HIGH RISK INFANT FOLLOW-UP QUALITY OF CARE INITIATIVE DATA FINALIZATION PROCESS GUIDELINES AND TOOLS

HIGH RISK INFANT FOLLOW-UP QUALITY OF CARE INITIATIVE DATA FINALIZATION PROCESS GUIDELINES AND TOOLS 2013 BORN INFANT RECORDS 2015 BORN INFANT STANDARD VISIT #1 FOR ALL EXPECTED 2016 BORN INFANT REFERRAL/REGISTRATIONS 2016 CALIFORNIA CHILDREN S SERVICES (CCS) & CALIFORNIA PERINATAL QUALITY CARE COLLABORATIVE (CPQCC), HIGH RISK INFANT FOLLOW-UP QUALITY OF CARE INITIATIVE (HRIF-QCI). THIS PUBLICATION IS COPYRIGHTED AND IS NOT TO BE REPRODUCED IN WHOLE OR IN PART WITHOUT WRITTEN PERMISSION FROM CCS/CPQCC HRIF-QCI. HRIF- QCI: DATA FINALIZATION PROCESS GUIDELINES AND TOOLS RELEASE 08.16 1

TABLE OF CONTENTS INTRODUCTION PAGE 3 Deadline Deliverables HRIF-QCI Support Contacts Communication Resources DATA FINALIZATION GUIDELINES PAGE 5 HRIF-QCI Closeout Checklist Overview Procedures for Finalizing Data REPORTING SYSTEM TOOLS OVERVIEW PAGE 8 HRIF Record Tracker CPQCC Reference Number Error and Warning HRIF/CPQCC Match Status Report HRIF- QCI: DATA FINALIZATION PROCESS GUIDELINES AND TOOLS RELEASE 08.16 2

INTRODUCTION CCS/CPQCC HRIF-QCI is responsible for all data finalization procedures for the CCS HRIF Programs. The purpose of this data finalization process is to assist HRIF Programs with meeting the HRIF-QCI Program goals for complete, accurate and timely data submissions. DEADLINE DELIVERABLES The following deadlines list deliverables that are required to be completed for data submission of records for infants born in 2013, Standard Visit (SV) #1 [and/or Additional Visit(AV)] for All expected 2015 born infants AND Referral/Registration (RR) Forms for infants born in 2016. January Submit a Help Ticket (www.cpqccsuppor.org) to schedule a data review (optional) March 1 st Qualify for the Super Star HRIF Program Award for completing the April 1 st deliverables April 1 st Submission of no priority cases for the birth year 2013 Submission of no error or warning cases for the birth year 2013 Submission of SV #1 (and/or AV) of All expected 2015 infants born April 2 nd Qualify for the HRIF Follow-up Rate Award for meeting the core visit follow-up rate for infants born in 2013 April 16 th Confirmation of the HRIF CCS report for the birth year 2013 NOTE: The report will be available on April 2nd. June 1 st Registered and accepted all eligible HRIF infants from your CPQCC CCS NICU center for birth year 2016 Review and sign-off on the CPQCC & HRIF-QCI Directory HRIF-QCI SUPPORT CONTACTS For questions or any assistance, it is recommended to submit a ticket to the CPQCC Help Desk (www.cpqccsupport.org). The Help Desk will be the primary source for all request related to HRIF-QCI. NOTE: When creating a ticket select HRIF Topic as the Help Topic, this will insure that the ticket will be sent to HRIF Support. Technical Support: CPQCC/HRIF provides technical support for the web-based Reporting System. Please direct all of your questions and comments regarding the HRIF-QCI Reporting System to our HRIF Support staff: CPQCC Help Desk Erika Gray www.cpqccsupprt.org Erika@cpqcc.org Policy and Procedure Support: For CCS HRIF Program policy and procedure issues contact Children's Medical Services (CMS) Branch Staff: CCS HRIF Program Maria Jocson, MD hrif@dhcs.ca.gov maria.jocson@dhcs.ca.gov HRIF- QCI: DATA FINALIZATION PROCESS GUIDELINES AND TOOLS RELEASE 08.16 3

