Transcript Q1 FY2011CGPI-HBPC.pps

Q1 FY2011
CGPI and HBPC Instrument Changes
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1Q FY11 Education
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The purpose of this presentation is to
acquaint you with some general changes
associated with EPRP data collection and the
1QFY11 changes to the CGPI and HBPC
instruments
You will receive additional Power Point
presentations to review changes to the
inpatient instruments and common modules
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Send us your questions!
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As you review the PPT presentations,
write down your questions and then
email them to me ([email protected])
A conference call(s) will be held to
review the questions and answers
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Learning Assessment
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The required learning assessment will be
made available to you following the
conference calls
It is important that you review all materials
and attend the conference calls prior to
completing the LA
Please DO NOT attempt to complete the
Learning Assessment without reviewing the
presentations and the questions and
definition/decision rules
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General Changes
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In an attempt to align terminology
with that used by VHA personnel there
are some changes in wording related
to question sets and exit reports
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What’s in a name?
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Instrument: set of questions for a
given topic (CGPI, PN, IHF, etc)
– No longer “data base questions”
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Module: same as before, subset of
questions within an instrument
Question name: label for an individual
question
– No longer called mnemonics
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Exit Report Label Changes
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Accountability Measures (AM):
used to
evaluate performance of the organization or
leaders within the organization. Includes:
– VA accountability measures
– Joint Commission measures
– HEDIS measures
– Formerly called Performance Measures
– Eligible for reconsideration
– Bolded on the exit report
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Exit Report Label Changes
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Quality Indicators (QI):
assess performance
on important aspects of patient care and
administrative processes in order to identify
opportunities and/or to ensure ongoing high
performance
– These were called HSIs on the exit report
in the past
– Not bolded on the exit report
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HSIs
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Health Systems Indicators (HSI):
broad
category to capture all measures collected and/or
reported by OQP
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This term is not used on the exit report
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Let’s look at changes to
CGPI
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The Low Back Pain module was deleted for 1Q11
– It is possible we will see a revised version in the
future
The OP Medication Reconciliation module has many
changes and is now pilot for only a few facilities
– 529, 568, 632, 646, 648, and 672
– You will receive additional guidance on this module later in
this presentation
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Validation Module
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Catnum 54 (Frail Elderly-age 75 years
and older) returns in 1Q11
After going through Topic Validation,
catnum 54 cases will get only the
ACOVE questions in the Core Module.
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Catnum 57
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Catnum 57 cases will now get only the
TBI module questions
– If the answer to non-vet is “no” you will
go directly to the TBI module
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Catnum 61
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The only other change in the TVG
module is to the dcstate (discharge
status) question
It now matches the same question in
the inpatient instruments
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Validation Module
Reminder!!!!
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Although this is not new, or not a change please
note the selckd question
Selckd:
– 11 = Chronic Kidney Disease or ESRD (end stage renal
disease)
Codes: 585.1, 585.2, 585.3, 585.4 585.5, 585.6, 585.9
Chronic kidney may also be documented as chronic renal disease,
chronic renal insufficiency, or chronic uremia.
Quality control findings indicate that this diagnosis is being missed
(not entered) in some cases.
Please review documentation carefully to see if the any of the terms
above are in the record
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LVSF
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There are wording changes to provide additional clarification
to questions about assessment of left ventricular systolic
function in the Ischemic Heart Disease and Congestive
Heart Failure Modules
Please note the new guidance in
– Lvfdoc2 and lvefind (IHD module)
– Lvsfdoc and narrlvsf (CHF module)
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It is important to make every effort to find the most recent
measurement of LVSF (EF) to answer these questions
accurately
The changes make the rules for these CGPI questions
consistent with the rules for the inpatient (Joint Commission)
questions.
