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Quality & Documentation PowerPoint Presentation, PPT - DocSlides

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For Heart Failure & AMI . Programs. Nathalie De . Michelis. , . Cardiovascular . Program Manager. July 24. th. , 2014. Formal . outpatient HF . Clinic program. 1535 HF . clinic . visits. 551 single pts. ID: 738101

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Slide1

Quality & DocumentationFor Heart Failure & AMI Programs

Nathalie De

Michelis

,

Cardiovascular

Program Manager

July 24

th

, 2014

Slide2

Formal outpatient HF Clinic program

1535 HF

clinic visits551 single ptsDischarge Unit & Servicesfor Primary HF Dx

Heart Failure ProgramInpatient and Outpatient FY 2013-2014

Inpatient visit volume174 PDx of AMI254 PDx of HF254 with 2nd Dx w/ Acute HF

Slide3

CV Program Design…Coordinated Care Across the Continuum

(In-patient)ED triage (CP unit, CP/AMI & HF Algorithms)Identifying patient population/AMI & HF program introduction Multidisciplinary Clinical PathwaysHF & PCI

EBT Cardiology Order Sets Please try to useA fib, AMI, CP, EP, HF,

Cath, PCIInitiation of patient education process by HF NP & HF CoachState-of-the-art diagnosticsCollaborative input for advanced treatments:interventional, device, surgical therapies, cardiac anesthesiaComprehensive discharge plan/case

mgmtf/u with in a week, Home Health when eligible,….

Palliative care/end of life

Research pool

Slide4

CV Program Design…Coordinated Care Across the Continuum(Out-Patient)

UCI Cardiac Rehab

Cardiology ClinicGeneral CardiologyEP/Pacemaker ClinicValve ClinicWoman Card ClinicAdult Congenital Clinic

CV Preventive ClinicHF Clinic

Open access & program follow-upTimely post-discharge HF recommendations to PCPHF Program f/u of moderate-advanced HFIV Lasix48 hrs and 1 month follow-up phone calls  to prevent ED ReadmitHF & DM Chronic Disease in person Coach

Care Palliative Care Collaboration soon…HF/Palliative clinic

Research pool

Slide5

HF & AMI

L

istHF/AMI ListCommunication tool, between the HF Program Manager & the care team, to assist with the identification & the care of this population

Let me know if patients need to be added or deleted from the list below.Please

clarify pink areas on the patient listMemorandum of Agreement between IM & Cardiology for HF for Heart Failure PatientsNew Onset HF Admit to Card ServiceAcute HF following in UCI Card Admit to Card Other Acute HF  request a Card consult

Slide6

Quality Initiatives

Joint Commission Certified HF

Program

since 2008Dr. D. Lombardo Medical Director

OC Cardiovascular Receiving Center since 2005Dr. P Patel Medical DirectorMultiple National & State Quality InitiativesAmerican Heart Association (Gold Plus HF AHA award)

American College Of Cardiology

CMS & Joint Commission Measures

Readmission Reduction Task Force

DSRIP projects

I

mprovement of Primary Care in

HF & DM

Disease management

Research

Slide7

What are Hospital Quality Measures

Measures based on:

Scientific evidenceReflect guidelinesStandards of care or practice parametersConverts medical information from patient records into a rate or percentage that can be assess

Slide8

Why quality measure are important?

Use to assess:

How well care is provided to our patientOur performance over timeHelps improve patient care

Benchmark for outcomes & resource utilization (Internal, External , Public)

Public ReportingCMS & The Joint Commission Healthcare consumerismCMS.gov (Hospital Compare), Healthgrades.com, WebMD.com, State organizations

Pricing, Payment and ContractingQuality data used by insurers in negotiating contracts

Rate affect Reimbursement

rate

Pay-for-performance, VBP, Readmission Reduction Program

Physician Quality Reporting System

(PQRS), HEDIS

Slide9

AMI Hospital Quality Measures - CMS, TJC

Outpatient Arrival time to ECG &

Troponin for CPAspirin within 24 hrs of Arrival (or clear documented contraindication)