COMMUNICATION o o MailChimp HRIF-QCI Program communication (i.e. Monthly Newsletter Bulletins, System Improvements, and other announcements) will be sent via the MailChimp email client. Make sure to update e-mails or contact changes in the CPQCC & HRIF-QCI Directory. If you are unable to receive MailChimp e-mails, please submit a Help Ticket. o To subscribe to our program e-newsletters and/or update your MailChimp profile, please complete the online form at: www.eepurl.com/4cosd CPQCC Help Desk Please submit a help ticket for all data and program related requests, inquiries, feedback etc. The help desk will also be the primary resource for data finalization request. Visit the CPQCC Help Desk Frequently Asked Questions page if you need additional instructions about how to use the CPQCC Help Desk Ticket System: https://www.cpqccsupport.org/kb/faq.php?id=16 When creating a ticket enter all relevant information: o Help Topic (required): HRIF Topic o Issue Summary (required): Data Entry/Report Questions, Data Finalization/Closeout Checklist, Data Review/Phone Appointment, Data Trainings, Eligibility Questions, General Inquiry/Feedback, Membership (Invoices), New Members/Name Changes, System Tools/Resources, Technical Support, Transfer Record/Duplicate Records, User Access/Password Reset, VON Files and Website Problems/Issues. o Issue Details: Describe the reason(s) for opening this ticket in a short summary. o Ticket response within 1-3 days. NOTE: Help Tickets will be closed if left idle for 3 or more days, after response by HRIF Support staff. NOTE: CPQCC/HRIF office hours are Monday Friday 8:00 am 5:00 pm. All requests sent after hours or on weekends will NOT be responded to until the following business day. RESOURCES 1. HRIF-QCI Website (Resource Corner): The HRIF-QCI Manual, Reporting Forms, and Data Finalization documentation is listed on the website: https://www.cpqcc.org/perinatalprograms/ccscpqcc-hrif-qci/resource-corner 2. CPQCC & HRIF-QCI Directory: Provides a list of CPQCC and HRIF Program data contacts by hospital. Available on the HRIF-QCI Reporting System under the Admin tab => Update Directory. 3. Family Information Form: Was developed to help HRIF Programs collect social-demographic information about HRIF patients and their families to determine the specific needs of this patient population and develop better standards of care for California HRIF Programs. The form is available on the website: https://www.cpqcc.org/perinatal-programs/ccscpqcc-hrifqci/resource-corner, under Reporting System Tools. HRIF- QCI: DATA FINALIZATION PROCESS GUIDELINES AND TOOLS RELEASE 08.16 4

HRIF-QCI CLOSEOUT CHECKLIST OVERVIEW DATA FINALIZATION GUIDELINES Effective April 2015, we implemented the online Closeout Checklist tool to guide HRIF programs through the Data Finalization Process (DFP). The tool is located in the HRIF-QCI Reporting System under the Admin tab. The Closeout Checklist consist of the following 5 columns: 1. #: the task item number. 2. Item: the description of the deliverable. 3. Resource: active links to tools and resources to aid in completing the deliverable. 4. Deadline: the due date of the deliverable. 5. Complete: checkbox and date stamp to indicate the deliverable is complete. a. Items #1, #2 and #4 are grayed out and automatically checked by the system once verified that the deliverable was complete. b. Item #3 and #6 is manually checked by HRIF Support staff once complete. c. Item #5 must be checked manually by the HRIF Program AFTER the deliverable is complete. HRIF- QCI: DATA FINALIZATION PROCESS GUIDELINES AND TOOLS RELEASE 08.16 5

AWARDS All earned awards for your HRIF Program will be displayed on the Closeout Checklist. The CPQCC website (www.cpqcc.org) has a page dedicated to each HRIF Program, the Data Management Awards page: www.cpqcc.org/about-us/data-management-awards. Programs can view all awards earned from 2014, and can sort the awards alphabetically or by number of awards earned. NOTE: Awards will be announced via CPQCC/HRIF Newsletter Bulletins (MailChimp). Super Star = Follow-up Rate = Surprise = Granted to HRIF Programs that completed items #1 through #3 on the Closeout Checklist by March 1 st Granted to HRIF Programs who meet the follow-up rates for the closing birth year: 1 St Visit => 80% 2 nd Visit => 70% 3 rd Visit => 60% Granted to HRIF Programs that a recognized for a random positive performance data quality aspect. HRIF- QCI: DATA FINALIZATION PROCESS GUIDELINES AND TOOLS RELEASE 08.16 6