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Shared Module: Antidiabetes drugs
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A new medication name has been
added to the list of oral anti-diabetes
medications
– saxagliptin (Onglyza)
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Two questions (who prescribed/who
changed statin medications) were
deleted
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Shared Module: Lipid
lowering drugs
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Two medications classes were deleted from the lists
of non-statin medications
– Cholesterol absorption inhibitors
– Omega-3 Fatty Acids
This change affects questions 78, 79, 81, 84, 100,
and 101
Questions about which provider prescribed,
changed etc. were deleted
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Shared Module: Anti-HTN
drugs
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Some medications have been added to
Table A, Anti-hypertension
medications
The new additions are in the fixed
dose combinations lists, middle column
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Mental Health Module
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There are several changes to the
questions about screening for
cognitive impairment
The major changes will be outlined
here, but be sure to read all
highlighted sections carefully
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Documentation of CI
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The timeframe for question 1
(modsevci) has changed
Look for clinician documentation that
the patient has moderate or severe
cognitive impairment during the past
year
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Standardized Cognitive
Assessment Tool
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The definition of a standardized
cognitive impairment assessment tool
has been modified (question 3
cogscrn):
Standardized tool: Cognitive assessment tool that
has been validated as identifying cognitive
impairment and degree of impairment (i.e. mild,
moderate, severe)
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Standardized Cognitive
Assessment Tool
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The BIMC (Blessed Information Memory
Concentration test) has been deleted from the list
of acceptable screening tools (question 5 wichcog)
Three new tools are listed in the definition/decision
rules
– Select 8 (other standardized instrument) if any of these
tools are documented
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Clinical Dementia Rating Scale
Global Deterioration Scale (GDS)
Functional Assessment Staging Tool (FAST)
– Scores for these tools that indicate a moderate degree of
impairment are in the d/d rules of question 6 (cogscor)
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Diagnosis of Dementia
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Question 7 (dementdx) is new
– During the past year, does the record document
a diagnosis of dementia as evidenced by one of
the following ICD-9-CM codes?
Dementia (290.XX)
Alcohol induced mental disorders (291.XX)
Dementia in conditions classified elsewhere (294.XX)
Other cerebral degeneration (331.XX)
1. Yes
2. No
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Review the Definition/Decision Rules for
dementdx
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The diagnosis of dementia or other condition
associated with dementia may be found on a
problem list or in health factors, but must be
verified by physician/APN/PA documentation
in the record.
Each health factor should have an associated
date that represents the date the health
factor was recorded.
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Excluded from MH Module
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Any one of the following will exclude a case
from the remainder of the MH module
– Clinician documentation of moderate or severe
cognitive impairment during the past year
– Score of CI screen indicating moderate to severe
impairment
– Diagnosis of dementia during the past year as
evidenced by codes in question 7
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Revised Definition/Decision Rules-Suicide
Ideation/Behavior Evaluation
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Please review the revisions to the
definition/decision rules for questions 90,
142 and 162 carefully
Additional guidance is provided regarding
what you must see in documentation for a
suicide ideation/behavior evaluation
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Revised Definition/Decision Rules-Suicide
Ideation/Behavior Evaluation
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A standardized instrument is NOT required for suicide risk
evaluation. Suicide evaluation includes an appraisal of the
patient’s subjective experience (suicide ideation, wish, plan,
and intent) and behaviors (warning signs).
The provider must, at a minimum, document that the
suicide risk evaluation was completed and that the
evaluation included a discussion with the patient that
addressed feelings of hopelessness; suicidal thoughts,
suicide plan (if suicidal thoughts), and any history of
suicide attempts AND clinical impression/conclusion
regarding patient’s risk.
Example: Suicide risk evaluation indicates patient requires
immediate MH intervention
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Prevention Indicators Module
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Changes include:
– Dates of influenza immunization season updated to
08/01/2010-03/31/2011
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Directions regarding acceptance of H1N1 (separate) vaccine
as in FY10 rules were deleted
– HIV questions were deleted
– The smoking/smoking cessation questions for catnum 61
cases now appear in this module
– Changes to the breast cancer screening questions
– Changes to the colorectal cancer screening questions
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Vascdis1 Question 36
Reminder!!!!!
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Quality Control findings indicate that vascdis1 is not always
selected even though the diagnosis of coronary artery disease
(CAD) is clearly documented in the record
As a result cases are being excluded from scoring for ihd16h
and ihd18hn that should have been included
Remember that even if selmi, selpci and/or selcabg are not
selected, vascdis1 should be selected if the CAD diagnosis is
documented as an active diagnosis in the last 2 years
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Question 65 mamgram2
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The answer options have changed
Does the medical record contain the report of a mammogram
performed for this patient within the past two years?
1. Yes
2. No
98. Patient refused to have mammogram performed
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Question 66 mamperva
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A new question asks if the
mammogram was performed by the
VHA
Mammogram performed by VHA
includes fee-based mammogram
ordered by VHA (but performed in a
private sector facility)
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Question 69 biradcod
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This is another new question which
asked you to enter the BI-RAD code
that was documented in the
mammogram report
If category 0 through 6 is not
documented, then answer 99 (no
documentation of BI-RAD code)
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Question 70-nomammo
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This question is now used to indicate
whether the patient had a bilateral
mastectomy or gender alteration in
the past
A “yes” answer will exclude the case
from scoring as in previous quarters
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Colorectal Cancer Screening
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There are extensive changes to the
fecal occult blood testing section
You will be looking for stool testing by
guaiac fecal occult blood testing
(gFOBT) or by fecal immunochemical
testing of stool (iFOBT aka FIT)
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gFOBT
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Question 41 asks whether 3 card
guaiac fecal occult blood testing was
done within the past year
This is basically the same question as
in previous quarters with a couple of
differences in the rules
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gFOBT
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If you are unable to determine
whether fecal occult blood testing is
guaiac or immunochemical, consider
as guaiac
Testing of stool by “clinic personnel”
has been deleted from the
definition/decision rules
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High Sensitivity gFOBT
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Question 42 is new and asks “Is the gFOBT
reported as a high sensitivity product?”
