Transcript Global Measures

Global
3Q FY2014
Objectives
 This presentation will provide an overview of the
Global instrument
 Scoring for the ED, IMM, TOB and SUB measures
will also be reviewed
Introduction
 Global is a set of measures that includes
 Emergency Department (ED)
 Immunization (IMM)
 Tobacco Treatment (TOB)
 Substance Use (SUB)
 VAMCs may choose to report IMM, TOB, or SUB to
the Joint Commission


One, two, or three of these measure sets may be reported
ED measures are not reported to TJC by VA facilities but the
data is collected and the measures appear on the EPRP exit
report
Sampling
 Patients discharged from acute inpatient care with a
length of stay less than or equal to 120 days are
eligible to be included in the sample
 There are 3 Global pull lists per quarter
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
Two lists are pulled with the first pull list of the quarter
The third Global list comes with the second pull of the quarter
 The lists are on a delayed sampling schedule
 For example the 4/14 pull list will have January discharges
 The 4/15 list will have February discharges
 Each list typically has about 51 records
Initial Data Elements
 Several data elements are the same as found in other
inpatient instruments
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Date and time of acute care arrival
Date and time of admission (auto-filled: can be modified)
Date (auto-filled) and time of discharge
ICD-9-CM principal and other diagnosis codes (auto-filled:
can be modified)
ICD-9-CM principal and other procedure codes
Discharge disposition
 Definition/decision rules for these questions are the
same as in other inpatient instruments
Four Measure Sets
 The rest of the presentation will look at the questions
and scoring for the four measure sets
 It is important that you read the questions and
definition/decision rules carefully as we will provide
only an overview here
 The Global Exit Report Guide provides details of the
scoring
Emergency Department
 Q12 edpt
 Did the patient receive care/services in the
Emergency Department of this VAMC?

Care/services may include outpatient services such as lab work
if the service was received in the ED
Q12 edpt
 Answer no
 If the patient was seen Fast Track ED, Urgent Care, or terms
synonymous with urgent care unless the patient also received
care/services in the ED
 If the patient is transferred in from any ED or observation unit
outside of the VAMC under review
This applies even if the ED or observation unit is part of this
hospital’s system, has a shared medical record or provider number
or is in close proximity
 Answer no even if the transferred patient is seen in this facility’s
ED


If the patient is transferred to your hospital from an outside
hospital where he/she was an inpatient even if the transferred
patient was seen in this facility’s ED
Date/Time of Decision to admit
 Q13 and 14 ask you to enter the earliest documented date
and time of the decision to admit the patient by the
physician/APN/PA

This will not necessarily coincide with the date/time the patient is
officially admitted to inpatient status
 The only acceptable source for these data elements is
the ED record which includes any documentation from
time of ED arrival to the time the patient physically
departed from the ED
 Includes (but not limited to): Admit order date/time,
Disposition order date/time
 Excludes (but not limited to): Bed assignment date/time,
direct admit patients seen in the ED
Date/Time of Decision to Admit
 Use the first documentation of decision to admit for
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either observation or inpatient
Decision to admit date/time includes documentation of a
decision to send the patient to the cath lab or to surgery
Do not include documentation from external sources (e.g
ambulance record) obtained prior to arrival
Enter 9s if the decision to admit date/time is prior to the
date/time of patient arrival or after the date of departure
or is unable to be determined
If the date of arrival is the same as the date of admission,
the decision to admit date will be auto-filled
Decision to Admit Time
 When abstracting decision to admit time from
narrative documentation that clearly refers to the
decision to admit to observation or inpatient status,
or that the patient will be going to the cath lab or
surgery, take the initial note time unless there is a
later time specified within the note
Date of Departure from the ED
 Q15 Enter the date the patient departed from the
Emergency Department
 Only acceptable source: ED record
 If the patient is placed into observation under the
services of the ED, abstract the date of departure
from observation services

If the patient is placed into observation outside the services of
the ED, abstract the date of departure from the ED
 If the date of departure is unable to be determined
enter 99/99/9999
Time of Departure from the ED
 Q16 Enter the time the patient departed from the
emergency department
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This is the time the patient physically left the ED
Intent is to capture the latest time at which the patient
received care in the ED
Only acceptable source: ED record
Abstract the latest time if more than one acceptable time is
documented
ED Departure Time (cont.)
 If the patient is placed into observation under the
services of the ED, abstract the time of departure
from observation services