PROCEDURES FOR FINALIZING DATA NOTE: All Reporting System tools are located in the HRIF-QCI Reporting System under the Tools tab, and are updated in real-time. 1. January thru March Submit/edit data for completeness and accuracy by utilizing reporting system tools 2. March 1 st HRIF Super Star Award Granted 3. April 1 st Deadline: a. 2013 born infant data records are complete and finalized i. Make corrections and close online entry: Referral/Registration (RR), Standard Visit (SV), Additional Visit (AV) and Client Not Seen/Discharge (CNSD) Forms for all closing year submitted case records. ii. Review the CPQCC Reference Number report to verify that all eligible CPQCC born infants have a valid CPQCC Patient I.D. Number entered. iii. Review the HRIF Record Tracker tool to verify that all closing year case records are closed. Focus on Priority and Warning Cases. iv. Review the Error and Warning Report tool to verify that all closing year case records are complete. b. Submission of SV #1 (and/or AV) for all expected 2015 born infants i. Review the HRIF Record Tracker tool to verify that all expected 2015 born infant records have a SV #1 or AV form submitted and closed. 4. April 2 nd HRIF Follow-up Award Granted 5. April 2 nd until April 16 th - Review and Confirm the final 2013 HRIF CCS Report: a. The HRIF CCS Report will be available on April 2 nd (located under the Report tab) b. The HRIF Medical Director or Coordinator must confirm the report by April 16 th. c. If the HRIF Medical Director of Coordinator is unable to confirm, then a proxy can confirm the report. 6. June 1 st Deadline: a. Register all 2016 born infants. The Reporting System will NOT accept referrals of infants born prior to 2017 i. Collaborate with the CPQCC Data Contacts or NICU Discharge Planner to verify that all HRIF eligible infants have been referred/ registered. ii. Review the HRIF/CPQCC Match Status Report available at www.cpqccreport.org. Submit a Help Ticket if you need access to the CPQCC Report website. iii. Review the CPQCC Reference Number report to verify that all eligible CPQCC 2016 born infants have a valid CPQCC Patient I.D. Number entered. b. Review and sign-off on the HRIF-QCI Directory i. The directory survey is located under the Admin tab. ii. It s required to enter a full name before submitting the survey. 7. July thru December Submit/edit data for completeness and accuracy by utilizing reporting system tools HRIF- QCI: DATA FINALIZATION PROCESS GUIDELINES AND TOOLS RELEASE 08.16 7

REPORTING SYSTEM TOOLS OVERVIEW HRIF RECORD TRACKER The purpose of the HRIF Record Tracker tool is to help HRIF Programs track and finalize/close patient records. The system will display the Date Expected for when the patient should have been seen for SV #1, #2 and #3, based on the recommended time frames. The Date Expected is calculated by using the patient s gestational age. Once the SV is submitted the Visit Date and the visit Disposition will override the Date Expected. NOTE: The HRIF Record Tracker is located in the HRIF- QCI Reporting System under the Tools tab and is updated in real-time. Case Status Definitions: Priority Cases are patient records with current adjusted age => 37 months and has one of the following: 1. Only has a RR Form in the system (No SV forms submitted) 2. Open Forms = the This Form is Closed check box has not been checked 3. Non discharged disposition selected to close the case 4. Priority Cases are highlighted in RED Warning Cases are patient records with current adjusted age < 37 months with a non discharged disposition selected to close the case and has one of the following: 1. Open Forms the This Form is Closed check box has not been checked 2. Missing SV Form(s) 3. Warning Cases are highlighted YELLOW Closed Cases are patient records with the following: 1. All forms are Closed the This Form is Closed check box has been checked 2. A discharged disposition has been selected to close the case Guidelines (Priority Cases): 1) If the record is missing any Standard Visit (SV), Client Not Seen/Discharge (CNSD) or Additional Visit (AV) Forms. The HRIF Program must enter the form(s) and then close the case. 2) If the patient was never seen, OR the latest SV or CNSD Form entered has a non discharged disposition (ex: Schedule to Return ) and the client NEVER returned for further visits. The HRIF Program must submit a Client Not Seen/Discharge Form and select a discharged disposition to close the case. 3) If the patient received 3 SVs, and the 3 rd visit disposition = Will be followed by Another CCS HRIF Program, this indicates the case as open due to the non discharged disposition entered. The HRIF Program can either change the 3 rd visit disposition to Discharged - Completed HRIF Core Visits, Referred for Additional Resources OR if the client returned for a further visit, then submit an AV Form and select a discharged disposition to close the case. 4) If the latest SV or CNSD Form entered has a disposition = Will be followed by Another CCS HRIF Program, BUT the record was NEVER properly transferred, then there may be a duplicate record in the system. Submit a Help Ticket at www.cpqccsupport.org to resolve the issue. NOTE: If no duplicates are found, then the HRIF Program must submit a CNSD Form and select a discharged disposition to close the case. HRIF- QCI: DATA FINALIZATION PROCESS GUIDELINES AND TOOLS RELEASE 08.16 8

