context of 7 days Acceptable reasons include: Patient refusal of follow-up or refusal of an appointment scheduled within 7 days Out-of-town visitor who will follow-up with PCP in another state, region, or country Follow-up not scheduled because patient is cognitively impaired and has no caregiver available to receive details of the scheduled appointment

26 ACHF-02 Algorithm Highlights Copyright, The Joint Commission

27 ACHF-03 Care Transition Record Transmitted Denominator: All heart failure patients discharged from a hospital inpatient setting to home or home care Numerator: Care transition record transmitted to a next level of care provider within 7 days of discharge containing ALL of the following:

28 ACHF-03 Care Transition Record Transmitted Numerator: Reason for hospitalization Procedures performed during this hospitalization Treatment(s)/Service(s) provided during this hospitalization Discharge medications, including dosage and indication for use Follow-up treatment(s) and service(s) needed

29 ACHF-03 Excluded Populations Patients with Comfort Measures Only documented Patients enrolled in a Clinical Trial Patients discharged to locations other than home, home care, or law enforcement

30 ACHF-03 Data Elements Denominator: Admission Date Birthdate Clinical Trial Comfort Measures Only Discharge Disposition ICD-9-CM Other Procedure Codes ICD-9-CM Principal Diagnosis Code ICD-9-CM Principal Procedure Code ICD-9-CM Principal Procedure Date

31 ACHF-03 Data Elements Numerator: Care Transition Record Transmitted Care Transition Record-Discharge Medications Care Transition Record-Follow-Up Treatment(s) and Service(s) Needed Care Transition Record-Procedures Performed During Hospitalization Care Transition Record-Reason for Hospitalization Care Transition Record-Treatment(s)/Service(s) Provided

32 Care Transition Record Transmitted Allowable Values: 1. The medical record contains a care transition record that was transmitted to the next level of care provider no later than the seventh postdischarge day 2. The medical record contains a care transition record but was not transmitted to the next level of care provider by the seventh post discharge day 3. The medical record does not contain a care transition record, or unable to determine from medical record documentation

33 Care Transition Record Transmitted A care transition record may consist of one document or several documents The first post-discharge day is defined as the day after discharge The next level of care provider is the clinician, hospital or clinic responsible for managing the patient s heart failure after hospital discharge

34 Care Transition Record Transmitted Methods for transmitting: EMR access Fax USPS In-hospital mailbox Medical transport personnel Giving a copy of the care transition record to the patient DOES NOT comprise transmission

35 Care Transition Record- Discharge Medications All medications prescribed for the patient at discharge Includes PRN medications NOT limited to only those medications prescribed for heart failure Medication name, dosage, and indication for use Select YES if no medications were prescribed at discharge

36 Follow-Up Treatment(s) and Service(s) Needed Treatments/services after discharge: Laboratory tests and results Imaging services (MRI, PET/CT, US) Rehabilitation services (PT, OT, SLT) Respiratory treatments (O2, CPAP) Nutrition services Hospice or home care Mental health / counseling services Durable medical equipment (DME) / medical transport (Medi-car)

37 Procedures Performed During Hospitalization List of any diagnostic procedure(s), therapeutic procedure(s), or surgery(s) performed during the hospital stay Procedures described by name, ICD-9-CM Principal or Other Procedure Codes are acceptable Select YES if no procedures were performed during the hospitalization

38 Reason for Hospitalization Patient s primary diagnosis Patient s other or secondary diagnoses Documentation of the patient s chief complaint on the care transition record

39 Treatment(s)/Service(s) Provided Treatments and services provided during the hospital stay Includes documentation of tests performed during the hospital stay with results pending that will require follow-up after discharge

40 ACHF-03 Algorithm Highlights Copyright, The Joint Commission

41 ACHF-03 Algorithm Highlights Copyright, The Joint Commission

42 ACHF-04 Discussion of Advance Directives/Advance Care Planning Denominator: All heart failure patients Numerator: Patients who have documentation in the medical record of a one-time discussion of advance directives/advance care planning with a healthcare provider

43 ACHF-04 Excluded Populations Patients with Comfort Measures Only documented Patients discharged to another hospital Patients discharged to home for hospice care Patients discharged to a health care facility for hospice care Patients who expire

44 ACHF-04 Data Elements Denominator: Admission Date Birthdate Comfort Measures Only Discharge Disposition ICD-9-CM Other Procedure Codes ICD-9-CM Principal Diagnosis Code ICD-9-CM Principal Procedure Code ICD-9-CM Principal Procedure Date

45 ACHF-04 Data Elements Numerator: Discussion of Advance Directives/Advance Care Planning

46 Discussion of Advance Directives/Advance Care Planning A one-time discussion with the patient/caregiver documented anywhere in the medical record Discussion may be with a physician/apn/pa, social worker, pastoral care, or nurse

47 Discussion of Advance Directives/Advance Care Planning Select YES for discussion: Do Not Resuscitate (DNR) orders or an executed advance directive is present in the medical record Patient/family/caregiver refusal of discussion Patient s cultural beliefs are in conflict with discussion, e.g., Navajo Indian Patient did not wish/unable to name a surrogate decision maker

48 ACHF-04 Algorithm Highlights Copyright, The Joint Commission

49 ACHF-05 Advance Directive Executed Denominator: All heart failure patients Numerator: Patients who have documentation in the medical record that an advance directive was executed

50 ACHF-05 Excluded Populations Patients with Comfort Measures Only documented Patients discharged to another hospital Patients discharged to home for hospice care Patients discharged to a health care facility for hospice care Patients who expire

51 ACHF-05 Data Elements Denominator: Admission Date Birthdate Comfort Measures Only Discharge Disposition ICD-9-CM Other Procedure Codes ICD-9-CM Principal Diagnosis Code ICD-9-CM Principal Procedure Code ICD-9-CM Principal Procedure Date

52 ACHF-05 Data Elements Numerator: Advance Directive Executed

53 Advance Directive Executed Advance directive, health care proxy, living will, MOLST/POLST, power of attorney in the patient s medical record Legal document Do Not Resuscitate (DNR) orders do not count as an executed advance directive

54 ACHF-05 Algorithm Highlights Copyright, The Joint Commission

55 ACHF-06 Post-Discharge Evaluation for HF Patients Denominator: All heart failure patients discharged from a hospital inpatient setting to home or home care AND patients leaving against medical advice (AMA) Numerator: Patients who have a documented re-evaluation conducted via phone call or home visit within 72 hours after discharge

56 ACHF-06 Excluded Populations Patients with Comfort Measures Only documented Patients enrolled in a Clinical Trial Patients discharged to locations other than home, home care, or law enforcement

57 ACHF-06 Data Elements Denominator: Admission Date Birthdate Clinical Trial Comfort Measures Only Discharge Disposition ICD-9-CM Other Procedure Codes ICD-9-CM Principal Diagnosis Code ICD-9-CM Principal Procedure Code ICD-9-CM Principal Procedure Date

58 ACHF-06 Data Elements Numerator: Post-Discharge Evaluation Conducted Within 72 Hours

59 Post-Discharge Evaluation Conducted Within 72 Hours A post-discharge evaluation with patient/caregiver conducted within 72 hours (day after discharge = Day 1): telephone electronically ( ) home health evaluation office visit After 3 unsuccessful attempts, select YES.

60 ACHF-06 Algorithm Highlights Copyright, The Joint Commission

61 Direct questions to

62 Thank you Copyright, The Joint Commission