If the patient is placed into observation outside the services of
the ED, abstract the time of departure from the ED
 Do not use discharge order time
 A departure time listed within a disposition heading
from the ED may be used
 If the ED departure time is unable to be determined
enter 99:99
ED Measures
 ed1, 2, 4
 Median time from ED arrival to ED departure for admitted ED
patients
ed1: overall rate
 ed2: reporting measure
 ed4: psychiatric/mental health patients

ED 1, 2, 4
 The denominator for each measure includes
 Cases with LOS <=120 days
 Patients who received care and services in the ED
 Cases with a valid date and time of ED arrival and ED
departure
 Cases with a principal diagnosis code from Table 7.01
(Mental Disorders) are excluded from the denominator of
ed2
 Cases without a principal diagnosis code from Table 7.01
are excluded from the denominator of ed4
ED 1, 2, 4
 Numerator
 ED departure date and time minus ED arrival date and time is
calculated for each case
 The score is the median time of all records in the denominator
Ed 5, 6, and 7
 ed5: Admit decision time to ED departure time for
admitted patients-overall rate
 ed6: Admit decision time to ED departure time for
admitted patients- reporting measure
 ed7: Admit decision time to ED departure time for
admitted patients-psychiatric/mental health patients
Ed 5, 6, and 7
 The denominator for each measure includes
 Cases with LOS <=120 days
 Patients who received care and services in the ED
 Cases with a valid date and time of decision to admit and ED
departure
 Cases with a principal diagnosis code from Table 7.01
(Mental Disorders) are excluded from the denominator of
ed6
 Cases without a principal diagnosis code from Table 7.01
are excluded from the denominator of ed7
Ed 5, 6, and 7
 Numerator
 ED departure date and time minus decision to admit date and
time is calculated for each case
 The score is the median time of all records in the denominator
Immunizations
 Pneumococcal and influenza immunizations
 Immunization questions are skipped if a principal or other
procedure code is from Table 12.10 (organ transplant) or if
discharge status is expired
 The pneumococcal immunization question is skipped if the
principal or other diagnosis code is from Table 12.3
(pregnancy)
Pneumococcal Immunization
 Q17 (vaxstat) What is the patient’s pneumococcal
immunization status?

1. Pneumococcal vaccination was given during this
hospitalization
Select option 1 if pneumococcal vaccination was given during this
episode of care even if it was also given at anytime in the past
 There must be documentation that the vaccine was given including
a date and signature
 Progress notes, BCMA

Pneumococcal Immunization
 2. Pneumococcal vaccination was received in the
past, not during this hospitalization
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Verify documentation found in clinical reminders by looking at
the progress notes
Review remote data
Pneumococcal Immunization
 4. Documentation of :
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Allergy/sensitivity to pneumococcal vaccine, OR
Is not likely to be effective because of bone marrow transplant (or
autologous stem cell transplant, ASCT) within the past 12 months,
OR
Currently receiving a scheduled course of chemotherapy or radiation
therapy, or received a chemotherapy or radiation during this
hospitalization or less than 2 weeks prior, OR
Received the shingles vaccine (Zostavax) within the last 4 weeks
 Allergy=patient with specific documented
allergy/sensitivity to vaccine including any component of
vaccine including thimerosal
Pneumococcal Immunization
 98. Documentation of patient or caregiver refusal of
pneumococcal vaccine
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
There must be documentation of refusal during this
hospitalization
See definition/decision rules for examples of caregiver
 99. None of the above/not documented/unable to
determine from medical record documentation
Pneumococcal Immunization
 There are several examples of names of the
pneumococcal immunization in the
definition/decision rules however these are not all
inclusive
 If documentation supports selection of more than
one value, select the smallest number unless
documentation supports 98 and 4, select 98
Imm1, 2, 3
 There are three measures for pneumococcal
immunization
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imm1 Pneumococcal Immunization-Overall Rate
imm2 Pneumococcal Immunization-Age 65 and older
imm3 Pneumococcal Immunization-High Risk Populations
(Age 18-64 years)
imm1
 Pneumococcal Immunization-Overall Rate
 Denominator includes
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LOS <=120 days
Discharge disposition is home, hospice, hospice facility, other healthcare
facility or UTD
Age >=65
Age>5 and<=65 if there is a principal or other diagnosis code on Table
12.1, 12.2, 12.5, 12.6, 12.7, 12.8, 2.1 in Joint Commission Appendix A
Age>19 and there is a principal or other diagnosis code on Table 12.4
(asthma)
 Denominator exclusions
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Principal or other diagnosis code on Table 12.3 (pregnancy)
Principal or other procedure code on Table 12.10 (organ transplant during
current hospitalization)
Discharge disposition is acute care facility, expired, left AMA
imm1
 Numerator
 Pneumococcal vaccination was given during this
hospitalization
 Pneumococcal vaccination was received in the past, not during
this hospitalization
 There is documentation of one of the following
Allergy/sensitivity to pneumococcal vaccine, OR
 Is not likely to be effective because of bone marrow transplant within
the past 12 months, OR
 Currently receiving a scheduled course of chemotherapy or radiation
therapy, or received a chemotherapy or radiation during this
hospitalization or less than 2 weeks prior, OR
 Received the shingles vaccine (Zostavax) within the last 4 weeks