PCI Within 90 Minutes of Arrival for STEMIFibrinolytic within 30 Minutes of Arrival for STEMI (not used at UCI)

Discharge on (or clear documented contraindication if not)Aspirin ACE or ARB for LVSD

Beta Blocker

Statin

AMI

30 days Mortality rate

AMI 30 days Readmission rate

Slide10

AMI Composite

Slide11

AMI 30 Day Readmission rate

Slide12

Hos

pital compare for

AMI- PCI & ASA-CP measureshttp://www.medicare.gov/hospitalcompare/search.html

Slide13

Hospital

compare -

HCAHPS

Slide14

HF Hospital Quality Measures

% of HF patients given:

Discharge Instructions (need all 6 items)Diet  Cardiac diet  be more descriptive – i.e. 2g low salt, low fat….

Activity levelDaily

Weight Monitoring  Even if on DialysisMedications (complete reconciliation w/home & hosp. Rxwith indication for each Rx (NEW TJC measure)Symptom

managementRecommend

pt

to call if weight gain is >3lbs in a day or > 5lbs in a week

Follow-up

appointment

(with date and time on DC Instruction)

Documentation

of LVS function

ACE

or ARB for

LVSD at discharge

(or clear documented contraindication)

HF 30 days Mortality rate

HF 30 days readmission rate

Slide15

HF TJC & AHA GWTG Measures

DVT Prophylaxis while in hospital

Prior to Discharge on (or clear documented contraindication if not)Pneumococcal VaccinationInfluenza Vaccination During Flu SeasonICD Placed or Prescribed For EF≤ 35 (exclude new onset):

ICD Placed or Prescribed CRT-D or CRT-P Placed or Prescribed if QRS ≥120 or QRS ≥ 150 or LBBB

Discharge on (or clear documented contraindication if not)Evidence-Based Specific Beta Blockers for LVSD (Bisoprolol, Carvedilol, Metoprolol

CR/XL)Aldosterone Antagonist

Anticoagulation

for Atrial

Fibrillation

Hydralazine

Nitrate ( for African Americans on OGMT)

Post Discharge Appointment

(including date

,

time, location; or

home health

visit)

Follow-Up Visit Scheduled

Within 7 Days

or

Less

Slide16

HF Hospital Quality Measures –

HF Composite

Slide17

Hospital compare for

HF

Slide18

GWTG Achievement & TJC Measure –

Evidence-Based Beta Blockers

[TJC Target 90%]

[GWTG Target 85%]

Slide19

GWTG Achievement & TJC Measure –

Aldosterone Antagonist for LVSD at DC

[GWTG Target 75%]

Slide20

GWTG Plus Quality Measure

Anticoagulation for A. Fib

[GWTG Target 75%]

Slide21

GWTG

Achievement

Measure Follow-up at Discharge (with date, time & location)

[Target 85%]

Slide22

HF 30 Day Readmission rate

Slide23

How to improve HF/AMI measures & outcomes?

Slide24

How to improve HF/AMI measures?

Treating all present health

issuesMake sure well compensated when DCEducation during hospital stay- Patient should be familiar & competent with: Condition

MedicationSymptom ManagementLife style change

Importance of follow-up ( to prevent no show)Proper Documentation of Guideline therapy or explicit contraindicationi.e. ACE & ARB contraindicated at this time due to worsening renal function

i.e. Not on anticoagulation for A. Fib due to active GI bleeding

Proper

Documentation

of conditions & procedures

as it affect Coding

Slide25

How to improve HF/AMI measures?

Use Disease Specific Order Set

Proper DischargeMedication ReconciliationAll needed components are on Discharge instructionsThe discharge summary document must contain

Provider contact informationDischarge date Discharge DiagnosisUpdated summary of the patient’s hospitalization.

