Transcript 4QFY14 Update.ppsx

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4Q FY2014
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 The
purpose of this presentation is to outline the
changes to EPRP instruments for 4Q FY2014
 Please review the slides that follow along with the
4Q questions that were sent to you via email
 As usual, a learning assessment will allow you to
check your knowledge of the changes after you
have reviewed the PPT and questions
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 The
4Q changes are not extensive
 Most instruments only have minor
alterations
 HBPC does have several changes, so we will
start by looking at that instrument
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 The
question medrev2 has been revised and there
are some changes to the definition/decision rules
 Did the record document the patient’s HBPC
medication management plan as evidenced by ALL
of the following?
o The note containing the HBPC medication management plan must
be signed by the pharmacist; and
o The HBPC pharmacy medication review; and
o The medication management plan/note contains specific
recommendations for change or no change in the medication
regimen
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 The
HBPC pharmacy medication review consists of
o Review of all medications for
• Appropriateness
• (e.g., indication for medications or medication is
no longer indicated, dosage)
• adverse reactions and interactions
o Communicating concerns and recommendations to the
HBPC provider and primary care provider
 The
timeframe for review of the patient’s
medication management plan has not changed
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
All of the following must be documented in the medication
management plan except:
A.
B.
C.
D.
Pharmacy medication review to include all medications
Specific recommendations for change or no change in the
medication regimen
Signature by the HBPC nurse
Signature by the pharmacist
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The correct answer is C
Signature of the HBPC nurse is not required
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
True or False: Review of all medications for
appropriateness, adverse reactions and interactions is part
of the HBPC Pharmacy medication review.
The statement is True.
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 There
is a change to q14 clindt
 The most recent HBPC face to face visit may be by
a Pharmacist, as well as physician/NP/CNS/PA, RN
or LPN
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 If
the answer to q17 (hospice) is yes, instead of
going to the end of the module as before, you will
go to the caregiver strain questions
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 There
are some changes to q18 alreddx
o Option 3, delirium must be current
• Exclude previous history of delirium that has resolved
o Option 5, Traumatic Brain Injury has been added as a
new option
• happens when something outside the body hits the
head with significant force
• individuals who sustain a TBI may experience a
variety of effects, such as an inability to concentrate,
an alteration of the senses, difficulty speaking, and
emotional and behavioral changes
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 There
are changes to the previous questions about
behavioral triggers
 Now there is only one question, prestrig2
o Did the HBPC clinician document the presence or
absence of behavioral triggers (i.e., warning signs)
suggestive of dementia or other cognitive impairment?
• 3. Yes: Presence of behavioral triggers is documented.
• 4. Yes: Absence of behavioral triggers is documented.
• 99. No: No documentation of presence or absence of behavioral
triggers or unable to determine from medical record documentation.
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 For
patients admitted to HBPC less than or equal to
1 year, clinician documentation in HBPC preadmission/admission note of behavioral triggers
assessment within 30 days prior to HBPC
admission is acceptable
 HBPC Clinician:
o physician, PA, APN, Clinical Nurse Specialist (CNS)
o RN, LPN
o social worker
o psychologist
o pharmacist
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The intent of this question is to determine that the HBPC
clinician observed the patient for evidence of behavioral
triggers suggestive of dementia or other cognitive
impairment and documented the presence or absence of
behavioral triggers
Answer “3” when the HBPC clinician documents that
behavioral triggers suggestive of dementia or other
cognitive impairment are present
Answer “4” if the HBPC clinician documents that there are
no behavioral triggers (or similar wording like no evidence of
cognitive impairment, no signs or symptoms of dementia)
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 Please
note that it is not a requirement that the
exact term “behavioral triggers” be found in the
record
 There are examples of behavioral triggers
suggestive of dementia or other cognitive
impairment in the definition/decision rules, but the
list is not all inclusive
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 If
there is conflicting documentation regarding the
presence or absence of behavioral triggers during
the specified timeframe, use the most recent
documentation of the presence or absence of
behavioral triggers
 Use the “99” option if there is no documentation of
the presence or absence of behavioral triggers
suggestive of dementia or other cognitive
impairment, or unable to determine
o If you choose 99, you will skip to the caregiver strain section
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 Q20
behavdt
 Enter the date of the most recent documentation
by the HBPC clinician noting presence or absence
of behavioral triggers suggestive of dementia
 If hcstatus=3, the date must be within the past
year
 If hcstatus=2, the date must be <= 30 days prior to
or on the date of admission and <=30 days after
the date of admission
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
The patient was admitted to HBPC on 5/1/2014.