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There is documentation of patient/caregiver refusal of
pneumococcal vaccine (during this hospital stay)
imm2
 Pneumococcal Immunization-Age 65 and
older
 Denominator includes:
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LOS <=120 days
Discharge disposition is home, hospice, hospice facility, other
healthcare facility or UTD
Age >=65
 Denominator exclusions:
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Principal or other diagnosis code on Table 12.3 (pregnancy)
Principal or other procedure code on Table 12.10 (organ transplant
during current hospitalization)
Discharge disposition is acute care facility, expired, left AMA
imm2
 Numerator:
 Pneumococcal vaccination was given during this
hospitalization
 Pneumococcal vaccination was received in the past, not during
this hospitalization
 There is documentation of one of the following
Allergy/sensitivity to pneumococcal vaccine, OR
 Is not likely to be effective because of bone marrow transplant within
the past 12 months, OR
 Currently receiving a scheduled course of chemotherapy or radiation
therapy, or received a chemotherapy or radiation during this
hospitalization or less than 2 weeks prior, OR
 Received the shingles vaccine (Zostavax) within the last 4 weeks
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There is documentation of patient/caregiver refusal of
pneumococcal vaccine (during this hospital stay)
imm3
 Pneumococcal Immunization-High Risk Populations
(Age 18-64)
 Denominator includes
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LOS <=120 days
Discharge disposition is home, hospice, hospice facility, other healthcare facility or UTD
Age>=18 and <65
Principal or other diagnosis code on table 12.1, 12.2. 12.5, 12.6, 12.7, 12.8, 2.1 (diabetes,
ESRD, COPD, nephrotic syndrome, asplenia, HIV or heart failure)
Principal or other diagnosis code is on Table 12.4 (asthma) and age is >=19
 Denominator excludes
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Principal or other diagnosis code on Table 12.3 (pregnancy)
Principal or other procedure code on Table 12.10 (organ transplant during current
hospitalization)
Discharge disposition is acute care facility, expired, left AMA
imm3
 Numerator:
 Pneumococcal vaccination was given during this
hospitalization
 Pneumococcal vaccination was received in the past, not during
this hospitalization
 There is documentation of one of the following
Allergy/sensitivity to pneumococcal vaccine, OR
 Is not likely to be effective because of bone marrow transplant within
the past 12 months, OR
 Currently receiving a scheduled course of chemotherapy or radiation
therapy, or received a chemotherapy or radiation during this
hospitalization or less than 2 weeks prior, OR
 Received the shingles vaccine (Zostavax) within the last 4 weeks
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There is documentation of patient/caregiver refusal of
pneumococcal vaccine (during this hospital stay)
Influenza Immunization
 Q18 (flustat) What is the patient’s influenza
immunization status?
 Discharges October through March are included in
scoring
 Refer to definition/decision rules for examples of
names of influenza vaccination

Does not include pandemic monovalent vaccine, e.g. H1N1
Influenza Immunization Answer Options
 1. Influenza vaccine was given during this
hospitalization

Look for documentation that the patient received the vaccine
during this episode of care
Progress notes
 BCMA
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
Documentation that the vaccine was given must include a date
and signature
Remember that information in clinical reminders must be
verified in a progress note
Influenza Immunization Answer Options
 2. Influenza vaccine was received prior to admission
during the current flu season, not during this
hospitalization

If there is documentation the patient received the vaccine, and
only the current year is documented, select “2.”

