Transcript 4QFY2015 EPRP Update.ppsx

EPRP UPDATE
4Q FY2015
4TH QUARTER UPDATE
• This presentation will serve to highlight the revisions
to EPRP instruments and scoring for 4QFY2015
• As always, it is critical that you read the questions
and definition/decision rules, paying particular
attention to highlighted areas
• Please review the following slides and have them
available as you complete the 4Q Learning
Assessment
HBPC
HBPC
• We will begin with the HBPC instrument which has
the most changes for 4QFY2015
• All changes are in the Environment Safety/Risk
Assessment section and involve a series of questions
about oxygen safety
OXYGEN SAFETY
• You will notice a change in the order of the
questions in the Environment Safety section with all
the oxygen safety questions now at the end.
• If the patient is not oxygen dependent, you will go
to the end of the HBPC instrument after answering
question 45 (envoxy)
• Note that oxygen consult has been added as a suggested
data source for q45
QUESTION 46
• Q46 asesoxy is not new, but has been re-formatted
to include the required components of a home
oxygen safety risk assessment in the question
• During a face-to-face encounter within 30 days of
HBPC admission date, was a home oxygen safety
risk assessment documented by a HBPC team
member to include all of the following
components?
• Whether there are smoking materials in the home,
• Whether or not the home has functioning smoke detectors, and
• Whether there are other fire safety risks in the home, such as the
potential for open flames
QUESTION 46
• Remember:
• Any HBPC team member may complete and document the
Home Oxygen Safety Risk Assessment.
• The risk assessment must be performed during a face-toface encounter in the Veteran’s place of residence by a
member of HBPC team.
• Suggested Data Sources:
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HBPC Environment Assessment note
HBPC Home Oxygen Checklist
HBPC Rehabilitation Therapy (KT/OT/PT) Assessment
Nursing Admission Assessment or notes
HBPC Respiratory Therapy notes
NEW QUESTION-oxyedu
• If a home oxygen safety risk assessment was done
(q46=yes) you will get a new question
• Q47 oxyedu
• Did the HBPC team member inform and educate
the patient/caregiver about all of the following?
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The findings of the oxygen safety risk assessment
The causes of fire
Fire risks for neighboring residences and buildings
Precautions that can prevent fire-related injuries
Q47 oxyedu
• Any member of the HBPC team may inform and
educate the patient/caregiver regarding home
oxygen safety.
• Review the suggested data sources for
documentation that the patient/caregiver was
educated about all of the components as listed in
the question
• If the answer to q47 is “yes”, you will go to question
48
NEW QUESTION 48 - oxyrec
• Did a HBPC team member document
recommendations to address identified oxygen
safety risk(s)?
• 3. Yes
• 4. No
• 5. HBPC team member documented that NO oxygen
safety risks were identified
Q48-oxyrec
• If any member of the HBPC team documented
recommendations to address identified oxygen
safety risks, select value 3, yes
• Please review the examples of documentation of
interventions to address oxygen safety risks in the
definition/decision rules
• If oxygen safety risks were identified but there is no
documentation of recommendations to address
them, select value 4, no
• If an HBPC team member documented NO oxygen
safety risks were identified, select value 5.
NEW QUESTION-oxyrecres
• If recommendations to address oxygen safety risks
were documented (oxyrec=3) you will go to
question 49, oxyrecres
• Following documentation of the home oxygen
safety/risk care plan or intervention, was response
to the care plan/ intervention evaluated by a HBPC
team member?
• 3. Yes
• 4. No
• 5. No HBPC visit between home oxygen care
plan/intervention and study end date
Q49-oxyrecres
• Evaluation of the response to the care plan/intervention
may be
• face to face,
• telephone or
• clinical video teleconference (CVT)
• Any member of the HBPC team may document
response to care plan/intervention
• Please review the examples of response to interventions
in the definition/decision rules
• If no response to the care plan/intervention was
documented, select value 4, no
• Select value 5 if there was no HBPC visit between home
oxygen care plan/intervention and study end date
HBPC EXIT REPORT/SCORING
• There are no changes to HBPC scoring or to the exit
report
• The new oxygen assessment questions are not included in
any measure although envoxy and asesoxy continue to be
part of scoring for hc31
CGPI
CGPI
• There are changes in the Mental Health, Prevention
and Medication Reconciliation modules of CGPI
• All other CGPI modules are unchanged
MENTAL HEALTH MODULE
• There is a new skip at the beginning of the MH
module
• If dochospce = 1, go out of module; else go to
dementdx2
• Cases with terminal illness as per the dochospce
question will be excluded from mental health
screening questions and the associated measures
PI MODULE
• dochospce: wording has been added to indicate
that a “yes” answer also excludes the case from the
Mental Health module
• There is a skip change in the Pap test series of
questions
• When compap=1 and compap2=2 or 3, the next question is
compapro
• This allows collection of data needed for ctr7-11
PI MODULE
• The question mamperva has been removed and
replaced with a new question, mamperva2
• Was the mammogram performed by the VHA?
