Provider Education Training - PowerPoint Presentation

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Provider Education Training 09/16/2021

MAKING HEALTHCARE RIGHT. TOGETHER

Matching Care Desired to Care Given, Seeing Our Dear Enrolled lives Body, Mind and Spirit, Giving True Informed Consent.

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EVERY DIAGNOSIS COUNTS CASE STUDY #1

This is a Real Patient Cared for in our Select IE SNP, admitted to a SNF just a few months ago.You are on call and get a call from a SNF: “84 yr. old being admitted from the Acute and calling to let you know.  Dx from the Acute:  Sepsis, AKI, Dementia, HBP and an ESBL UTI with a foley catheter.” What do you do next?

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CASE STUDY #1 - CoN

tinuedYou verify the transfer meds:Risperdal 1 mg bidDepakote 125 mg bidQuetiapine 50 mg hsEscitalopram 30 mg q dVicoden 5/325 qid prn, taking daily for yearsAtivan 0.5 mg bid

Gabapentin 100 mg bid

Macrobid 100 mg bid for 4 more days

Metoprolol 25 mg bid

Tyl

325 mg prn

Zestoretic 20/25 mg q dMelatonin 5 mg hsAmbien 10 mg hsMVI q dCalcium Carbonate 600 mg and Vitamin D 200 mg bid What do you do next?

You ask the condition of our dear enrolled life and get the vitals. 

The facility want you to verify her meds.

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CASE STUDY #1 - CoN

tinuedPolypharmacy!!Medication Combinations that make no sense.Make a mental note to reduce and eliminate.Curbside our BND Psychiatrist Jim Pratty, MD, to think through this together:  310-717-9750  (Text him first if he doesn’t already have your number.) What do you do next?

Hopefully think through the medication list!

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CASE STUDY #1 - CoN

tinuedYou approve the transfer orders, even though the medication regimen doesn’t make sense, making the mental note to review when you visit the next day.

What Labs do you order?

Nothing at all??  Yes or NO??

CBC, Yes or No??

BMP, Yes or No??

CMP, Yes or No??

TSH, Yes or No??

UA C+S, Yes or No??

Depakote Level, Yes or No??

 

What do you do next??

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CASE STUDY #1 - CoN

tinuedYou inquire about the POLST and patient defaults to Full Code as Never Addressed. If the patient is unstable or any urgent issues, call the family, but in this situation, no acute issues and no need to call. Adjust your schedule to see our dear enrolled life in the morning.How Many HCC/RAF Dx are in the above history?

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CASE STUDY #1 - CoN

tinued 1? 2? 3? 4? 5?WHAT DO YOU THINK?

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CASE STUDY #1 - CoN

tinuedSepsisARFSD with BehaviorMDD, RecurrentNeuropathy, in other diseasesDrug Use Disorder:  (Opiates, Hypnotics and Anxiolytics)Catheter Associated ESBL UTIHCC/RAF Dx

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CASE STUDY #1 - CoN

tinuedHopefully, you see this patient the next day (but this dear enrolled life was not seen for 4 days), and complete the H+P.You get more history by reviewing every page sent over form the acute:You Verify And Document the previous Dx.ALOC Well Documented and improving.CXR Found Aortic AtherosclerosisFacility hasn’t done a height and weight yet, but the hospital documents 5’5” and 110#’s.

No labs ordered at Facility, but significant labs from the hospital show:

Last WBC 9.4k; H/H:  9/27; Platelet Count 129k.

BUN/Creatinine:  34/1.5

You find out our dear enrolled life is eating 50% of meals on average, range of 25-75%;  No one has any idea when the last BM was.

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Your PE is unremarkable except for:

Frail Elderly, a bit lethargic, 85 yr. old gentle womanBruises to the Left Upper ExtremityDry MM’s with oral thrush2/6 SEMCVS to BLE to Ankles, with No foot or LE Hair. You have asked and answered the “Would I be surprised if this dear enrolled life died in the next year?” Question.How many Additional RAF Scores do you now have?

CASE STUDY #1 - CoNtinued

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CASE STUDY #1 -

CoNtinued

Aortic Atherosclerosis

Cachexia

Senile Purpura

PVD

Thrombocytopenia

HCVD with CKD III

What do you do next?