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If there is documentation the patient received the vaccine the year
prior to the current year and the discharge is NOT January, February,
or March, select “99.”
 For example, the record documents the patient received the vaccine
in 2012 and the discharge date for this hospital stay is October
2013, select “99.”
 If the discharge is in January, February or March 2014 AND there
is documentation the patient received the vaccine in 2013, select
“2.”
Review remote data to capture immunization given at another
facility
Influenza Immunization Answer Options
 4. There
is documentation of :
Allergy/sensitivity to influenza vaccine, anaphylactic latex
allergy, or anaphylactic allergy to eggs, OR
 is not likely to be effective because of bone marrow transplant (or
autologous stem cell transplant, ASCT) within the past 6 months,
OR
 prior history of Guillian-Barre syndrome within 6 weeks after a
previous influenza vaccination

The allergy/sensitivity must be accompanied by the exact
complication
 Must be a specific allergy/sensitivity, not just
physician/APN/PA preference

Influenza Immunization Answer Options
 6. Only select this option if there is documentation
vaccine has been ordered but has not yet been
received by the hospital due to problems with
vaccine production or distribution AND none of the
other options apply

To use this option you must see the pharmacy record stating
the date the vaccine arrived on station (shipping slip,
inventory record, etc.) and date must be after the discharge
date
Influenza Immunization Answer Options
 98 Documentation of patient’s refusal or caregiver’s
refusal of influenza vaccine

Documentation must indicate the patient/caregiver refused
the influenza vaccine during this hospitalization
May be found in progress note
 May be found in BCMA
 Documentation in a clinical reminder must be verified in a
progress note

 99 None of the above/not documented/ unable to
determine from medical record documentation
 If the length of stay is <=3 days, the review ends
after the immunization questions
imm4
 Influenza Immunization
 Denominator includes:
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Discharges >=10/1/2013 or <4/1/2014
LOS <=120 days
Discharge disposition is home, hospice, hospice facility, other
healthcare facility or UTD
 Denominator exclusions:
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Principal or other procedure code is on Table 12.10 (organ
transplant during current hospitalization)
Discharge status is acute care facility, AMA or expired
There is documentation the vaccine has been ordered but has not
yet been received by the hospital due to problems with vaccine
production or distribution AND none of the other options apply
imm4
 Numerator
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A procedure code for this hospital stay is from Table 12.9 (influenza
vaccination) or
Influenza vaccine was given during this hospitalization or
Influenza vaccine was received prior to admission during the current
flu season, not during this hospitalization or
There is documentation of : -- Allergy/sensitivity to influenza
vaccine, anaphylactic latex allergy, or anaphylactic allergy to eggs OR
-- is not likely to be effective because of bone marrow transplant
within the past 6 months, OR -- prior history of Guillian-Barre
syndrome within 6 weeks after a previous influenza vaccination or
Documentation of patient’s refusal or caregiver’s refusal of influenza
vaccine (during this hospital stay)
Comfort Measures
 Q19 comfort
 This is the same question as in other inpatient
modules
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Answer options and definition/decision rules are the same
If the answer to comfort is 1, 2, or 3 review ends
Cognitive Impairment
 Q20 (cogimp) Is there documentation in the medical record
that indicates the patient was cognitively impaired during
the entire hospitalization?
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Cognition refers to mental activities associated with thinking, learning, and
memory.
Include: Altered mental status, altered level of consciousness (LOC), cognitive
impairment, cognitively impaired, confused, memory loss, mentally retarded, obtunded
Cognitive impairment for the purposes of the tobacco and substance use
measures, is related to documentation that the patient cannot be screened
for tobacco and alcohol use due to the impairment (e.g., comatose,
obtunded, confused, memory loss) during the entire hospitalization.
Cognitive impairment must be documented at all times during the hospitalization in
order to answer “Yes”.
If there is documentation in the medical record that a patient is cognitively impaired,
and there is no additional documentation that the patient’s mental status was normal
at any other time during the hospitalization, i.e., alert and oriented, the abstractor can
select value “Yes”.
Tobacco
 There is a series of questions regarding tobacco use
status and tobacco use treatment
 If a patient is a tobacco user, you will also get a series
of questions about post-discharge follow up
Tobacco Use Status
 Q21 (tobstatus2) What is the patient’s tobacco use status
documented within the first three days of
admission?
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
The day after admission is defined as the first day
Include:
Smokeless tobacco
 Chewing (spit) tobacco
 Twist
 Redman
 Moist snuff
 Dry snuff
 Plug tobacco
 snus