Documentation by an HBPC clinician on 5/5/2014 includes
“no dementia warning signs.” The correct answer to
prestrig2 is
o 3
o 4
o 99
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
The correct answer is 4 (Yes: Absence of behavioral triggers
is documented)
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There are some changes to the skip pattern following the
behavioral triggers question as well as changes to the
assessment of cognitive function questions
If the presence of behavioral triggers is documented
(prestrig2=3) you will go to the questions about assessment
of cognitive function
If there is documentation that behavioral triggers are not
present (prestrig2=4) you will skip the cognitive assessment
questions and go to caregiver strain questions
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Q21 asescog
 This is similar to the cognitive assessment questions in
previous quarters but in a different format

o Was the patient’s cognitive function assessed using a standardized and
published tool?
• 1. Yes
• 2. No
• 98. Patient refused assessment of cognitive function
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The intent is to have an objective assessment of cognitive
function, using a standardized and published tool, for the patient
with documented behavioral trigger(s) suggestive of dementia or
other cognitive impairment
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

There are examples of standardized tools in the
definition/decision rules
Remember that the tool must be named and the result of
the assessment must be documented in accordance with
the specific tool used
o e.g., positive or negative, numeric value for total scale score, or
other designation
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Please note there is a patient refusal option for this
question
If a cognitive assessment was done during the applicable
timeframe, you will enter the exact date in q22, cogdt
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Q23, cogout remains the same although there are some
changes to the definition/decision rules
The result of the cognitive assessment must be
documented in the record in accordance with the specific
tool used (e.g., positive or negative, numeric value for total
scale score, or other designation).
o Examples of other designation include, but are not limited to:
“assessment of cognitive function indicates mild cognitive
impairment”,
o “results not indicative of cognitive impairment”.
o
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Q24, impair, also remains the same but has some
clarification in the definition/decision rules
o The intent of the question is to determine if the outcome of the
assessment indicated any degree of cognitive impairment or not
o The record must document the clinician’s interpretation of the
cognitive assessment outcome
• Abstractor judgment may not be used
o Answer “1,” if the cognitive assessment is interpreted as positive,
even if impairment is noted to be mild. Look for language such as
“impaired”, “positive”, or “suggestive of cognitive impairment”.
o Answer “2,” if the cognitive assessment is interpreted as negative.
Look for language such as “within normal limits”, or “results not
indicative of cognitive impairment”
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
Q25, addfolo, is another familiar question with some
changes
o During the timeframe from (computer to display cogdt to cogdt + 30
days and < stdyend), did the HBPC clinician document a plan for
follow-up of the positive cognitive assessment?
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The clinician performing and reporting the results of the
cognitive assessment should document an initial plan for
follow up
The follow-up plan must be related to the patient’s cognitive
impairment and documented within 30 days after the
cognitive assessment
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Follow-up for positive cognitive assessment may include
o referral to the PCP for further evaluation
o ordering a diagnostic workup,
o care planning and/or treatment
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Follow-up could also include documentation by the clinician that
cognitive impairment has remained stable over time (e.g., since
last year’s assessment) and reinforcement of current treatment
plan
Follow up actions do not need to occur during a face-to-face visit;
o they may be documented in the medical record as part of the plan or,
o in the case of education and support, via telephone contact with
Veteran/caregiver
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Examples of a follow up plan related to the positive
cognitive assessment ( but not limited to these)
o taking a medical history
o performing or referring for blood work
o depression screening
o referring for psychology/psychiatry consult
o referring for neuropsychological testing
o referring for neurologic exam
o referring for brain imaging
o care planning with Veteran/family for dementia or other similar
diagnosis
o supportive counseling for patient, and caregiver education and/or
support
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
Which of the following is true about a plan for follow up of a
positive cognitive impairment assessment?