Additional RAF Scores

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Call the Family:

They are over the moon happy with the call, as the hospitalist never returned their phone calls.Review the Polypharmacy and Medication Reduction Options:Curbside Psychiatry for wisdom and input.

Stop 1 of 2 Atypical Antipsychotics.

Consider changing Antidepressant to an Appetite Stimulating Antidepressant.

Stop Combination of Anxiolytic and Hypnotic.

Wean off Anxiolytic if at all possible.

Wean down and stop Opiate if at all possible.

Must Give True Informed Consent about Atypical Antipsychotics:  Black Box Warning and Sudden Death.

Get more history, talk to family about the Cachexia and share the Risk Factors, Overall Prognosis.

CASE STUDY #1 -

CoN

tinued

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POLST Discussion:

“Please don’t be scared by this question, I have to ask it Every Time Anyone comes back from the hospital.  It is an important question, because you are the Captain of your Loved Ones Care, not me.All of us Naturally have our heart stop beating someday.

When your mom’s heart Naturally stops beating someday,

Do you want your mom to have a Natural Death, or do you want your mom to have Chest Compressions?  CPR?”

Family confirms Mom always wanted to have a Natural Death and are further upset she was full code in the hospital.  They agree to No Feeding Tubes as well.

Manage the Bowels.

Add a Protein Shake.

Manage the oral thrush.

Adjust medications based on all of the above.

Get our dear enrolled life up and OOB at least 2 hours twice a day.

Complete the POLST.

 

What’s the 2’nd to the last thing you do?

CASE STUDY #1 -

CoN

tinued

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Express Gratitude

to be able to take care of their Loved One.And What is the Last Thing you do??

CASE STUDY #1 - CoNtinued

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CASE STUDY #1 -

CoNtinuedMake the Someday Statement:

In Honor of Joyce Brown, NP!

“Someday, not today, I am going to call you and let you know I believe your beloved mom is at the end of her life.

 

We’ll talk about Hospice and End of Life Care then.”

 

 

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Meaningful results:

BND had a 2020 and YTD 2021 RAF Score of <2

2021 RAF Score with above Dx: >3

>$1000/month payment Change.

More Benefits for our Dear Enrolled Life.

Change of Full Code to Allowing a Natural Death.

Dramatic Pharmacy Reduction.

Matching Care Desired to Care Given, Seeing Our Dear Enrolled Lives Body, Mind and Spirit, Through Giving Full Informed Consent.

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EVERY DIAGNOSIS REALLY DOES COUNT!

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ACUTE RENAL FAILURE

(N17.9)Rapid loss of kidney function within 48 hours of pre-existing normal kidney function, or within 48 hours of pre-existing Chronic Kidney Disease.Requires > 0.2 mg/dl increase from baseline

Can be due to Shock, Sepsis, PE, CHF, Hepatic Failure, Excessive Diuresis and missed all the time.Must have the lab documentation.

RAF score is: 0.683

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ALCOHOL USE DISORDER

(F10.20; if in Remission, F10.21)I ask the CAGE questions and Document if 2 or more Positives (even though some say if even just 1 question is answered positive); or go with Consequences: Physical, Legal, etc., or a combination of both.If no longer drinking alcohol, but was had the Use Disorder when quit, document and code Alcohol Use Disorder, in Remission, no matter the length of sobriety (Days to Decades)RAF Score is: 0.279

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ANY AMPUTATION BELOW THE WAIST

BKA: Z89.51* (0.779 RAF SCORE)AKA: Z89.61* (0.779 RAF SCORE)TMA: Z89.9* (0.779 RAF SCORE)Foot: Z89.43* (0.779 RAF SCORE)

Ankle: Z89.44* (0.779 RAF SCORE)GREAT TOE: Z89.41* (0.779 RAF SCORE)

OTHER TOE: Z89.42* (0.779 RAF SCORE)

MUST DOCUMENT EVERY YEAR

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ANY ARTIFICIAL OPENING

Gastrostomy: Z93.1 (0.651 RAF Score)Colostomy: Z93.3 (0.651 RAF Score)Jejunostomy: Z93.4 (0.651 RAF Score)Ileostomy: Z93.2 (0.651 RAF Score)

Nephrostomy: Z93.6 (0.651 RAF Score)Cystostomy/ Suprapubic Cath: (0.651 RAF Score)

Tracheostomy: Z93.1

MUST DOCUMENT EVERY YEAR

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AORTIC

AORTIC CALIFICATIONS (170.0) AND AORTIC ANEURYSM W/O REPAIR (171.9) AND AORTIC ECTASIA (177.819)

Must have CXR or US or CT Scan Results Verifying, document the date of exam!