5) If the patient has completed all 3 core visits AND has a discharged disposition, then the record must have open forms. The HRIF Program must check the Case History to make sure all form status = Closed. MANAGE CPQCC REFERENCE NUMBER The purpose of the CPQCC Reference Number tool is to provide a full list of all your HRIF programs registered infants and allow program staff to update the CPQCC Reference Numbers. The tool can be filter by Infant s Birth Year/Month and/or Birth Weight: All, Small Baby (=< 1500 grams) and Big Baby (=>1500 grams). NOTE: All Small Babies born or discharged from a CPQCC CCS NICU should be assigned a CPQCC ID Number. Data Item Definition - CPQCC Reference Number Enter the last six-digits of the discharging/referring or birth CCS NICU hospital s Office of Statewide Health Planning and Development (OSHPD) facility code (Appendix E) and the infant/child s CPQCC Network Patient Identification Number from the discharging/referring or birth CCS NICU hospital, where the infant/child was born or admitted within 28 days of birth. The CCS NICU discharging the infant/child home could also be the same facility referring the infant/child to the HRIF Program. The OHSPD facility code and CPQCC Network Patient ID Number must match. If you use the birth hospital s OSHPD code then you must use the birth hospital s CPQCC Network Patient ID Number. NOTE: Enter 99999 as the CPQCC Network Patient ID Number or check the Infant NOT CPQCC Eligible check box, for infants who did not qualify for CPQCC NICU eligibility criteria. Every CPQCC / CCS NICU hospital has a CPQCC data contact person that keeps a record of each patient who meets the CPQCC NICU eligibility criteria (Appendix E). The CPQCC & HRIF-QCI Directory is available in the Reporting System located under the Admin tab => Update Directory, use this directory to identify the CPQCC data contact person(s) from the discharging/ referring or birth CCS-approved NICU hospital. NOTE: Enter 00000 as the CPQCC Network Patient ID Number, if you are not sure if the infant met the CPQCC NICU eligibility criteria or the CPQCC data contact person is backlogged and, therefore has not assigned a CPQCC Network Patient ID Number for the infant. Use the CPQCC Reference Number Report to replace assigned CPQCC Network Patient ID Number(s). NOTE: Enter 77777 as the CPQCC Network Patient ID Number, if the infant met CPQCC NICU eligibility criteria, but was not assigned a CPQCC Network Patient ID Number. HRIF- QCI: DATA FINALIZATION PROCESS GUIDELINES AND TOOLS RELEASE 08.16 9