General Rules for tobstatus2
 If there is definitive documentation that the patient either currently uses
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tobacco products or is an ex-user that quit less than 30 days prior to
arrival, select the appropriate allowable value, regardless of whether or
not there is conflicting documentation
Disregard documentation of tobacco use history if the current tobacco use
status or timeframe that patient quit is not defined (e.g., “20 pk/yr smoking
history”, “History of tobacco abuse”).
Do not include documentation of smoking history referenced as a “risk
factor” (e.g., “risk factor: tobacco”, “risk factor: smoking”, “risk factor:
smoker”), where current tobacco use status is indeterminable.
When there is conflicting information in the record with regard to volume,
for instance, one document indicates patient is a light smoker and another
indicates patient is a volume greater than light smoking, assume smoking
at the heaviest level and select value 1.
If the medical record indicates the patient smokes cigarettes and the
volume is not documented or is unknown, assume smoking at the heaviest
level and select value 1.
Tobstatus2 Answer Options
 1. The patient has smoked cigarettes daily on average in a volume of
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five or more cigarettes (>= ¼ pack) per day AND/OR cigars daily
AND/OR pipes daily during the past 30 days
2. The patient has smoked cigarettes daily on average in a volume
of four or less cigarettes (< ¼ pack) per day AND/OR used
smokeless tobacco AND/OR smoked cigarettes but not daily
AND/OR cigars but not daily AND/OR pipes but not daily during
the past 30 days
3. The patient has not used any forms of tobacco in the past 30 days
98. The patient refused the tobacco use screen
99. The patient was not screened for tobacco use within the first
three days of admission or unable to determine the patient’s tobacco
use status from medical record documentation
Practical Counseling
 If the answer to tobstatus2 is “1” or “2” question 22 is
applicable
 Did the patient receive practical counseling that
included all of the following components within the
first three days of hospital admission?
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Recognizing danger situations
Developing coping skills
Providing basic information about quitting
Components of Practical Counseling
 Danger situations (potential triggers) might
include
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alcohol use during the first month after quitting
being around smoke and/or other smokers
times/situations when the patient routinely smoked (in the
car, on break at work, with coffee, after a meal, upon waking
up, social events, etc.)
 Developing coping skills may include but is not
limited to
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advise on identifying triggers for tobacco use
plan or strategies for how to handle.
Components of Practical Counseling
 Providing basic information about quitting
may include but is not limited to
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setting a quit date
removing all tobacco products from the home
supportive message about how quitting smoking will improve
patient’s health
a referral to the VA Quitline
Handing the patient a phone number to call for the Quitline will
not meet the intent of practical counseling
 There must be interaction between the patient and the caregiver.

Practical Counseling
 Select answer “1” (yes) if there is documentation that
practical counseling that included all 3 components
was provided to the patient within the first 3 days of
admission
 Select answer “2” (no) if there is no documentation
that counseling was given to the patient or if the
documentation is not explicit enough to determine if
all 3 components were included or if the counseling
meets the intent of the measure
 Select “98” if the patient refused or declined practical
counseling within the first three days of admission
Tobacco Cessation Medications
 If the answer to tobstatus2 is “1” you will get
questions about tobacco cessation medications
 Q 23 (tobtxmed) Did the patient receive one of the
FDA-approved tobacco cessation medications within
the first three days of hospital admission?