A.
B.
C.
D.
E.
The HBPC clinician documents the plan
The plan must be documented within 30 days of the positive
assessment and prior to the study end date
The plan must be related to the patient’s cognitive impairment
All of the above
None of the above
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
The correct answer is:
D. All of the above
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There are some changes to the series of questions about
caregiver strain
The definition of “caregiver” has been revised
A caregiver provides substantive assistance, i.e., assistance
with Activities of Daily Living (ADL) and/or with Instrumental
Activities of Daily Living (IADL), on an ongoing basis for the
Veteran in the Veteran’s place of residence. The assistance
may involve, but is not limited to, direct personal care
activities, such as bathing, dressing, grooming or other
activities, such as laundry, shopping, meal preparation.
The caregiver may be a family member, friend, or neighbor
who lives with or lives separately from the Veteran
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There is additional guidance in q27 (caregivr)
Look for specific documentation by HBPC staff that
identifies whether or not the patient has a caregiver.
o If HBPC documentation is conflicting (e.g., caregiver vs no
caregiver), accept the most recent HBPC documentation

Suggested data sources:
o HBPC assessment/admission note
o HBPC annual assessment
o HBPC Care Plan
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
True or False: If you finding conflicting documentation in
the record regarding whether or not the HBPC patient has a
caregiver, accept the most recent documentation.

The statement is True
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
Question 29 (scrncare) is new, although the intent is not
o During the past year, was the caregiver screened for caregiver strain
using the Zarit Burden Interview Screening scale?
o 1. Yes
o 2. No
o 98. Caregiver refused screening for caregiver strain
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Note that there is an option to indicate refusal was
documented in the record
o The refusal option fails hc22
o The refusal option excludes the case from hc25 and hc28
o See exit report guide for more information
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
Please note the addition to the definition/decision rules for q33
(indther) and be aware of the differences between therapy
individualized to the caregiver situation and other types of follow up for
a positive caregiver strain screen (carefolo)
o In contrast to other types of follow-up noted for the CAREFOLO question,
therapeutic intervention typically implies working with the caregiver for more
than one encounter.
o Therapeutic intervention provides support/services for the caregiver and might
include
counseling
psychoeducation (e.g. education about illness, behaviors and coping strategies)
skills-training
stress-management
specific individual, couples, family, or group caregiver therapy (e.g., REACH-VA, FamilyCaregiver Therapy)
• other interventions that aim to help the caregiver cope with caregiver strain and/or
improve self-care
•
•
•
•
•
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There are a couple of changes in the nutrition/hydration
section
Q35 (nuthyd): The rules now specify that the initial
nutritional and hydration assessment must be performed by
a registered dietician during a face-to-face encounter in the
Veteran’s home within 30 days of HBPC admission.
