7th Annual Association for Clinical Documentation Improvement Specialists Conference Integrating Quality Into Your CDI Program: The Case for All-Payer Review Katy Good, RN, BSN, CCDS, CCS CDI Program Coordinator Flagstaff Medical Center Flagstaff, Ariz. Benjamin Keeler, RN, BSN, PCCN, MHI Quality Manager Flagstaff Medical Center Flagstaff, Ariz. 2
Learning Objectives At the completion of this educational activity, the learner will: Explain the benefits of an all-payer CDI program Identify areas of focus. Describe model for integrating with the Quality (and other departments) staff to provide best outcomes for the hospital. Recognize several potential pitfalls and methods to manage fallout 3 Background: Our Hospital Mid-sized rural hospital 267 beds Level 1 trauma center Large joint program Cardiothoracic surgery Tertiary referral center Bariatric surgery center of excellence Certified stroke center 4
Background: Our Program Initially housed in care coordination UR Case management Disease management Moved to clinical value department in Jan 2013 Quality management RNs Patient safety program Geriatric fracture program ICD-10 implementation Infection prevention In December 2012 we had 2.5 FTEs dedicated primarily to Medicare In January 2013 we expanded to 8 FTEs dedicated to all-payer review 5 A Changing Marketplace Affordable Care Act Pay for performance Value-based purchasing Readmissions Reduction Program ICD-10 It s still difficult to predict the long-term impact of these changes. More changes are inevitable! 6
Mitigating Risk A well-staffed, well-trained, and well-educated CDI team allows facilities to respond quickly to changes as they occur Eyes in the charts (regardless of payer) Relationships with the physicians Ability to work interdisciplinarily with other departments Quality needs concurrent, real-time review on every patient to meet the numerous mandated objectives 7 Is Your Program Focused Only on the Dollars? Many hospitals begin their CDI programs as a way to secure accurate reimbursement for services provided Focus on DRG payers where impact is easily recognizable As programs develop, they begin to see other areas of potential impact in the facility 8
Moving Forward Shift in mind-set? As reimbursement is increasingly tied to quality, CDI programs need to expand their programs and knowledge base to work closely with other departments to ensure the best documentation across all patients seen in the facility 9 Initiatives to Improve Quality 10
O:E Ratio: Death Record Review Problem: unfavorable Observed:Expected mortality rate identified O:E ratio is based off all patients Actual and expected mortality rate publically reported on HealthGrades and HospitalCompare May indicate that SOI/ROM is not accurately reflected in the coded data 11 O:E Ratio: Death Record Review Assessment: No quality of care issues identified. Assumed to be a documentation/coding issue. O:E ratio is based off of all payers, so reviewing any segment of complex patients would likely garner results. However, reviewing expired patients is the obvious choice. Easy to identify Highly scrutinized 12
O:E Ratio: Death Record Review Solution: collaboration with coding and CDI to develop a post-discharge review process for death charts to ensure accurate assignment of SOI/ROM Post-discharge Coded in draft and sent to CDI for review Queries sent (if indicated) and feedback provided Electronic worklist/database built 13 14
O:E Ratio: Death Record Review Promoting buy-in from key groups Coding Coding summaries on expired patients often receive extra scrutiny. Accurate coding to the highest severity is essential. Physicians O:E ratio is an important quality indicator used to assess physician performance (OPPE). Billing Complete and accurate coding ensures accurate reimbursement. 15 Malnutrition 16
Quality of Care: Early Identification of At-Risk Patients Problem Malnutrition: Often unidentified diagnosis that adds significant complexity to patient picture Delayed healing Increased staffing demands (feeding, physical therapy) 17 Quality of Care: Early Identification of At-Risk Patients Assessment Often dietitians were not consulted on at-risk patients Physicians are uncomfortable providing documentation specificity (severity) for malnutrition without input from dietitian When consulted, documentation between physicians and dietitians does not match Greater specificity provided by dietitian Denial risk as significant clinical indicators are often not identified in physician documentation 18
Quality of Care: Early Identification of At-Risk Patients Solution: work with nutrition department and IT team to develop system to promote consistency CDI notified by nutrition each time they make a diagnosis of malnutrition CDI ensures this documentation is transferred into progress notes Query if indicated Nutrition notified by CDI when they see potential indicators of malnutrition but the physician has not consulted dietary Early identification = better patient care! IT team consulted to develop system in which the nutrition department is automatically notified when a patient PREVIOUSLY diagnosed with malnutrition is readmitted to the facility so they can assess for nutrition needs Early identification = better patient care! 19 Intervention 20
Quality of Care: Early Identification of At-Risk Patients Promoting buy-in from key groups Dietary: Better patient care: Early identification means more time to treat patients in house Better data capture: Coding of malnutrition showcases the work they did Proves value to the hospital Supports FTEs Physicians: Better patient care Better transfer of information between providers Ensures that they have the appropriate clinical indicators to make a diagnosis Reduces RAC/denial risk 21 Quality Initiative: Core Measures The Quality/CDI Collaborative 22