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3. Mammogram performed at a VAMC
4. Mammogram performed outside VHA, fee basis
5. Mammogram performed private sector, not fee basis
95. Not applicable
• Only mammograms performed at a VAMC (value
3) will be included in the CTR measures
mamperva2
• Please review the definition/decision rules for
mamperva2
• Value 3 = mammogram was performed at a VAMC.
• Value 4 = mammogram performed outside VHA, fee
basis
• Fee basis may be determined by checking to see if
mammogram was ordered by and a consult placed by VHA.
• Value 5 = mammogram performed private sector, not
fee basis
• includes documentation the mammogram was performed
outside VHA such as patient self-report documented by VHA
staff or outside mammogram report without evidence it was
ordered by VHA
OP MEDICATION RECONCILIATION
• There is an important clarification to the
definition/decision rules of question 9, opmedlist
• When medication changes are noted, the medication list
should reflect the changes or documentation should indicate
that the reconciled medication list was provided to the patient
after the changes were made
• For example, APN notes, “Increase Lisinopril to 20 mg daily.
Copy of reconciled med list given to patient.”
• Please review the documentation carefully to be
sure it meets the intent as stated above; if it does
not, answer “no” to opmedlist
CGPI EXIT REPORT/SCORING
• dochospce=1 is now an exclusion for the following measures
that appear on the CGPI Exit Report:
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mdd40-Screened for depression with PHQ-2 or PHQ-9
mdd41-Positive depression screen with timely suicide evaluation
ptsd51-Screened for PTSD at required intervals with PC-PTSD
ptsd52-Positive PC-PTSD screen with timely suicide evaluation
sa7-Screened for alcohol use with AUDIT-C
sa17-AUDIT-C score 5 or greater and brief alcohol counseling documented
sre1-Positive depression or PTSD screen with timely suicide evaluation
• An * appears by these measures on the CGPI exit report
• dochospce=1 is also an exclusion for the following measures
that do not appear on the CGPI Exit Report: mdd45 and 46,
ptsd54 and 55
COMBINED COHORTS EXIT
REPORT/SCORING
• The Combined Cohorts exit report guide will
highlight the changes
• if mamperva2 is anything but 3, the case will be excluded
from all CTR measures for mammogram
• There is a change in the pap section of ctr7-11
TBI
QUESTION 26- reschevl2
• “Caregiver” has been added to answer option 98
• On the date of or within 14 days after the patient was a no
show or cancelled the initial Comprehensive TBI Evaluation
appointment, does the record document that the facility
successfully contacted the patient to reschedule the
Comprehensive TBI Evaluation?