Q37 (nutintv) and q38 (nutresp): A change to the rules
notes that a dietician student/intern/trainee with
appropriate co-signature by registered dietician is
acceptable to document the plan of care intervention and
evaluation of the patient’s response
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There are similar changes in the home environmental
safety/risk assessment questions
The home environmental safety/risk assessment and the
oxygen safety risk assessment must be performed by a
rehabilitation therapist during a face-to-face encounter in
the Veteran’s home
A rehabilitation therapist student/intern/trainee with
appropriate co-signature by rehabilitation therapist is
acceptable to document a plan of care or intervention to
address home environmental safety/risk assessment
findings and the patient’s response to the plan of care
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Q 43 (envintv) The plan of care or intervention to address
home environmental safety/risk assessment findings must
be documented by a rehabilitation therapist
The evaluation of the patient’s response to the
intervention/plan of care must also be evaluated by a
rehabilitation therapist (q44, envresp)
A rehabilitation therapist student/intern/trainee with
appropriate co-signature by rehabilitation therapist is also
acceptable for the questions above
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
Some additional information has been provided in the
header of HBPC DACs
o Date of most recent documentation of presence or absence of
behavioral triggers suggestive of dementia (behavdt)
o Date of most recent cognitive assessment with standardized,
published tool (cogdt)
o Most recent Zarit Burden Interview screen (caredt)
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Hc22, hc25 and hc28
o Cases are no longer excluded if hospice=1
o The question scrncare replaces caredt in scoring
• The refusal option fails hc22 and excludes the case from hc25 and
hc28
Hc26 and 27
o Exclusions added
• Known diagnosis of TBI
• Absence of behavioral triggers is documented
• Presence of behavioral triggers is documented and patient refused
assessment of cognitive function
Hc29, hc30, hc31, hc32
o Cases are no longer excluded if hospice=1
Please see exit report guide for more information
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
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Most CGPI modules do not have changes
There are changes to the
o Mental Health module
o PI module
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
A new option has been added to question 16 sudclin
o 8. 548 Intensive-SUD-Individual
o
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As with the other answer options, patient’s seen in this clinic in the
past year are excluded from SA17
(There is a change in the list of acceptable providers for the
suicide ideation/evaluation and depression/PTSD triage
questions
o LMFT has been change to MFT (Marriage and Family Therapist)
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Several questions in the Prevention Module have been
deleted
The questions having to do with bone fractures have been
deleted from the osteoporosis section
o P21h was discontinued in 3Q14

The questions about bone mineral density testing remain
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There are no changes to CGPI scoring or to the exit report
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There are no changes to TBI questions, scoring or exit
report
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The highlighted changes in the ACS modules are mostly
minor wording changes only
There are no changes to scoring or to the exit report
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There are some minor wording changes in IHF
If clntrial=1, the case will be a “do not review” which will be
consistent with other inpatient instruments
There are no changes to IHF scoring or to the exit report
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As with other inpatient modules, most of the changes in
Pneumonia are minor wording changes
Validation module
o A section of the definition/decision rules has been deleted from
arrvdate and arrvtime with regard to timing of antibiotic
administration as related to arrival in urgent care
o Please follow the rules with regard to acute care arrival date/time
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Acute Care module
o “perfusion” has been deleted as an administration route in abrecvd
and routeadm
o There are other minor wording changes
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There are no changes to Pneumonia scoring or to the exit
report
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The changes in SC are also mainly wording changes
“Perfusion” has been deleted as a route of administration
from the questions recvanti and bioroute
When clntrial=1 the case will be a “do not review”
There are no changes to the Informed consent module
There are no changes to scoring or to the exit report
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Please see q29 (dtalscrn) for important directions regarding
screening with AUDIT-C
If the patient is screened for alcohol misuse with the AUDITC multiple times within the first 3 days of admission and
any AUDIT-C total score is 5 or greater, enter the date of the
earliest AUDIT-C screen with total score of 5 or greater
within the first 3 days of admission.
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
The patient was admitted on 5/10/2014 and was screened
for alcohol misuse as follows:
o 5/10/2014: AUDIT-C score 2
o 5/11/2014 AUDIT-C score 6
o 5/13/2014 AUDIT-C score 5

Which date would you enter to answer the Global question
dtalscrn?
