Transcript 280165

Advanced Practice CDI: Using a
Patient-Centric Model to Take Your
Program to the Next Level
Jennifer Woodworth, RN, BSN, CCDS
Director, Clinical Documentation Integrity Program
Swedish Medical Center, Seattle
Lara Broussard, RHIA
Coding Manager
Swedish Medical Center, Seattle
Objectives
• A year in the life of a new CDI program
• Meeting the challenge of a “patient-centric
model” in the real documentation world
• The documentation specialist: Critical link
• Gaining momentum and sustaining it!
• Renewing the CDI vision and taking it home
Swedish Medical Center,
Seattle
Cancer Institute
Neurovascular Institute
5-hospital system
Regional leader in healthcare
Community-based
Orthopedic Institute
Cardiovascular Institute
Pictures: Swedish Medical Center, Seattle.
Clinical Documentation
Integrity Program (CDIP)
• Managed by a director with 11 CDISs
• Currently reviewing patients at 3 of the 5
•
•
•
•
•
•
hospitals with plans to review all 5 by end of
2012
1,900 discharges per FTE
Review all payers
Utilize vendor (JA Thomas & Associates)
1 physician champion, VP medical affairs
Complete electronic health record (Epic)
Outcome data management (Crimson)
Organizational Structure:
Baseline for Success
Vice President, Medical Affairs
Director, Care Delivery Efficiency and Effectiveness (CDEE)
Vice President,
Finance
Director, Clinical Documentation Integrity
Program (CDIP)
Clinical Documentation Integration Specialists (CDIS)
Executive and Physician
Support
Achieving support at both the executive and the
physician level is critical and serves as the
base for overall program support
Staff
Midlevel/manage
ment
Executive/MD
CDIS Job Description
• Responsible for managing the improvement of
the overall quality and completeness of clinical
documentation through interaction with
physicians, nursing staff, other patient
caregivers, and HIM coding staff
• Works to ensure the appropriate reimbursement
is assigned for the level of service rendered to
patients with a DRG-based payer
CDIS Job Description (cont.)
• Facilitates the accuracy and completeness of
clinical information used for appropriate coding,
core measures, severity of illness measures
• Current license to practice as a registered nurse
in the state of Washington
• A minimum of 4 years’ experience as an RN in
an ICU or emergency department is required
Summary: SMC Critical Factors
for Success
•
•
•
•
•
Dedicated CDI manager
Reports up through clinical administration
Has accountability to finance leaders (CMI)
CDI staff only do CDI
Coding/HIM is separate function with own
reporting structure – collaborative working
relationship vital for success
• MD to MD education at startup and on a
continuing basis
Every Patient Counts
If you are still doing “chart review”...
where does
the
patient come
into
the
picture?
Moving Toward a ‘PatientCentric’ Model
“Today, hospitals cannot afford to lose one
patient __________.”
… complication coded without
ensuring it is a true complication
… admission that met criteria/was
appropriate
… core measure indicator that
was met
… severity of illness
indicator
… comorbidity that was treated
… procedure that was
performed
… patient safety indicator left
unnoticed
Today,
hospitals
cannot
to
lose
one
afford
patient.
With This in Mind …
• Consider advanced practice CDI model
– Patient-centric
– CDI focus is multidisciplinary and with a
“hands-on” approach
– Documentation specialist is at the center of
the clinical picture
– Involvement with outcome measurement
(physician profiles, core measures, patient
safety indicators)
To use a patient-centric model, CDI
professionals must move from
being “chart reviewers” to being
“chart do-ers.”
Current Model
POA/HAC
core measures
Treat and cure
Provide direct
care
Core measures
POA/HAC
Patient safety
Diagnosis clarification
MD education
Translate
Patient active problem list
Compliance
Core measures
Abstract Data
Severity of illness/risk of
mortality
Medical necessity
Outcome management
Patient-Centered: CDS as
Integral Part of Clinical Team
Diagnosis clarification
POA/HAC
Core measures
Severity of illness/risk of mortality
Patient safety
Documentation specialist
Translators of care
Outcome management
Compliance
MD education
Medical necessity
Clinical team
at bedside
Caregivers
The CDS Role: Where Is Yours
Going?
CMS core measures data
Physician education
Optimal
reimbursement $
Patient safety
POA/HAC
Concurrent diagnosis
clarification
Severity of
illness/risk
of mortality
Hospital active
problem list
Outcome measurement
Compliance
Gaining Momentum – and
Sustaining It!
• Show real value to organization – learn who
•
•
•
•
your data people are and what reports to ask for
Track individual CDS progress as well as team
accomplishments
Get involved with outcome measurement
Re-invite yourself to meetings with key
stakeholders – bring data and education
Translate data so it is meaningful to providers
The Challenge (and Possible
Momentum Staller!)