Pending labs, test and imagingOther follow-up issues for next providerComplete set of discharge instructions

Slide26

Discharge Process

Proper transition of care

Early follow-up (7 days post dc with PCP & needed specialties)Give Date & time of appointment before dischargePrompt transfer of hospitalization information to PCP or to next care providerAccess to care and medicationRefer to Home Health, Cardiac Rehab, Telemonitoring

Refer to free UCI Patient education classes.HF, Heart Diet, DM, HTN

The discharge summary creates the Discharge instructionsBe certain the nurse provides the patients with the FINAL versionmust notify nurse if there are any last minute changes Go over the instructions with the patient/family Fax/e-fax/mail discharge summary to the next care provider

Slide27

Discharge note –Core Measures

Please complete on all AMI & HF (chronic or acute)

Memory Aids &Last chance to meet measures

Slide28

Memory Aids

Slide29

Memory Aids

Slide30

UC Irvine HealthThe importance of Clinical Documentation

Slide31

Why should we care?Documentation

drives:

The levels of coding, billing and reimbursementMeasure ComplianceSeverity of Illness (SOI) and Risk of Mortality (ROM)Measures by which healthcare organizations

& healthcare providers are evaluated and rankedStay competitive in the market

Insurance Companies’ ContractingGeneral public shopping for careDue to trend of greater transparency & availability of clinical performance data, on internet websites (e.g. Healthgrades, hospital compare)

Prevention of random audits by the

government

and

serves to support the care provided by a healthcare provider in such an

event

Reduce

liability in

the event of legal

action

Slide32

Surfing for Quality of Care and Priceshttp://hospitalcostcompare.com

Hypertension Without Major Complications

Slide33

Hospital & Physician Report CardsHealthgrades.com Medicare.gov/hospitalcompare

Slide34

One thing leads to the next

Documentation

ICD CodeDRG (Diagnosis-Related Group)Severity adjusted DRGSeverity of illness & Mortality dataOutcomes + Accurate Documentation = Quality

Observed mortality

Expected mortality(From severity adjusted DRGs)

Slide35

What is a DRG and how does it work?

Identifies

the "products" that a hospital providesDRGs have been used in the US since 1982 to determine how much Medicare pays/reimburses the hospital for each "product“It is similar to a known recipe:Each DRG has a relative cost weight & expected LOS

Slide36

DRGsDRGs that are associated with a higher frequency of mortality are

frequently under documented

in regard to severity of illness i.e. heart failure, pneumonias, urinary tract infections, & malignanciesExample:Patients have who that have respiratory failure and cardiac arrestMost go into Hypotensive shock and have com. respiratory failure So if would document theseit would change the MS-DRG

and improve predicted mortality measuresInherently, the MSDRG system penalizes rushed documentation

Slide37

SOI, ROM, CC & MCCEvery patient we treat

get assigned a SOI & ROM rate based on the documentation between 1 and 4 . -1: Minor - 2: Moderate -3: Major -4: ExtremeSecondary Diagnosis Coding Rule and impacts: DRG Assignment, Severity of Illness/Risk of Mortality Reporting; and Organization and Physician Profiling, evaluation and ranking. Documentation of Diagnosis with severity (Acute, Acute on Chronic or chronic) instead of signs and symptomassist with CC/MCC, SOI & ROMImportant to document in detail the CCsAll co-morbidities

(Condition present on admission) All complications (Condition that develop after admission)

Slide38

Cardiac Diagnosis(Dx with** are not counted if patient expires)

Slide39

Respiratory Diagnoses(Dx with** are not counted if patient expires)

Slide40

Case Example 55 y/o female LOS 11 days - expired

When ≥ 3 different

organs are affected  start to

see MCC

Slide41

Heart Failure DRGs Comparison

Slide42

3MMS DRG 285 AMI, expired w/o CC/MCC Dx suggestion to consider

M= Affect

DRG S=Affect Severity R=Affect Mortality

Slide43

MSDRG are assigned a mortality risk model

Using

specific variable descriptionsThe mortality is than calculated and give us:our expected morality rate versus actual observe mortality The goal is to have high expected rate for low observe rateThis rate is used in our data and benchmarking