ERROR AND WARNING The purpose of the Error and Warning tool is to alert HRIF Programs of missing or incorrect data entries and to help aid them in completing and finalizing their data. The system will display patient records with any of the following issues: Duplicate Record, Missing CPQCC ID Number, No Forms, Transfer Record Incomplete, Met Age Limit for Program, Missing Birth Date of Mother, Incorrect Date of Visit, Duplicate Core Visit and Infant Still in Hospital with an action plan to resolve the issue. NOTE: The Errors and Warning tool is located in the HRIF-QCI Reporting System under the Tools tab and is updated in real-time. Issue Definitions: 1. Duplicate Record = displays matched records across the entire HRIF-QCI database. 2. Missing CPQCC ID Number = displays patients with birth weights =< 1500 grams, and the CPQCC Reference Number CPQCC Network Patient ID Number is coded as 00000, 99999, or 0000. 3. No Forms = displays records for patients who are currently => 12 months adjusted age and DO NOT have a (SV, AV or CNSD) form submitted in the database. 4. Transfer Record Incomplete = displays records that have a Will be Followed by Another CCS HRIF Program disposition entered on the SV, AV or CNSD Forms. 5. Met Age Limit for Program = displays records for patients who are currently => 3 years old and the record has not been closed with a discharged disposition. 6. Missing Birth Date of Mother = Mother or Both Parents selected as Primary Caregiver, then Birth Mother s DOB can NOT be entered as Unknown. 7. Incorrect Date of Visit = enrollment date cannot be the same as the infant s date of birth. 8. Duplicate Core Visit = record has more than one of the same core visit (ex: two core visit #1 s). 9. Infant Still in Hospital = displays records with Still in Hospital checked on the RR Form. Guidelines: 1) How to Resolve Duplicate Records: a. Contact the HRIF Program with the duplicate case to review the records. b. Make sure all data variables are captured on the Referral/Registration Form (CPQCC Reference Number, Birth Mother s Date of Birth, Discharge Date to Home, etc). c. *Combine all data forms (SV, AV and CNSD Forms) into the current or record of choice. d. The HRIF Program not currently following the patient should use the orange "Delete" button located at the bottom of the RR Form entry screen to remove their record from the system. *TIP: Use the "Patient Data Quality Self-Audit Instrument Report" located in the "Patient's Case History" page to review the details of the record. HRIF- QCI: DATA FINALIZATION PROCESS GUIDELINES AND TOOLS RELEASE 08.16 10

2) Missing CPQCC Network Patient ID Number: a. Contact the CPQCC Data Contact person from the birth OR discharging CCS NICU to obtain the CPQCC Network Patient ID Number. Use the CPQCC & HRIF-QCI Directory to get contact information. b. Review the HRIF/CPQCC Match Status Report available at www.cpqccreport.org. Submit a Help Ticket if you need access to the CPQCC Report website. NOTE: The OHSPD facility code and CPQCC Network Patient ID Number must match. If you use the birth hospital s OSHPD code then you must use the birth hospital s CPQCC Network Patient ID Number. 3) No Forms: a. Submit the missing SV or AV form(s) b. If the child was never seen submit a CNSD form and indicate the reason and disposition as to why the patient was not seen 4) Transfer Record Process: a. Contact the CCS HRIF Program Coordinator where the patient will be transferred for follow-up care, to inform them of the patient and the HRIF ID #. b. Submit a CNSD Form, before requesting to transfer the patient s record: Category: "No Scheduled Appointment Reason: "Infant Referred to Another HRIF Program" Disposition: "Will be Followed by Another CCS HRIF Program" c. Submit a Help Ticket at www.cpqccsupport.org to request the record transfer to another CCS HRIF Program. Include in the transfer request the patient s HRIF ID Number, Date of Birth and the CCS HRIF Program, where the patient will be transferred. NOTE: Records are transferred every Friday; request received on Friday will be transferred the following week. Records are only transferred to CCS HRIF Programs. If the infant is referred to a NON-CCS or Out of State HRIF Program, submit a CNSD Form to close the case: Category: Discharged Reason: Infant Referred to Another HRIF Program Disposition: Discharged Will be Followed Elsewhere 5) Met Age Limit for HRIF Program: a. Submit a CNSD, to close the patient s record: Category: Discharged Reason: Select a reason or code as Other = Aged out of Program Disposition: Discharged Closed Out of Program 6) Infant Still in Hospital: a. Uncheck the Infant Still in Hospital check box b. Enter the date when the child was discharged to home NOTE: The Date of Discharge to Home is a required field and must be completed. HRIF- QCI: DATA FINALIZATION PROCESS GUIDELINES AND TOOLS RELEASE 08.16 11

