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The Afterlife: Mortality in the Post Apocalyptic World of ICD 10 Debbie Malick, RN, BSN, MBA, CNML Clinical Nurse Specialist Cone Health at Alamance Regional Medical Center Burlington, NC 1

No Really, It Is Everything 2013 Back to Life: Let SOI/ROM/PEPPER Invigorate Your CDI Program 2014 Leading the Way: Program Management for the Innovative CDI Team Vicki is moving to Las Vegas, Nevada!

1 The Afterlife: Mortality in the Post Apocalyptic World of ICD 10 Debbie Malick, RN, BSN, MBA, CNML Clinical Nurse Specialist Cone Health at Alamance Regional Medical Center Burlington, NC 1 Background for Subject Matter Vicki Davis, RN, CDS, previously presented: 2012 Documentation Is Everything! No Really, It Is Everything 2013 Back to Life: Let SOI/ROM/PEPPER Invigorate Your CDI Program 2014 Leading the Way: Program Management for the Innovative CDI Team Vicki is moving to Las Vegas, Nevada! Substitute for this year: Debbie Malick, RN, BSN, MBA, CNML 2016 The Afterlife: Mortality in the Post Apocalyptic World of ICD 10 2 Cone Health Accolades Cone Health is one of the region s largest and most comprehensive nonprofit health organizations in North Carolina (Cone Health, 2015) The organization includes six hospitals, outpatient surgery and urgent care centers, a retirement community, and greater than 75 physician practices serving six surrounding counties and accounting for more than 11,000 employees, including 1,300 providers (Cone Health, 2015) 3

Learning Objectives At the completion of this educational activity, the learner will be able to: Discuss the impact ICD 10 had on the risk of mortality Describe how the work of a CDI program can make

is Greek for a disclosure of knowledge a lifting of the veil or a revelation. In the modern world, apocalypse is commonly used to describe the so called end of the world.

2 Learning Objectives At the completion of this educational activity, the learner will be able to: Discuss the impact ICD 10 had on the risk of mortality Describe how the work of a CDI program can make or break mortality scores Define observed/expected ratio and how it is used to determine mortality scores Use provided tools to start/reenergize a CDI mortality program 4 Post Apocalypse Apocalypse is Greek for a disclosure of knowledge a lifting of the veil or a revelation. In the modern world, apocalypse is commonly used to describe the so called end of the world. ICD 10 was our apocalypse right? Or was it? ICD 10 was supposed to end the world as we know it! 5 The Cost of Dying In 2009, Medicare reported payments in excess of $50 billion for doctor and hospital bills during the last two months of patients lives. And it has been estimated that 20 to 30 percent of these medical expenditures may have had no meaningful impact. cost of dying/3/ 6

3 Life or Death for CDI Reimbursement is not enough of an incentive to gain buy in from most of the medical staff! The providers may not see the direct impact of revenue enhancement programs (CDI), so they may become apathetic about documentation! What s in it for the provider? Provider mortality score cards! CDI specialists play a key role in mortality scoring by helping the providers capture the SOI/ROM for their patients! 7 Buried Alive? Mortality score cards reflect how well the provider took care of the patient. The scores are based on all the codes submitted. Those conditions are scored and compared to patients with the same conditions that survived. YOU CAN HELP PROVIDERS PROVE THEIR PATIENT WAS HIGH RISK FOR DEATH! Documentation is everything! 8 5 Costly Ways to Die Per Medicare cost reports, the following five conditions have the highest aggregate costs and approximately double the average cost per stay: Septicemia Complication of device Respiratory failure Acute myocardial infarction Intracranial injury AHRDQ, Cost of Hospital Stays in 2010 (see hyperlink at the end of the presentation) 9

Why CDI? Mortality is a good focus for CDI Mortality reviews take CDI a step further Mortality is advanced work for CDI Mortality work is patient centered Mortality work do it because it s right Dr.

4 Why CDI? Mortality is a good focus for CDI Mortality reviews take CDI a step further Mortality is advanced work for CDI Mortality work is patient centered Mortality work do it because it s right Dr. Gold (CDI Talk Feb. 18, 2016 at 10:06 pm) 10 CDI Reviews Drive Quality Patient Care CDI review Quality patient care Accurate coding Reimbursement Hospital resource utilization 11 Back to Life Where We Started in 2012 Sample set of our data tracking Green dots = 4 Yellow dots = 3 Red dots = 1 or 2 CDS intervention definitely has an Impact! 12

Expecting More and Observing Less Mortality O/E ratio (observed/expected) is a calculated index of the facility s observed number of deaths divided by the expected number of deaths.

0 is WORSE than expected 13 Breathe Life Back Into Your Program MORTALITY REVIEWS can help breathe life back into your program 1. MDs are aware of their mortality scores! 2.

5 Expecting More and Observing Less Mortality O/E ratio (observed/expected) is a calculated index of the facility s observed number of deaths divided by the expected number of deaths. A value less than 1.0 is BETTER than expected A value greater than 1.0 is WORSE than expected 13 Breathe Life Back Into Your Program MORTALITY REVIEWS can help breathe life back into your program 1. MDs are aware of their mortality scores! 2. CC/MCC captures do affect SOI and ROM 3. SOI/ROM scores are intrinsic to calculating the DRGs as well as mortality indexes and PEPPER (audit risk) 4. CODE EVERYTHING!!!!!!!! 14 ID Risky Business Initiatives Patient Assessment Instruments/HospitalQualityInits/Measure Methodology.html 15

Models of Death So many models, so little time Risk adjusted mortality indexing is complex! Different reporting agencies use different models and methods for calculating risk!