Core Measures: Identifying Patients Concurrent, real-time review has become the only way to reach 100% on our quality measures Finding these patients while in hospital was the challenge 23 Core Measure: Stroke Problem Monthly fallouts in the stroke core measure FMC is a certified stroke center Level 1 trauma center Stroke will be a part of value-based purchasing 24
Core Measure: Stroke Assessment Difficulty identifying hemorrhagic patients which eventually code to a stroke DRG Traumas, spontaneous bleeds Frequently finding stroke patients after discharge once chart has been coded and dropped Too late to impact the patient or coding CDIs in every inpatient chart, quality is not Examined how to incorporate quality needs into their workflow 25 Core Measure: Stroke Solution Involved the CDI team to assign a working DRG Automated list generated daily with these patients CDIs started to flag these patients and alert the quality management RNs The QMRN then engages to ensure the best quality care for the patient Daily automated list now goes to QMRNs, care coordinators, disease management RNs, stroke team 26
Core Measure: Stroke Results 100% for stroke core measure for first time in November with continued strong results Notification to a large team for a wide range of high-risk patients 27 FMC Core Stroke All-or-None Bundle April 2011 January 2014 Intervention 100 90 80 70 60 50 40 30 20 10 0 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-13 28
Core Measures: Heart Failure Problem Heart failure population identification Significantly impacts CMS Readmissions Reduction Program, value-based purchasing, and core measures (IQR) 29 Core Measures: Heart Failure Assessment Difficulty identifying the heart failure population Difficulty monitoring this population Care coordination frequently missing inpatients that are a part of the heart failure population Missing opportunities for follow-up, creating appointments 30
Core Measures: Heart Failure Solution CDIs started to flag these patients and alert the quality management RNs The QMRN then engages to ensure the best quality care for the patient Daily automated list goes to QMRNs, care coordinators, and disease management RNs 31 Core Measures: Heart Failure Results The lowest readmission rate in Arizona Actively identifying patients with heart failure often in the emergency department 100% in the heart failure core measure for 9 months for the calendar year 2013 32
Arizona Readmission Rate Figure 3 compares your hospital s all-cause readmission rate to other Arizona hospitals with a similar number of discharges. Results are displayed from lowest readmission rate (far left side of the graph) to the highest readmission rate (far right side of the graph). Your hospital is shown in red in the figure. Source: HSAG 33 Core Measures: Promoting Buy-In Quality department Improvements in the core measures Core measures are primarily based on coded data Physicians Improve individual quality scores for OPPE Many physician groups have bonuses tied to core measures Senior management/the board Value-based purchasing Readmission Reduction Program Bragging rights Nursing Best care for their patients Evidence-based practice 34
100 FMC All or None Bundle July 2008 January 2014 90 80 FY 2013 FY 2014 70 FY 2011 FY 2012 60 FY 2010 Percent 50 40 30 FY 2009 Goal is 100% 20 10 0 Jul 08 Aug 08 Sep 08 Oct 08 Nov 08 Dec 08 Jan 09 Feb 09 Mar 09 Apr 09 May 09 Jun 09 Jul 09 Aug 09 Sep 09 Oct 09 Nov 09 Dec 09 Jan 10 Feb 10 Mar 10 Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sep 10 Oct 10 Nov 10 Dec 10 Jan 11 Feb 11 Mar 11 Apr 11 May 11 Jun 11 Jul 11 Aug 11 Sep 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12 Apr 12 May 12 Jun 12 Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 13 May 13 Jun 13 Jul 13 Aug 13 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 35 Quality Initiative: Hospital- Acquired Conditions (HACs) 36
Quality Initiative: HACs Problem Identification of HACs is not accurate Coding not catching all HACs due to inadequate documentation by medical providers 37 Quality Initiative: HACs Assessment Medical providers are not documenting HACs correctly Lack of knowledge regarding what counts as a HAC and how to accurately document 38
Quality Initiative: HACs Solution CDIs just starting to identify certain HACs CAUTIs, VAEs, BSIs Working with coding to understand need to code HACs Help medical providers with charting of HACs Created separate query for infection prevention 39 Quality Initiative: HACs Results Initial increase in the number of CAUTIs Followed by a dramatic reduction and sustaining CUSP CAUTI Initiative Need to further refine and expand our HAC quality efforts 40
CAUTI at FMC: IP vs. Coding 6 Catheter Associated UTIs Per 1000 Inpatients 5.6 5.8 5 4.4 4 3.4 Rate 3 2 1.8 2.2 1.7 1.7 2.3 1.8 1.7 1.8 2.0 1 0.8 0.8 0.4 0.5 0.5 0 0 0 Feb 2012 Mar 2012 Apr 2012 0 0 0 0 May 2012 Jun 2012 Jul 2012 Aug 2012 Sep 2012 0 Oct 2012 0 0 0 0 0 Nov 2012 Dec 2012 Infection Prevention Data Jan 2013 Feb 2013 Mar 2013 Coded Data Apr 2013 0 0 0 May 2013 Jun 2013 Jul 2013 Aug 2013 0 0 0 Sept 2013 Oct 2013 Nov 2013 41 A How-To Guide to Integrating Quality and CDI A Starter s Guide 42
How to Bridge the Gap Identify areas of focus Core measure data Assess for areas of focus O:E ratio HACs Identify key players Managers Database analysts Physician leadership Senior management The board 43 How to Bridge the Gap Educate! Get out there! What is CDI? Unique view of the record Concurrent review of all payers Understanding of how documentation drives coding Quality measures driven by coded data Offer support: Communication Identification Other? 44
How to Bridge the Gap Maintain distinct roles We do not recommend that CDI be responsible for core measures or other quality data Find EASY ways to communicate data that can be absorbed into your workflow Crystal Reports Excel CCL Reports Keep CDI and quality distinct Merge loss in identity 45 Thank you. Questions? 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. 46