Refer to Joint Commission Appendix C Table 9.1 for the list of
FDA-approved tobacco cessation medications
Reason for No Tobacco Cessation Medications
 If the answer to tobtxmed is “2” (no) you will go to
question 24 (notobmed)
 Is there documentation of a reason for not
administering one of the FDA-approved tobacco
cessation medications within the first three days of
admission?
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Allergy to all of the FDA-approved tobacco cessation
medications.
Drug interaction (for all of the FDA-approved medications)
with other drugs the patient is currently taking.
Other reasons documented by physician/APN/PA or
pharmacist.
Reason for No Tobacco Cessation Medications
 Reasons for not administering FDA-approved
tobacco cessation medications must be documented
by a physician/APN/PA or pharmacist and the
reason must be explicitly documented
 An allergy or adverse reaction to one of the FDAapproved cessation medications would not be a
reason for not administering another of the cessation
medications
OP Tobacco Cessation Counseling
 If tobstatus2=1 or 2, the next question is refoptob
 Did the patient receive a referral for Outpatient
Tobacco Cessation Counseling?

1. The referral to outpatient tobacco cessation counseling
treatment was made by the healthcare provider prior to
discharge
group counseling
 individual counseling
 facility smoking cessation clinic
 VA Smoking Cessation Quitline (1-855-QUIT-VET)
 defined as a telephone counseling in which at least some of the
contact is initiated by the Quitline counselor to deliver tobacco
use interventions

OP Tobacco Cessation Counseling
 Refoptob answer 2
 Referral information was given to the patient at discharge
but the appointment was not made by the provider/facility
prior to discharge

If the patient is provided with contact information for e-health or
internet smoking cessation programs which tailor program
content to the tobacco user’s needs (collect information from the
tobacco user and use algorithms to tailor feedback or
recommendations, permitting the user to select from various features
including extensive information on quitting, tobacco dependence,
and related topics) select value 2.

If the patient is provided with self-help materials that are not tailored to
the patient’s needs and do not provide a structured program, select value
99.
OP Tobacco Cessation Counseling
 4. The referral for outpatient tobacco cessation
counseling treatment was not offered because the
patient’s residence is not in the USA
 98. Patient refused the referral for outpatient
tobacco cessation counseling treatment and the
referral was not made
 99. The referral for outpatient tobacco cessation
counseling treatment was not offered at discharge or
unable to determine from the medical record
documentation
Tobacco Cessation Medication at Discharge
 Q26 (tobmedc) Was an FDA-approved tobacco
cessation medication prescribed at discharge?




1. A prescription for an FDA-approved tobacco cessation
medication was given to the patient at discharge
3. A prescription for an FDA-approved tobacco cessation
medication was not offered because the patient’s residence is
not in the USA
98. A prescription for an FDA-approved tobacco cessation
medication was offered at discharge and the patient refused
99. A prescription for an FDA-approved tobacco cessation
medication was not offered at discharge or unable to
determine from medical record documentation
Tobacco Cessation Medication at Discharge
 Conflicting documentation of tobacco cessation
medication at discharge


In cases where tobacco cessation medication is in one source but is
not mentioned in other sources, it should be interpreted as a
discharge medication. Select value 1 unless documentation elsewhere
in the medical record suggests that tobacco cessation medication was
not prescribed at discharge
If documentation is contradictory (physician noted “d/c Varenicline”
or “hold Varenicline” in the discharge orders, but Varenicline is
listed in the discharge summary’s discharge medication list), or after
careful examination of circumstance, context, timing, etc.,
documentation raises enough questions, the case should be deemed
unable to determine, select value 99
Reason for No Tobacco Cessation Meds at Discharge
 Q27 (notobrxdc)
 Is there documentation of a reason for not administering
one of the FDA-approved tobacco cessation medications at
discharge?



Allergy to all of the FDA-approved tobacco cessation medications
Drug interaction (for all of the FDA-approved medications) with
other drugs the patient is currently taking
Other reasons documented by physician/APN/PA or pharmacist
 Same rules as q24 (notobmed)
Tobacco Use Post Discharge
 If tobstatus2=1 or 2 you will answer questions about
post-discharge tobacco status
 Contact may be made by phone call, discussion at a
follow-up clinic visit, or by mail
 There are specific timeframes for the follow up so
please read the questions carefully
Tobacco Use Follow Up
 Q44 folotob Was contact made with the patient
relative to tobacco use status between 15 and 30 days
post discharge?
 Read the answer options and definition/decision
rules carefully in order to select the correct answer
Tobacco Use Post Discharge
 1. A follow-up contact was made between 15 and 30
days post discharge relative to the patient's tobacco
use status