If not reported as high sensitivity (HS)
assume the gFOBT is not and select “no”.
– The letters HS must be included as part of the name of the panel
name: (OCCULT BLOOD GUAIAC-HS X3 SCREEN), test name
(OCCULT BLOOD-HS#1 OCCULT BLOOD-HS#2 OCCULT BLOODHS#3), print name FOBHS#1 FOBHS#2 FOBHS#3) and test
header (FOB-HS #1 FOB-HS #2 FOB-HS#3)
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This question is not part of scoring
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Immunochemical FOBT
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New questions have been added to collect
data on immunochemical fecal occult blood
testing
Immunochemical testing uses antibodies to
detect the presence of globin in the stool
There are many internet articles that
compare the use of iFOBT to guaiac FOBT
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Questions 44-46: iFOBT
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If the patient did not have serial guaiac FOTB in the
past year, you will get the new questions about
immunochemical FOBT within the past year
Requirement for the number of iFOBT/FIT vials for
stool samples depends on the manufacturer’s
directions for the product being used
The requirement may be for 1, 2 or 3 tests
Please review the definition/decision rules for question 45
carefully to understand what you must see on the laboratory
report to determine if the required number of tests have been
completed
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iFOBT/FIT
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For iFOBT/FIT tests performed within VHA,
the lab report must indicate the number of
tests that are required by the manufacturer
along with the results of each of the test, for
example:
– Results reporting for a FIT product that requires
two tests should include the following information:
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panel name: OCCULT BLOOD FIT X2 SCREEN
test names: OCCULT BLOOD (FIT) #1 OF 2
OCCULT BLOOD (FIT) #2 OF 2
print names: FIT1/2 FIT2/2
test headers: FIT1/2 FIT2/2
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iFOBT/FIT
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If iFOBT/FIT was done by private sector provider,
documentation must indicate the test results.
Either the lab report or a report from the private
sector provider containing the iFOBT/FIT results for
at least one iFOBT/FIT vial must be documented in
the record. The date must also be documented in
sufficient detail to be able to compute if the test
was completed within the acceptable timeframe.
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FOBT Ordered
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If neither guaiac or immunochemical
FOBT was done within the past year,
you will go to question 47 to indicate
whether gFOBT or iFOBT/FIT was
ordered for or a screening kit was
provided to the patient by the VA
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FOBT Ordered
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Review orders and/or clinic notes for the
past year to determine if
– gFOBT or iFOBT ordered, but no tests returned
– gFOBT or iFOBT ordered, but less than required number
of tests returned
– No documentation gFOBT or iFOBT was ordered or
provided to the patient
– Patient refused FOBT
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If gFOBT or iFOBT was ordered for or a screening
kit was provided to the patient, enter the most
recent date in question 48
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Following the FOBT
questions…….
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You will proceed to the questions about CRC
screening via colonoscopy, sigmoidoscopy
and double contrast barium enema
The only change to these questions is for
question 53 (dcbe) which now asks if the
DCBE was performed within the past 5
years and prior to 10/01/10
– DCBE will not “count” in scoring for CRC
screening after if performed after that date
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CRC Not Clinically Indicated
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If no CRC screening has been done within the appropriate
timeframe, and there is no documentation of CT colongraphy
or stool based DNA testing, you will go to new question 59
(nocrctest)
During the past year, did the physician/APN/PA explicitly
document a reason why colorectal cancer screening was not
clinically indicated for this patient?
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CRC Not Clinically Indicated
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Examples include, but are not limited to:
– Limited life expectancy
– Medical co-morbidities that make the patient unable to
tolerate further diagnostic testing and/or treatment if the
screen was positive
– For example, physician notes, “Patient has advanced
COPD that precludes screening for CRC.”
Note: This information is being collected for information only.
Provider documentation of a reason that CRC is not clinically
indicated is NOT an exemption to the CRC performance
measure at this time.