• 1. Yes
• 2. No
• 98. Patient/caregiver refused to reschedule the CTBIE
TBI EXIT REPORT/SCORING
• There are no changes to the TBI exit report or
scoring
HOP
HOSPITAL OUTPATIENT
• Two new questions have been added to the HOP
instrument to allow for collection of provider
contact date and provider contact time
• These questions will be used in scoring a new
measure hop20: Door to Diagnostic Evaluation by a
Qualified Medical Professional
NEW QUESTION 7-provcondt
• Enter the date the patient first had direct personal
exchange with the physician/APN/PA or
institutionally credentialed provider to initiate the
medical screening examination in the emergency
department
• Advanced Practice Nurse (APN, APRN) titles may vary between
state and clinical specialties
• Some common titles that represent the advanced practice
nurse role are
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•
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Nurse Practitioner (NP)
Certified Registered Nurse Anesthetist (CRNA)
Clinical Nurse Specialist (CNS)
Certified Nurse Midwife (CNM)
• Exclude triage nurse
QUESTION 7-provcondt
• The only acceptable source is the ED record
• If the date of provider contact is not documented, but
you are able to determine the date from other ED
documentation, enter the date
• Enter 99/99/9999 if
• the date the patient first had direct contact with the physician/APN/PA
or institutionally credentialed provider is unable to be determined from
medical record documentation
• If there is documentation the patient left against medical advice and it
cannot be determined whether the patient had direct contact with the
physician/APN/PA or institutionally credentialed provider
• When the date documented is obviously in error (not a valid
format/range or outside of the parameters of care) and no other
documentation is found that provides this information
NEW QUESTION 8-provcontm
• Enter the time the patient first had direct personal
exchange with the physician/APN/PA or
institutionally credentialed provider to initiate the
medical screening examination in the emergency
department
• The intention is to capture the earliest time at which
the patient had direct contact with the
physician/APN/PA or institutionally credentialed
provider in the emergency department
• Exclude the triage nurse
• The ED record is the only acceptable source
QUESTION 8-provcontm
• Enter 99:99 if:
• the time the patient first had direct contact with the
physician/APN/PA or institutionally credentialed provider is
unable to be determined from medical record
documentation
• If there is documentation the patient left against medical
advice and it cannot be determined whether the patient
had direct contact with the physician/APN/PA or
institutionally credentialed provider
• the Provider Contact Time is documented prior to arrival or
after departure/discharge from the ED
• the time documented is obviously in error (not a valid
format/range) and no other documentation is found that
provides this information
HOP EXIT REPORT AND SCORING
• Hop20 has been added to the Exit Report
• Door to Diagnostic Evaluation by a Qualified Medical
Professional
• The score will be the median time from date/time of arrival
to date/time of first direct personal exchange with the
physician/APN/PA or institutionally credentialed provider
• Details of scoring will be provided in the HOP Exit Report
Guide
INPATIENT INSTRUMENTS
NO CHANGES
• There are no changes to the following instruments or
to the associated Exit Report and scoring:
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ACS
IHF
PN
Surgical Care
VTE (skip changes only)
GLOBAL
• There is only one change to the Global instrument
• An example, based on Joint Commission
clarification, has been added to the
definition/decision rules of question 33, briefint
• Example:
“Patient drinks above recommended limits and was advised
to abstain from alcohol use. Medical problems associated
with alcohol use were reviewed with the patient. Specifically
the following were reviewed: Medication interactions,
psychiatric disorders. Patient declined referral to Substance
Abuse Treatment”. Select 1, 2 and 3.
GLOBAL EXIT REPORT AND SCORING
• There are no changes to the Global Exit Report or
scoring for 4QFY2015
HBIPS
• Clarification of the timeframe and required
documentation has been added to the
definition/decision rules for four elements of admission
screening
• assessud
• The intent of this data element is to screen the patient for
substance use within the 12 months prior to admission.
• Documentation of substance use must at a minimum state over the
past 12 months.
• Documentation of a past history of substance use should
differentiate the use being either within the past 12 months or prior
to the 12 month time frame.
• Documentation of “no history” cannot be used, unless it is
associated with a time frame. For example:
• “No history of substance use within the past 12 months.” OR
• “History of substance use 2 years ago.”
HBIPS-ADMISSION SCREENING
• Assesalc
• The intent of this data element is to screen the patient for
alcohol use within the 12 months prior to admission.
• Documentation of alcohol use must at a minimum state over
the past 12 months.
• Documentation of a past history of alcohol use should
differentiate the use being either within the past 12 months or
prior to the 12 month time frame.
• Documentation of “no history” cannot be used, unless it is
associated with a time frame. For example:
• “No history of alcohol use within the past 12 months.” OR
• “History of alcohol use 2 years ago.”
HBIPS-ADMISSION SCREENING
• Harmothr
• The intent of this data element is to screen the patient for
violence risk to others within the 6 months prior to admission.
• Documentation of violence risk to others must at a minimum
state over the past 6 months.
•
Documentation of a past history of violence risk to others should
differentiate the risk being either within the past 6 months or prior to
the 6 month time frame.
• Documentation of “no history” cannot be used, unless it is
associated with a time frame. For example:
• “No history of violence risk to others within the past 6 months.”
OR
• “History of violence risk to others over a year ago.”
HBIPS-ADMISSION SCREENING
• Harmself
• The intent of this data element is to screen the patient for
violence risk to self within the 6 months prior to admission.
• Documentation of violence risk to self must at a minimum state
over the past 6 months.
•
Documentation of a past history of violence risk to self should
differentiate the risk being either within the past 6 months or prior to
the 6 month time frame.