Slide44

Case example risk model 901:Assigned MSDRG of 285- AMI, expired without Comorbidity or Complication (CC)/Major

CC

Mortality model 901Variable Description

Model Group

Beta

Odds Ratio

95% Lower Confidence Interval

95% Upper Confidence Interval

P-Value

Intercept

901

4.452

Vent on Admission Day

901

1.938

6.943

6.137

7.854

0.000

Cardiac Arrest

901

1.816

6.149

4.943

7.649

0.000

Shock

901

1.589

4.897

4.290

5.590

0.000

Aortic Aneurysm Dissection/Rupture

901

1.520

4.571

2.763

7.561

0.000

Female, Age >= 85

901

1.418

4.127

3.541

4.811

0.000

Male, Age >= 85

901

1.393

4.026

3.404

4.761

0.000

Male, 80 <= Age < 85

901

1.195

3.304

2.738

3.987

0.000

Endocarditis

901

1.027

2.793

1.924

4.054

0.000

Female, 80 <= Age < 85

901

0.979

2.661

2.187

3.238

0.000

Other Pulmonary

901

0.887

2.428

1.571

3.750

0.000

Male, 75 <= Age < 80

901

0.795

2.214

1.817

2.697

0.000

Female, 75 <= Age < 80

901

0.769

2.159

1.743

2.674

0.000

CC Metastatic Cancer

901

0.760

2.137

1.658

2.756

0.000

Hypotension

901

0.724

2.062

1.784

2.384

0.000

Vfib

901

0.702

2.018

1.573

2.587

0.000

Ischemic Stroke

901

0.631

1.879

1.350

2.615

0.000

AMI Subsequent

901

0.576

1.779

1.232

2.569

0.002

Female, 65 <= Age < 75

901

0.563

1.756

1.470

2.097

0.000

Severe Brain/Spinal Conditions

901

0.562

1.754

1.479

2.081

0.000

Renal Disease/Failure

901

0.521

1.683

1.533

1.848

0.000

Male, 65 <= Age < 75

901

0.473

1.605

1.362

1.891

0.000

Acute Liver Disease

901

0.441

1.554

1.234

1.956

0.000

Sepsis

901

0.437

1.549

1.272

1.886

0.000

Admit Source = Transf From Skilled Nursing/Long Term Care

901

0.435

1.546

1.211

1.972

0.000

CC Fluid & Electr Disorders

901

0.351

1.421

1.289

1.566

0.000

CC Peripheral Vasc Disease

901

0.261

1.298

1.163

1.449

0.000

Aortic Stenosis

901

0.243

1.274

1.114

1.458

0.000

CC Coagulopthy

901

0.230

1.259

1.075

1.476

0.004

Admit Source = Transf From Acute

901

0.225

1.253

1.136

1.381

0.000

Male, 31 <= Age < 51

901

0.467

0.627

0.477

0.824

0.001

Slide45

UCI Q1 2014 Clinical Outcome reportRisk-Adjusted Mortality

Slide46

AMI case exampleOriginal attestation sheet

SOI of 3 and ROM of 3 (Major

)DRG 285 - Acute myocardial infarction, expired w/o CC/MCCDRG payment $9117.25

Slide47

Documentation correction

Patient

chart documentation improvement that affects SOI & ROM:Pleural effusion only (would affect SOI)Add

Acute Diastolic Heart Failure (would give it a CC, and affect DRG, SOI & ROM)

IntubatedInstead on a mechanical ventilator (would give it a

MCC)Fluid overload & Hyperkalemia

Instead

Fluid

&

Electr

Disorders (hyperkalemia)

(would

affect

ROM)

 

Also to affect DRG, SOI &ROM Prior to arrest could document:

Com Respiratory failure

Hypotension shock

Coma

Slide48

Coding attestation post documentation

SOI of

4 and ROM of 4 (Extreme)DRG 283- Acute myocardial infarction, expired w MCCDRG payment $22597.06 (+ $13479.81)