Missed all the Time, found reviewing Radiologic Reports.

RAF Score is: 0.301

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ATRIAL FIBRILLATION (I48.91) AND

CHF (I50.9)

I add these, because they are often Missed, when Treated and Stable.Just because Our Dear Enrolled Life is in NSR, we can still Dx Atrial Fibrillation if they had Surgery/Procedures/Medications to keep in NSR (Cardioversion, ablation, BB’s, CCB’s, Antiarrhythmics)

Same thing with CHF. Just Because Our Dear Enrolled Life has their CHF Controlled, we can still Dx CHF if they had the Underlying Problem Treated, or if they had Surgery and are on Lifestyle and Medications to Maintain. (ACEI’s, ARB’s, Diuretics, BB’s Aldosterone Antagonists, Digoxin, ICD’s, Valve Replacements, etc.)

A Fib RAF Score is: 0.295

CHF RAF Score is: 0.368

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CACHEXIA

(R64)Any BMI < 19.

Yes, BMI is a HEDIS Measure.Complex Metabolic Syndrome associated with underlying illnesses, characterized by loss of muscle, with or without loss of fat mass.

RAF Score is: 0.674

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CHRONIC HEPATITIS C (B18.2) AND B(B18.1) VS. HEPATITIS C AND B

Hepatitis C and Hepatitis B do NOT Risk Adjust, Chronic Hepatitis C and Chronic Hepatitis B doesRAF Score is: 0.071

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CKD, NOT IN DM, III (N18.3), IV (N18.4), V (N18.5)

CKD IIIa/b added by CMS due to High Risk, and Now Risk Adjusts, just since 2020.Must have GFR Documented.RAF Score is:

Stage 5 HCC136 0.231

Stage 4 HCC137 0.105

Stage 3 HCC138 0.021

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COMPLICATIONS AND MALFUNCTIONS:

Clogged Urinary Catheter: T83.098A, RAF Score: 0.911Infection Associated with a Urinary Catheter: T83.51XA, RAF Score: 0.911Pain due to a Knee Replacement: T84.84XA. RAF Score: 0.911

Insulin Pump Malfunction: T85.694A, RAF Score 0.911Infected Internal Fixation Device: T84.60XA, RAF Score 0.911

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DEMENTIA

DEMENTIA W/O AGGRESSIVE BEHAVIOR (F03.90) AND W/ AGGRESSIVE BEHAVIOR (F03.91)Added in 2020 with CMS Acknowledging the Ramifications of this Disease.

RAF Score is: 0.224Not Related to Alzheimer's or Parkinson’s

Dementia related to Alzheimer's G30.9 (0.224 RAF Score)

Dementia with Parkinson's G20

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Diabetes Mellitus

DM WITHOUT COMPLICATIONS (E11.9) AND WITH COMPLICATIOMNS (TNTC CODES, SEE ATTACHED)

We see DM coded All the Time with no Complications.

While this is possible, it is Not Likely.

Always Document and Capture when there is DM with Any Co-Morbid Condition: CKD, PVD, PN, Retinopathy, CAD, 

Huge RAF Score Impact, see attached.

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DRUG USE DISORDER

(F11.20 Opioid Use Disorder, F11.21 if in remission; F13.20 for Any Hypnotic or Anxiolytic Use Disorder, F13.21 if in remission; F19.20 Other Drug Use Disorder, F199.21 if in remission)

Document if patient is on a Daily Opiate, Hypnotic or Anxiolytic for >3 months.If patient is not using but ordered prn, please stop the prn and can’t document current dependence, but you can document in remission if appropriate.

Remember some of our dear enrolled lives take prn’s daily, and totally dependent if on daily >3 months.

Remember saying someone is dependent, doesn't mean they are abusing, often we clinicians order these meds and are taken at our direction.

Tramadol does carry a warning for dependence as it is an opiate, and CMS says we can Document Drug Use Disorder if on daily for >3 months.