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No changes to:
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CKD module
Diabetes module
SCI module (Autonomic Dysreflexia
module was deleted)
SMI module
TBI module
Core module
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CGPI Scoring Changes
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Changes will be highlighted in the exit
report guide
There are several changes to catnums
that are included in or excluded from
certain indicators
– Refer to the catnum column of the exit
report guide for this information
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CGPI Scoring Changes
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P6nh was replaced by p61h (CRC screening age 5175)
Dmg10 and dmg11nh were deleted (hgbA1c <8
and hgbA1c <7, age < 65)
Influenza scoring will not be on the exit report until
3QFY11
Most other changes were due to changes to
question names
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OP Medication Reconciliation
Module
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Limited to 6 pilot facilities
– 529, 568, 632, 646, 648, 672
Limited to catnum 50 and 51 cases
Limited to certain Nexus clinics (wichnxus)
****If you are not assigned to one of the
facilities above, you may skip ahead to slide
65
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Revisions to Med Recon Module
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While some of the questions in this module are
similar to those in the previous Medication
Reconciliation module there are revisions/changes
to all the questions and the rules
Please read all questions and the definition/decision
rules carefully
There are no highlighted changes because these
are all considered new questions
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Question 1 optmed
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The intent of question 1 is to determine if the
clinical staff involved the patient/caregiver in the
review of the patient’s medication list and/or the
active list of medications in the record at the most
recent outpatient clinic visit.
Answer yes if there is documentation in the record
that the clinical staff reviewed the patient’s list of
medications and/or the active medication list with
the patient/caregiver
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Question 1 optmed
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Answer no (2) if the documentation does not
indicate that the patient/caregiver was involved in
review of the medication list
– e.g. physician documents “active med list
reviewed. No changes noted.”
Answer 3 is applicable only if there is specific
documentation that the patient was not currently
prescribed any medications at the time of the most
recent outpatient clinic visit
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If the answer to question 1 is no,
go to Question 2
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opnolist asks if the record documents one of the
following reasons why the medication list was not
reviewed with the patient/caregiver.
– Documentation in the record indicates that an emergent, lifethreatening situation existed with this patient prohibiting
completion of medication reconciliation at this time
– Documentation that the patient/caregiver was unable to confirm
the medications AND attempts at contacting caregivers and/or
family were unsuccessful.
– Documentation that the patient was unable to confirm their
medications.
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Question 2 Rules
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Documentation of one of the reasons must be at
the time most recent OP visit in order to answer
yes
See the definition/decision rules for examples of
emergent, life-threatening situations
– Documentation of an emergent, life-threatening
situation does not have to be linked to inability
to obtain a list of medications from the
patient/caregiver
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Question 3 opdiscrp
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During the most recent outpatient clinic visit, is
there documentation the physician/APN/PA,
pharmacist, or nurse identified medication
discrepancies between the patient’s medication list
and the medication list in the clinical record?
The intent of the question is to determine whether the
physician/APN/PA, pharmacist, or nurse documented
the presence or absence of medication discrepancies
that were identified as a result of comparing the
patient’s medication list with the medication list in the
clinical record.
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Question 3 opdiscrp
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Select from the answer options as follows:
– 3. Documented medication discrepancies were identified
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Example: clinician notes “lisinopril discontinued by private
cardiologist”
– 4. Documented medication discrepancies were not
identified
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Example: pharmacist notes “no medications discrepancies
identified”
– 99. No documentation during the most recent outpatient
clinic visit regarding medication discrepancies
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Use this option if there is no documentation at the most
recent clinic visit of the presence OR absence of medication
discrepancies
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Next…
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If the answer to question 3 is “4” or
“99” you will go to the end of the
module
Otherwise, you will go on to question
4 (opaddisc)
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Address Medication Discrepancies
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The intent of question 4
is to determine whether
the physician/APN/PA,
pharmacist, or nurse
addressed the medication
discrepancies during the
most recent outpatient
clinic visit.
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Actions to address medication
discrepancies include but are
not limited to:
– updating medication list
– discontinuing medications
– providing education to
patient/caregiver
– communicating medication
discrepancies to the responsible
prescribing provider
– referring the patient to another
provider with the necessary
expertise for reconciliation
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Question 5
opmedlist
At the time of discharge from the most
recent outpatient clinic visit, is there
documentation that a written list of the
reconciled discharge medications was
provided to the patient/caregiver?
– Select “1” if there is documentation that the
patient/caregiver was given a list of
reconciled medications
– Also select “1” If there is documentation that
patient education/instructions were given to
the patient AND the education/instruction
included a list of reconciled medications
– Select “3” if there is documentation that
medications are not prescribed or changed
during the most recent OP clinic visit
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Question 6 folothr
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Did the physician/APN/PA document the patient
was to be referred to or follow-up with another
health care provider for medication management?