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The correct date is
o 5/11/2014 AUDIT-C score 6
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This is the date of the earliest AUDIT-C screen with total
score of 5 or greater within the first 3 days of admission
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There are no changes to Global scoring or the exit report
Additional information will be provided on DACs to help with
reconciliation
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
Some information will be provided in the DAC header
o The patient refused the tobacco use screen (tobstatus2=98)
o Patient uses tobacco (tobstatus2=1 or 2)
o Drug or alcohol use coded
• Princode or othrcode is an ICD-9 code on TJC Appendix A Tables 13.1 or
13.2 OR Princode or othrcode is an ICD-9 code on TJC Appendix A Table
13.3
o Drug or alcohol use documented (sudisord=1)
o Patient refused referral for addictions treatment and referral not made
(addtxref=98)
o Patient refused referral for outpatient tobacco cessation counseling
treatment and the referral was not made (refoptob=98)
o Follow up contact with patient post-discharge to assess tobacco use
(folotobdt)
o Follow up contact with patient post-discharge to assess substance use
(folosubdt)
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
Additional information will also follow the failure statement
for composite measure sub60 as below:
o sub60
• Contact not made for substance abuse status between 7 and 30 days
post discharge (folosub=2 or 99)
• Patient not attending the referred addictions counseling post discharge
(sudcoun=99)
• Patient not taking the prescribed medication post discharge
(sudcmed=99)
• No status of the patient’s alcohol use at post discharge follow-up
contact (alcdcquit=99)
• No status of the patient’s drug status at post discharge follow up
contact (sudcquit=3 or 99)
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
Additional information will also follow the failure statement
for composite measure tob60 as below:
o tob60
• Contact not made for tobacco use status between 15 and 30 days post
discharge (folotob=2 or 99)
• Patient not attending outpatient tobacco cessation counseling post
discharge (tobcoun=99)
• Patient not taking the recommended tobacco cessation medication
post discharge (tobdcmed=99)
• No documentation patient quit using tobacco products post discharge
(tobdcquit=99)
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There are no changes to the HBIPS instrument
Examples of medication indications have been added to
q27 plndcmed
o Examples of medication indications include, but are not limited to:
for depression, for anxiety, for psychosis, for hyperlipidemia, for
hypertension
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There are no changes to HBIPS scoring or to the exit report
Additional information will follow the failure statement for
composite measures as follows
o Ips1
No screen for at least 2 strengths (strength=2)
No screen for psychological trauma history (traumahx=2)
No screen for alcohol and substance abuse (assessud=2)
No screen for risk of violence to others over past 6 months
(harmothr=2)
• No screen for risk of violence to self over past 6 months (harmself=2)
•
•
•
•
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Ips7
o Continuing care plan does not include the principal discharge
diagnosis (carplndx=2)
o Continuing care plan does not include the reason for hospitalization
(careason=2)
o Continuing care plan does not include the discharge medications
with indications for use (plndcmed=2)
o Continuing care plan does not contain next level of care
recommendations (planext=2)
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Ips5
o Continuing care plan with principal discharge diagnosis not
transmitted (plndxsen=2)
o Continuing care plan with reason for hospitalization not transmitted
(caresent=2)
o Continuing care plan with discharge medications not transmitted
(send5med=2)
o Continuing care plan with next level of care recommendations not
transmitted (plnexsen=2)
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The Fall Assessment module will no longer be part of review
starting in 4Q
There are no changes to the Delirium Risk module or to
Inpatient Medication Reconciliation
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There are some changes to scoring of some measures on
the Combined Cohorts exit report
Mrec21 and mrec22
o Exclusions added for:
• clntrial=1
• patients discharged to hospice-health care facility, acute care facility,
other health care facility (dcdispo=3,4, 5)
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Mrec42
o Exclusions added for clntrial=1
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Thank you for taking time to do a thorough review of the 4Q
changes
This is also a good time to review all questions and rules so
they are fresh in your mind
Please consult with your RM when you are uncertain about
how to answer a review question
An accurate review is essential to giving the facilities a true
picture of how they are performing on the measures
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