• The CDS has to be looking for new and
innovative ways to translate medicine into ICD-9
• What language do your doctors speak?
– Hospitalists
– Family practice
– Surgeons
• General
• Cardiothoracic
• Orthopedic
• Specialists
Example: The Society of
Thoracic Surgeons (STS)
The STS CABG Composite Score
Risk-adjusted
major morbidity
Riskadjusted
mortality
All of the four
medications believed to
improve a patient’s immediate
outcome and long-term risk of
developing more blockages were
prescribed
Use of at least one of the
arteries from the underside of
the chest wall
STS Definition vs. ICD-9
• Cont Coma >= 24 hours: Indicate whether the
patient had a postoperative coma that persists for at
least 24 hours secondary to anoxic/ischemic and/or
metabolic encephalopathy, thromboembolic event,
or cerebral bleed
• Consider “Encephalopathy in the setting of
________”
Closed eyes
Depressed brainstem reflexes, such as pupils not responding to light
No responses of limbs except for reflex movements
No response to painful stimuli, except for reflex movements
Irregular breathing
STS Definition vs. ICD-9
• Renal failure: Indicate whether the patient had
acute or worsening renal failure resulting in one
or more of the following:
–Increase of serum creatinine to > 2.0 and 2x
most recent preoperative creatinine level
–A new requirement for dialysis postoperatively
• Consider “Expected AKI post bypass- resolving”
Serum creatinine rises by ≥ 26µmol/L within 48 hours or
Serum creatinine rises ≥ 1.5 fold from the reference
value, which is known or
presumed to have occurred within one week or
urine output is < 0.5ml/kg/hr for > 6 consecutive hours
Acute Kidney Injury, The Renal Association, March 8, 2011
Case Study: SMC Cardiologist With
6 Opportunities in 10 Cases
4
Perm.
PM + MCC
Initial ICMI = 1.50
Final CM = 1.81
3.5
3
2.5
AMI + MCC
2
Atherosclerosis + MCC
Syncope to Afib
1.5
Angina to CP
1
0.5
0
Case 1
Case 2
Case 3
Case 4
Case 5
Initial CMI (Severity of Illness)
Case 6
Case 7
Case 8
Case 9
Final CMI (Severity of Illness)
Case 10
Case Study: SMC Vascular Surgeon
With 3 Opportunities in 6 Cases
5
4.5
4
Added “Acute blood loss anemia in the setting of
postoperative amputation R foot wound”
3.5
3
Added “PVD secondary to DM with
metabolic encephalopathy”
2.5
Added “PVD”
2
1.5
1
0.5
0
Case 1
Case 2
Case 3
Initial CMI (Severity of Illness)
Case 4
Case 5
Final CMI (Severity of Illness)
Case 6
‘If I Had One Wish …’
Confessions of a CDIS
I’d want a professional website set up
so we can reference it for providers so
they understand what we really
do. And it would have all our data
like number of cases reviewed,
responses to queries by specialty, CMI
% change, and our pics, of course.
To know the best way to contact
each physician. To receive some
sort of reply, whether an auto
reply or personal, that lets me
know they have seen my query.
ASK!
Respected for what I bring to the
hospital.
One reliable, consistent mode of
communication with all providers in
which I can communicate if a
clarification is needed. Communication
is key in our job position; lack of it or
poor tools to work with in order to
communicate is always frustrating
when you have a large group of
people you need to reach.
Updated physician “mug shots”
(with stats such as friendliness,
cooperativeness, clinical
knowledge level, business skill
level, etc.) complete with contact
info.
The Secret to CDI Staff
Success
• Engage yourself
• Project that what they do is important to the
hospital
• Translate the data into real meaning
• Provide a consistent message
• Give them the tools they need to do their job
Show them how their work translates back to the
patient and you create the same motivation that
brought them into healthcare in the first place.
Creating a CDI Vision
• Does your hospital still consider you a “record
•
•
•
•
reviewer”?
Does your data show real value? (Are you
tracking all possible areas in which your
department impacts the organization?)
Where will your department be in 1 year? 2 and
5 years?
Are you able to take advantage of the new
technology? (i.e., computer-assisted coding)
How close is CDI to the patient?
What Does Vision Look Like?
Staff asking, “Can I help you?”…
… to, “Have you seen this
patient? She is really sick and I
want to make sure everything
is documented.”
Take It Home
The most successful CDI programs
(Insert your 3)
are ____________.
… patient centered
… data driven
… outcome measurers
Every Patient Counts
Thank you!
Swedish Medical Center CDI team
Questions?
In order to receive your continuing education certificate for
this program, you must complete the online evaluation which
can be found in the continuing education section at the front
of the workbook.