Successes in Nutrition Support: Malnutrition Initiative Robert DeChicco MS, RD, LD, CNSC Manager, Nutrition Support Team Cleveland Clinic, Cleveland, OH June 2, 2017
Learning Objectives List major milestones of Cleveland Clinic Malnutrition Initiative Describe process of program development List potential barriers List key actions that led to success
Cleveland Clinic Malnutrition Initiative: Background Large health system w/8 regional facilities 90+ registered dietitians different employers limited experience performing NFPE Ineffective nutrition screening program Unknown prevalence of malnutrition No standard method to diagnose or document malnutrition Multiple diagnostic (ICD-9) codes being used Limited understanding of malnutrition billing
Cleveland Clinic Malnutrition Initiative: Goals Improve nutrition screening program Standardize assessment and documentation of malnutrition by RDs Increase percentage of patients diagnosed with malnutrition by RDs Increase documentation of malnutrition by LIPs Increase reimbursement for malnutrition
Cleveland Clinic Malnutrition Initiative: Assets Support from leadership Advanced Practice RDs Multidisciplinary Simulation Center In-house Experts
Cleveland Clinic Malnutrition Initiative: Milestones Developed malnutrition training program Created NFPE competency Changed to validated nutrition screening tool RDs permitted to evaluate patients without consult RDs granted access to Epic Problem List RDs obtained order-writing privileges Developed Epic note quality monitor Epic reports and lists upgraded and standardized Epic note templates streamlined Accessed dashboard to track malnutrition Three RD FTEs approved
7 Key Actions: Begin with the End in Mind
Cleveland Clinic Malnutrition Diagnosis Rate cchs 8
Key Actions: Get Your House in Order Train staff Improve processes Nutrition screening EPIC reports & lists Note templates Provide tools to maximize efficiency Evaluate patients without consult Order-writing privileges Access to Epic Problem List
Key Actions: Identify Potential Barriers
Key Actions: Network
Key Actions: Get Your Ducks in a Row
PERCENT Nutrition Screening: Discipline-Based Results Methods: Randomly selected patients (N=109) from variety of inpatient medical and surgical nursing units on Cleveland Clinic Main Campus April/May 2014 Nutrition screening performed RN (part of Nursing Admission Assessment) and by RD Outcome: Percent of patients with a positive nutrition screen 100 Percent of Patients At Risk for Malnutrition Based on Discipline Performing Nutrition Screen 80 60 40 20 0 15.6 RN 57.8 RD
Key Actions: Collaborate Malnutrition DRG Task Force Established: April 2014 Project Leader: Executive Physician Project Members: CDIS, Nursing, Nutrition, IT, Finance, EBI, Project Manager Purpose: Improve recognition and documentation of malnutrition in adult hospitalized patients Key Accomplishments: Increased provider documentation of malnutrition Increased use of malnutrition as secondary billing diagnosis Providers EBI CDIS Nursing Finance Nutrition CDIS-clinical documentation improvement specialists EBI-electronic business intelligence IT
Key Actions: Have a (Business) Plan Components Background Regulatory information Details on strategy and tactics Financial impact Benefits vs costs Rules of thumb Match revenue with expenses Cover incremental expenses with incremental revenue
Increased Reimbursement for Malnutrition Documentation Crohn s Disease Crohn s Disease Crohn s Disease $11,269 $17,496 $34,811 MS-DRG 331 MS-DRG 330 MS-DRG 329 without CC or MCC with CC with MCC E87.6 Hypokalemia B37.0 Oral Thrush E43 Unspecified Severe Protein-Calorie R00.0 Tachycardia E46 Unspecified Protein-Calorie Malnutrition Malnutrition R63.4 Weight Loss 45.72 Small bowel resection with end to end anasto 45.72 Small bowel resection with end to end anasto 45.72 Small bowel resection with end to end anasto RW 1.6380 GMLOS 4.4 SOI 1 ROM 1 RW 2.5609 GMLOS 7.3 SOI 2 ROM 1 RW 5.1272 GMLOS 11.9 SOI 3 ROM 2
Get a Seat at the (Leadership) Table Healthcarebusinesstech.com
Talk the Talk: Language of Administration and Finance *Budget *Revenue *Charge *Net revenue *Operating income *Operating expense *Cost *Direct cost *Indirect cost *Fixed cost *Variable cost *EBITDA *Contribution margin *Net income *FTE *Variance *Denials *Strategy *Planning *Metrics *Ratios *Business plan *Capital *E&Ms *Dashboard *Realization rate *Data mart *Templates *Restricted *Unrestricted
Key Actions: Monitor & Evaluate Develop metrics and share with staff and key stakeholders Develop competencies to monitor staff s knowledge/skills and performance NFPE competency Note quality monitor Evaluate/adjust RD staffing levels
Key Actions: Summary Begin with the end in mind Get your house in order Identify potential barriers Network Get your ducks in a row Collaborate Have a (business) plan Get a seat at the (leadership) table Monitor & evaluate