Slide49

Documentation & coding

Coders are limited in what they can code

They are not allowed to “interpret”i.e. Hgb 5.0 ≠ to anemiaDocument anemia with specific type, acuity & causeV Fib, Chest compression, defibtillation, epi …Cardiac arrest/CodeBacteriemia

sepsisNo response no noxious stimuli ComaDocument suspicions to the highest degree

knownFail documentation often happen when unable to obtain a test or specimenDocument what the treatment is based on the clinical pictureI.e “Suspect G-pneumonia, ….Rx.. given, as unable to obtain a sputum specimen.” Do not under-state discharge diagnoses

 

Slide50

Heart Failure Documentation

r/o differential diagnosis if

n/a anymorei.e. COPS vs HF VS PN. HF is or is no longer the differential diagnosis for SOB/Volume Overload “Likely”= possible coding of that conditionDetermine if it is Right or Left Heart Failure

RHF = gets coded as 428.00 Unspecified HF , no code exist for RHF

Document cause of RHF i.e. RHF 2/2 Cor Pulmonale iF RHF alone need to meet all measures

Slide51

Heart Failure Documentation

Specify

to type Combine Systolic and DiastolicDiastolicSystolicDo not use systolic alone. Patients with systolic HF also have diastolic HF

Specify the acuityAcuteChronic

Acute on Chronic most acute HF patientsSpecify the etiology/cause if available (…HF 2/2…)Ischemic, Afib, HTN, Valvular,…

Slide52

Heart Failure SpecificityIf

the type is not document

event if acuity is It gets coded as 428.00 Unspecified HF i.e. Acute HF = 428.00 Unspecified HF A documented EF is not a diagnosis of HFEF 30% ≠ not coded as systolic

CHF exacerbation ≠ not coded as acute 428.00 Unspecified HF

≠ do not count as a comorbidityNew HF definition such as HFpEF, HFreF ≠ not coded Example proper documentation:Chronic

Systolic LV dysfunction 2/2 Ischemic CardiomyopathyAcute Diastolic LV dysfunction 2/2 Afib with RVR

Acute on Chronic Systolic LV dysfunction medication noncompliance

Right Heart Failure d/t acute Pulmonary HTN 2/2

Cor

Pulmonale

Slide53

ACS/AMI-Severity issues

Consist of 3 major clinical entities in a continuum

Unstable anginaNSTEMISTEMICaution with documentation of:ACS alone = gets coded as UAMI type 2 demand ischemia  gets coded as generic AMI (so

needs to meet guidelines)Otherwise to not document MI. Only Elevated troponin, demand ischemia 2/2….Severity issues

Identify new LBBBLocation of MIIdentify cardiogenic shockIdentify acute or chronic systolic HF when it is presentHypotension ≠ not codable as cardiogenic shockLow BP is not cardiogenic shockMulti organ failure ≠ not

codable

Slide54

STEMI & PCI documentation

If LBBB, Document if new or old.

If NEW = STEMI (needs to meet all AMI Measures)Document clearly if 1st ECG is STEMI or NSTEMIBe consistent through-out the chart

If PCI delay document:” PCI delay due to…”

Pt atypical presentation into the ED r/o aortic dissection prior PCI Pt hemodynamic and clinical instability requiring stabilization Difficult access to coronary arteries Difficult vascular access

Insertion of IABP prior PCI (w/i

90 min of arrival)

Cardiopulmonary arrest (w/

i

90 minutes of arrival)

Initial patient/family refusal

Pt wished to delay/wait before starting PCI (initially withheld consent)

Emergent testing required prior PCI 

Other  [write]

Slide55

SummaryDocumentation become our data

key

measure of performanceCorrect documentation is critical to improving performance It allows you to see where actual problems lieDiagnostic statements must be explicitly statedSymptoms, orders, treatments, X-ray evidence does not replace a diagnosisBenchmarking allows to compare performance against the expected averages

Slide56

THANK YOU

Question?


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