HRIF/CPQCC MATCH STATUS REPORT The purpose of this report is to show the HRIF registration status for each infant coded as discharged to home or discharged to home from the reporting center after one prior transfer out and readmission. The report lists the basic information included in an infant's HRIF registration and can be filtered based on a number of criteria. The HRIF/CPQCC Match Status Report is available on www.cpqccreport.org website. The HRIF/CPQCC linkage focuses on the following infant criteria that meet eligible for CPQCC and HRIF: Extremely Low Birth Weight Infants (ELBW) or infants with a birth weight of 1,000 grams who are admitted to the reporting NICU at age 28 days or earlier. Very Low Birth Weight Infants (VLBW) or infants with a birth weight of 1,500 grams who are admitted to the reporting NICU at age 28 days or earlier. Infants born at less than 28 weeks completed gestation who are admitted to the reporting NICU at age 28 days or earlier. Infants born at 29 to less than 32 weeks completed gestation who are admitted to the reporting NICU at age 28 days or earlier. Infants born at 36 weeks completed gestation or later and who received a diagnosis of moderate or severe HIE during their NICU stay who were admitted to the reporting NICU at age 28 days or earlier. Infants who experienced active cooling during their NICU stay and who were admitted to the reporting NICU at age 28 days or earlier. Infants with ECMO during their NICU stay and who were admitted to the reporting NICU at age 28 days or earlier. It is important to fully understand the group of HRIF registrations that might not be linked to a CPQCC record, since the eligibility criteria for CPQCC and HRIF are not identical. Unlinked CPQCC Records: The infant is registered in HRIF-QCI, but does not match to a CPQCC infant due to differences in the data variables (ie. birth weight, gestation age) submitted in HRIF-QCI and/or CPQCC. HRIF eligibility criterion with a dash might include CPQCC eligible infants who are not HRIF eligible. A CPQCC record with one of the above criterion (i.e. ELBW) should always match a HRIF registration. Identifying unlinked CPQCC infants that should be registered in HRIF-QCI Set the filter to Unlinked CPQCC record, HRIF Eligible due to VLBW, GA, HIE, ECMO or Cooling. Only those CPQCC records shown should be linked to an HRIF record, in order to meet the CPQCC close-out requirement of 100% HRIF registration of eligible infants. Unlinked HRIF Records: The infant is registered in HRIF-QCI and does not match a CPQCC record. With the exception of the group of VLBW infants and infants born at <32 weeks completed gestation, we do not know whether the infant actually qualified for CPQCC. To help you focus on those HRIF records that should link, we have highlighted records pertaining to VLBW infants or infants born at <32 weeks completed gestation in red font. HRIF- QCI: DATA FINALIZATION PROCESS GUIDELINES AND TOOLS RELEASE 08.16 12

Identifying unlinked HRIF Records Set the filter to Unlinked HRIF record. Only those HRIF records are shown that are not matched to a CPQCC record. NOTE: Not all these records have to be matched to a CPQCC record. In fact, some of these infants might not be part of the CPQCC data collection (i.e. admitted after 28 days; HRIF eligible, but not CPQCC eligible). Understanding why an HRIF registration does not show up at all HRIF registrations are shown if they have been either linked to a CPQCC record, or if they have not been linked to a CPQCC record, but the HRIF information in the record indicates that the infant should have been registered by the reporting NICU, i.e., the infant was discharged home from the reporting NICU. NOTE: The HRIF match pool is updated daily at midnight with all infants who were registered in HRIF the prior day. Always check the information on HRIF registrations and compare to must current HRIF/CPQCC Match Status Report. If a HRIF registration does not show up on the report: Check whether the infant was discharged home from the reporting NICU and is coded as such in the HRIF record. Check whether the HRIF registration was submitted prior to the most recent HRIF/CPQCC linkage update (date shown at the top of the report). HRIF- QCI: DATA FINALIZATION PROCESS GUIDELINES AND TOOLS RELEASE 08.16 13