RAF Score is: 0.279

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FECAL IMPACTION

(K56.41)Dry hard stool in the rectum making defecation difficult.Fecal Impaction is primarily diagnosed based on clinical signs: No BM for 3 Days; Hard BM’s; Overflow Diarrhea; Abdominal Pain and/or Distension: Hard Fecal Mass on Digital Exam; Radiologic Findings, etc.

Remember that Last Bowel Movement should be part of Every Vital Sign.Remember that

Fecal Impaction is the 5

th

Most Common ER Transfer

for one of our Dear Enrolled Lives we get to take care. RAF Score is: 0.414

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FUNCTIONAL QUADRAPLEGIA

(R53.2)“The inability to move due to sever disability or frailty caused by another condition without physical injury or traumatic damage to the spinal cord or brain. Very Common in our Dear Enrolled Lives with End Stage Dementia, which can last for years; but also found in many other conditions (Hypoxic Injury, Progressive Arthritis, ALS, Huntington's Disease, MS, etc.)

Requires Total Care, Inability to walk, Inability to Feed themselves. YOU MUST DOCUMENT THIS!

It does not mean they are bedbound.

RAF Score is: 0.224

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MAJOR DEPRESSION, RECURRENT

(F33.2; If in Partial or Remission: F33.4)Depression Or major depression does not risk Adjust, you must document Major Depression, Recurrent.A patient may be well controlled, without any symptoms at all, and still have this Diagnosis, because the treatment plan is working.

Any patient on continuing SSRI/Antidepressants.A patient can have Major Depression, Recurrent and Not be on any medication at all. They may be doing: therapy of various types; medication; ALF Milieu; etc.

RAF Score is: 0.352

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MORBID OBESITY (E66.01)

ANY BMI > or equal to 40.0 (there are ICD-10 Codes for BMI’s 40-50, 45-50 and so on, if you want to use.)RAF Score is: 0.183

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PATHOLOGIC FRACTURE

PATHOLOGIC FRACTURE OF THE FEMUR (M84.453A) AND PATHOLOGIC FRACTURES OF THE SPINE

 (M84.48XA)

Documenting Fractures of the Femur and Compression Fractures of the spine DO NOT RISK ADJUST.

You

Must

say

Pathologic Fracture of the Femur or of the Spine.You Must Document and Treat OP.Yes, this is a HEDIS Measure.Must Document Every Year.RAF Score is: 0.394

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NEUROPATHY, IN OTHER DISEASES, NOT IN DM

(G63)Missed all the time, I saw two charts today with gabapentin, not in a diabetic patient, with no Neuropathy Dx, and called the dear enrolled lives we get to take care of and both gave classic neuropathic complaints.Must document history and reason for the treatment.

RAF Score is: 0.407

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PROTEIN CALORIE MALNUTRITION, UNSPECIFIED

(E46)Any Hypoalbuminemia.Always get baseline CBC, CMP, and TSH’s, yearly thereafter or with any changes of condition.Weight loss >2% in 1 week, 5% in 1 month,

and food intake <50% for at least a week.Always include % of meal intake, weight and height (BMI) with every visit.

Albumin’s of <2.5 Absolutely support criteria for hospice and EOLC.

RAF Score is: 0.674

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SENILE PURPURA (D69.2) OR THROMBOCYTOPENIC PURPURA (D69.49)

Bruises, usually superficial, on the hands and forearms, but can be elsewhere.Super common and prevalent, but rarely documented. You MUST document the bruising on your PE.CMS Predictor of Demise.

RAF Score is: 0.312

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THROMBOCYTOPENIA (D69.6); Neutropenia (D70.9);PANCYTOPENIA (D61.8188)

Missed all the time.Must have the Lab Documentation.Document Significant Lab.RAF Score is: 0.312

Diseases of the blood and blood-forming organs

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THROMBOCYTOSIS

Missed all the timeMultifactorial: Infection, Stress to the Body; Cancer; Inflammatory States of Many Kinds; etc.RAF Score is 0.312

THROMBOCYTOSIS, SECONDARY/REACTIVE (D47.3) AND THROMBOCYTOSIS, PRIMARY: MYELOPROLIFERATIVE DISEASE (D47.1)

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Thank you.Host: George Fields, DO

Medical DirectorCo-Host: Mechelle ReedVice President of Configuration, Credentialing & Risk AdjustmentAny questions can be directed to the Provider Services email at Provider_Services@universalcare.com