Other health care provider includes VA and non-VA
providers. For example, primary care physician
notes, “Follows with Endocrinology for insulin
management.”
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If the patient was referred to another provider
for medication management, go to question 7
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Did the written list of reconciled discharge
medications include instructions that the
patient/caregiver was to follow-up with another
provider regarding specific medications?
When the patient was referred to another healthcare provider,
or is to follow up with another provider for medication
management look for documentation of the medication list as
reconciled including the need for the patient to follow up with
“x provider” regarding medications specified
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Med Recon Scoring
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The OP Med Recon indicators are on
the Pilot Exit report
The Pilot exit report guide will provide
details of cases included and cases
that pass
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Med Recon Scoring
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Mrec23: Patient’s medication list reviewed with patient at the
most recent OP visit
Mrec24: Documented reason medication list was not reviewed
with patient
Mrec25: Documented presence/absence medication
discrepancies
Mrec26: Medication discrepancies addressed
Mrec27: Reconciled medication list provided to patient
Mrec28: Documented patient to follow up with another health
care provider for medication management
Mrec29: Documented referral/follow up instructions on
reconciled medication list
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HBPC Changes
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There are a few changes to the HBPC
instrument
Please review carefully the questions
about
– behavioral triggers and assessment for
cognitive impairment
– Caregiver burden screening
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Behavioral Triggers
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The intent of question 22 (behvtrig) is to determine
that the clinician observed the patient for evidence
of behavioral triggers and documented the
presence or absence of triggers.
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Clinician=physician, PA, APN, Clinical Nurse Specialist, RN,
LPN, social worker, psychologist
The reviewer will accept documentation by the
clinician stating presence or absence of
behavioral triggers (not abstractor’s judgment
about whether triggers are present or absent)
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Question 23
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Prestrig asks if the clinician documented the
presence of behavioral triggers suggestive of
dementia
In order to answer yes, the clinician must
document that behavioral triggers were present
Documentation could include a check box that
indicates behavioral triggers are present, or a
description as in the examples (see
definition/decision rules)
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Date of Observation
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Enter the date of the documentation of observation
for behavioral triggers in BEHAVDT (either positive
or negative)
– Presence of one or more behavioral triggers indicates
further assessment for cognitive impairment should be
performed
 You will then move on to answer the questions
regarding screening for CI using a standardized tool
– If the documentation of the observation for behavioral
triggers indicates that no behavioral triggers were
identified, enter the date of the
documentation/assessment in BEHAVDT and the
assessment is complete
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Assessment of Cognitive Function
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Review highlighted sections of
questions 25-29 which mostly involve
a change in wording from “screening”
for cognitive impairment to
“assessment” of cognitive function
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Caregiver Strain
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The wording for option 3 of question
30 has changed
Use that option if there is documentation
that the patient lives in a
– Community Residential Care facility
– Assisted Living Facility
– Nursing home
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If option 3 is selected you will go to the end
of the instrument
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New Question-31 (caregivr)
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Does the record document that the HBPC
patient has a caregiver?
– One who provides ongoing support and care for a Veteran
in the HBPC program
– Refers to informal or unpaid caregivers
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If the patient lives alone, lives with another person
or is homeless AND the record documents that the
patient does NOT have a caregiver answer 2
If the record documents that the HBPC patient is
the caregiver for another person, answer no and go
on to question 32 (vetcargiv)
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New Question-32 (vetcargiv)

Does the HBPC patient serve as a
caregiver to another person?
– If there is explicit documentation that the
HBPC patient serves as the caregiver for
another person answer yes
– Example: Patient provides care to his wife
who has dementia
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Patient Caregiver

If the HBPC patient is a caregiver to
another person, and the patient was
screened for caregiver burden, you
can indicate that in question 34, new
option 7
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HBPC Exit Report Changes


HC 20, 21 and 23 have been deleted
New indicators
– Hc26: enrolled <90 days with positive assessment for
cognitive impairment and follow up within 30 days of
admission
– Hc27: Enrolled at least 120 days with positive assessment
for cognitive impairment and follow up annually
– Hc25: Patients with caregiver strain assessment using
Zarit Burden scale

The exit report guide will provide details of scoring
for these indicators
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Questions


Review the additional presentations
Email your questions:
– [email protected]


Join the conference call to for answers
and further guidance (dates/times tba)
You will receive an email regarding the
required learning assessment
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