• Documentation of “no history” cannot be used, unless it is
associated with a time frame. For example:
• “No history of violence risk to self within the past 6 months.” OR
• “History of violence risk to self over a year ago.”
HBIPS-Q 19 refrnext
• There are some additions and clarifications to question 19,
refrnext
• Please note the changes to responses 2 and 3
• 2. The medical record contains documentation of the following:
• the patient or guardian refused the next level of care provider upon
discharge from a hospital based inpatient psychiatric setting OR
• the patient or guardian refused to authorize release of information OR
• the patient was readmitted to the same facility within 5 days after discharge
• 3. The medical record contains documentation that the patient:
• eloped and was discharged OR
• failed to return from leave and was discharged OR
• was discharged from the hospital to another level of care outside of the
hospital system from a setting other than a Psychiatric Care Setting OR
• residence is not in the USA and patient is returning to another country after
discharge
HBIPS-Q 19 refrnext
• Clarifications in the definition/decision rules:
• A referral to attend support groups, i.e., Alcoholics
Anonymous (AA), Narcotics Anonymous (NA), etc. after
discharge is not a referral to a next level of care provider.
• When value 2 or 3 is selected, creation and transmission of a
continuing care plan is not required; the software will skip
these questions
HBIPS-Q20 psymedc
• There is an addition to the definition/decision rules
for question 20 psymedc
• All antipsychotic medications should be counted
regardless of the indication for use or the reason
documented for prescribing the antipsychotic
medication
• Also, the rules now refer to Joint Commission
Appendix C (instead of B), Tables 10.0 and 10.1
• This reference was sent to you in 2QFY2015
HBIPS-Q28 plndcmed
• Please note the important change in the
definition/decision rules for question 28 plndcmed
• If more than one list of medications is included in
the continuing care plan documents and the lists do
not match, select “2”.
• As there is a conflict between two separate documents, a
receiving practitioner would not be able to determine the
accurate medication regimen.
• Please carefully review the documents that make
up the continuing care plan and be certain you are
adhering to this abstraction rule
HBIPS EXIT REPORT AND SCORING
• There are no changes to the HBIPS Exit Report or
scoring
STROKE
• There are a few changes to skip patterns in the
Stroke instrument
• The changes are highlighted for your information but as
always the software will take you to the correct questions
• A revision has been made to q27(antithrom) and
q44 (dcanthrm) to clarify that heparin flush, heparin
SQ and Hep-Lock are not included as
antithrombotic therapy
STROKE EXIT REPORT AND SCORING
• There are no changes to the Stroke Exit Report or
scoring for 4Q.
COMMON MODULES
• The Delirium Risk module will be enabled only for
catnums 10, 29, 41, and 53
• The Inpatient Medication Reconciliation module will
be enabled only for catnum 29 and 53
REMINDERS
• The Regional Managers and those of us at WVMI
want to be helpful to you
• When you have an abstraction question or a
question about scoring we can be of better
assistance if we are clear about what issue we are
trying to address
ASKING QUESTIONS
• For abstraction questions it is important that you tell us which
instrument and which specific question you are trying to
answer
• In some cases we may also need to know the pull list date, the study
interval or dates of admission/discharge
ASKING QUESTIONS
• Sometimes we get questions like this: The patient refused
pneumococcal immunization two days before he was
admitted. The liaison says that counts. Can I take that?
• We could better answer the question if we knew (for
example): The instrument is Global and I am trying to answer
the question vaxstat. The only documentation about
pneumococcal immunization I found is that the patient
refused on 4/10/2015. The patient was admitted on 4/12/15
and discharged on 4/14/15. How do I answer vaxstat?
ASKING QUESTIONS
• Another example; this one is a scoring question: The
patient refused the influenza immunization in
February. Why is the case falling out on the DAC?
• We could better help you if we knew: Which
instrument (CGPI or GM) and the specific
mnemonic (e.g. p25h, p26h, or imm4)
• A little information up front will help us help you.
ALSO
• The exit report guides are not a guide to abstraction
• Exit report guides are to help you understand the scoring,
i.e. what is included in the measure, and what passes the
measure
• You should never decide how to abstract a data element
by using the exit report guide
• The definition/decision rules associated with each
question are the guide to abstraction. They help
you determine how to answer a question based on
the documentation you find in the record
THANKS!
• Thank you for taking time to review this presentation
and the 4Q questions and exit guides.
• We appreciate your attention to the details!