6 Models of Death So many models, so little time Risk adjusted mortality indexing is complex! Different reporting agencies use different models and methods for calculating risk! Better to report everything! Each DRG group may have a different risk model assigned to it don t stop documenting or coding once you reach a 4/4 for SOI/ROM! Your hospital will miss out on the value of all the other diagnoses that add severity/risk to your patient! 16 Saving Lives RAISING the expected mortality and LOWERING observed mortality DECREASES the hospital s overall mortality index 17 Clinical Documentation Specialists Involvement A CDI nurse reviews all mortality cases Queries to improve documentation and SOI/ROM Looks for clinical indicators Asks for second level review when looking for higher SOI/ROM Presents cases to determine steps to improve overall care, order set recommendations, education opportunities, and enhancement or palliative care/hospice services 18

7 Death Summary Tips REVIEW THE RECORD BEFORE THE DEATH SUMMARY IS WRITTEN! LOOK FOR CONDITIONS NEED DIAGNOSIS WITH SPECIFICITY! IDENTIFY COMFORT CARE MEASURES, HOSPICE PATIENTS, END OF LIFE CARE, TERMINAL WEANS, ETC. CDIs PICK UP EVERYTHING, MAKE SURE EVERYTHING IS CODED! 19 Life Saving Measures Accurate PDX selection CC/MCC captures Complication codes Procedure codes Organ dysfunctions/failures Palliative care codes Focus reviews (all or anything 4/4) Deaths after procedures HACs & Hierarchical Condition Categories 30 day readmissions 20 Digging Up More in ICD 10 Severity of illness goes hand in hand with CDI we look for those power conditions to drive the DRG. Do the same for SOI/ROM! Specificity still matters! Body system documentation rather than symptoms help move the SOI/ROM scores, pick up abnormal labs, unresponsive (COMA!), check BMIs, cachexia, history of pneumonia, trauma, cardiac issues, malnutrition the list keeps going. Don t forget to obtain specifics about procedures (EBL, blood products, vent, surgical interventions, complications, etc.). Each diagnosis is assigned a score of 1 4 for SOI and ROM under the AP DRG model. 1 = Minor 2 = Moderate 3 = Major 4 = Extreme Multiple CCs and MCCs are usually needed to increase SOI/ROM scores; however, other conditions associated with the Pdx can drive risk adjusted scores. In this case, sweat the small stuff. DNRs/comfort care measures are important! Review short stay cases multiple CC/MCCs are less likely to be documented on patients that were only with in house 1 2 days. 21

8 What Is Next? Mortality Reduction Steering Committee Membership: Chief of medical staff Vice presidents of nursing and patient care services of the 4 main acute care hospitals CDI nurse(s) HIM representative Medical staff quality member(s) Medical director of quality Medical director of palliative care services Medical staff representative(s) 22 Reasons? O/E too high and needed to determine opportunities for improvement Collected data: Came from home Most are not managed by a PCP Over age 70 Multiple comorbidities Needed prior discussion related to end of life wishes Attributed to sepsis 23 Mortality Reduction Steering Committee Functions: Review of data Education of providers Developed action plan and established subcommittees: Sepsis Palliative care/hospice Advance care planning screening tool CDI mortality reduction Harm/complication analysis tool data tracking 24

Clinical Documentation Specialist Involvement A CDI nurse reviews all mortality cases Queries to improve documentation and SOI/ROM Looks for clinical indicators Asks for second level review when

9 Clinical Documentation Specialist Involvement A CDI nurse reviews all mortality cases Queries to improve documentation and SOI/ROM Looks for clinical indicators Asks for second level review when looking for higher SOI/ROM Presents cases to mortality committee to determine steps to improve overall care, order set recommendations, education opportunities, and enhancement or palliative care/hospice services 25 Avoiding Death Some of the Cone Health mortality reduction efforts: Sepsis subcommittee was formed to increase efforts around surviving sepsis and decreasing the mortality rates of this patient population Palliative care subcommittee was formed to partner with community providers to increase awareness of the services offered by palliative care CDI mortality reduction project 100% chart reviews for mortality cases performed in order to capture all SOI/ROM Harm/complication analysis tool data tracking performed by the medical staff peer review coordinators for all mortality cases 26 Cone Health Better Than Top Decile for FY

What We ve Learned CDI can t solely own mortality!!! With so many risk adjusted models out there, it takes a collaborative approach involving multidisciplinary teams to impact mortality scores!

GOOD CARE in order to impact the observed rate! 28 References of Note www.hcup us.ahrq.gov/reports/statbriefs/sb146.jsp www.cms.

10 What We ve Learned CDI can t solely own mortality!!! With so many risk adjusted models out there, it takes a collaborative approach involving multidisciplinary teams to impact mortality scores! Community education palliative and preventive care Early recognition of deteriorating signs and symptoms Standardized order sets Extensive chart reviews Auditing and monitoring Patients must receive GOOD CARE in order to impact the observed rate! 28 References of Note us.ahrq.gov/reports/statbriefs/sb146.jsp Initiatives Patient Assessment Instruments/HospitalQualityInits/Measure Methodology.html cost of dying/3 AND 29 AHRQ: Agency for Healthcare Research and Quality 30

11 Closing Remarks The difference between the right word and the almost right word is like the difference between lightning and a lightning bug. Mark Twain 31 Thank you! Questions? Deborah.malick@conehealth.com 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 program guide. 32

Clinical Documentation: Beyond The Financials Cheryll A. Rogers, RHIA, CDIP, CCDS, CCS Senior Inpatient Consultant 3M HIS Consulting Services

Clinical Documentation: Beyond The Financials Cheryll A. Rogers, RHIA, CDIP, CCDS, CCS Senior Inpatient Consultant 3M HIS Consulting Services Clinical Documentation: Beyond The Financials Key Points of