Select 1 if information relative to tobacco use status was
obtained between 15 and 30 days post-discharge
Include contact with a family member or other person who
answered the questions on behalf of the patient
 Check progress notes of clinic visits during the time period to see if
information relative to tobacco use status was obtained

Tobacco Use Post Discharge
 2. A follow-up contact relative to the patient's
tobacco use status was made, but not between 15 and
30 days post-discharge
Tobacco Use Post Discharge
 3. A follow-up contact was not made within 30 days post-
discharge because the patient's residence is not in the USA,
the patient was incarcerated, contact number was no longer
valid, the patient had no phone, or the patient was
readmitted to the hospital within 30 days post discharge, or
at least 3 unsuccessful attempts to contact the patient were
documented

Also use answer 3 if




There is documentation at discharge that the patient is homeless
The patient died within 30 days post discharge
A return is received indicating the contact information is no longer valid when trying to contact the
patient by phone or mail
If the patient is readmitted following the initial hospitalization, select value 3 if the
hospitalization continued into the specified time frame for follow-up
Tobacco Use Post Discharge
 99. A follow-up contact relative to the patient's
tobacco use status was not made post discharge or
unable to determine from medical record
documentation
If less than 3 unsuccessful attempts were made, select value
99
 If follow-up contact is made by letter or email and no
response is received from patient within 30 days post
discharge, select value 99
 If folotob=2, 3, or 99 no more questions about tobacco
follow up are answered

Date of Contact
 If there is documentation of follow up contact, enter
the date in q45 (folotobdt)



The field will only accept a date >=15 days and <=30 days after
the date of discharge
If multiple contacts are made with the patient post discharge,
select the date of the latest contact where information is
received relative to tobacco use status.
If contact is made through email or letter, select the date of
receipt of the patient's tobacco use post discharge status, not
the date the email or letter was sent
Attending Counseling
 Q46 Is the patient attending (receiving) outpatient
tobacco cessation counseling post discharge?




1. The patient is attending outpatient tobacco cessation
counseling post discharge.
2. The patient is not attending outpatient tobacco cessation
counseling post discharge.
98. Patient refused to provide information relative to post
discharge counseling attendance.
99. Not documented or unable to determine from follow-up
information.
Attending Counseling
 Counseling can include any of the following:



telephone-based counseling (e.g., VA Quitline)
in-person counseling
group counseling.
 If the first counseling session has not occurred at the
time of the post discharge follow-up contact and the
patient intends to attend the scheduled appointment
select value 1
 If follow-up contact is made with the patient but no post
discharge tobacco use status information is collected,
select value 99
 The counseling information must relate to the follow up
contact date selected by the abstractor
Medications Post Discharge
 Q 47 (tobdcmed) Is the patient taking the recommend
tobacco cessation medication post discharge?



1. The patient is taking the recommended tobacco cessation
medication post discharge
2. The patient is not taking the recommended tobacco
cessation medication post discharge
98. Patient refused to provide information relative to tobacco
cessation medication use post discharge
99. Not documented or unable to determine from follow-up
information
Medications Post Discharge
 If the patient is taking an over the counter tobacco cessation product
not requiring a prescription, select value 1
 If the patient is not taking tobacco cessation medication because a
prescription for the medication was not given to the patient prior to
discharge, select value 2
 If an over the counter tobacco cessation medication was listed on the
discharge medication list and the patient is not taking the medication,
select value 2
 The medication use information must relate to the follow up contact
date selected by the abstractor
Tobacco Use Status Post Discharge
 Q48 (tobdcquit) Has the patient quit using tobacco
products post discharge?




1. The patient has quit using tobacco products post discharge
2. The patient has not quit using tobacco products post
discharge
98. Patient refused to provide information relative to tobacco
use status at the follow-up contact
99. Not documented or unable to determine from follow-up
information collected
Tobacco Use Status Post Discharge
 Quit=has not used tobacco in the past 7 days prior to
the follow up contact
 If the patient has initiated a quit attempt but has
been tobacco free for less than 7 days, answer “2”
 The use status information must relate to the follow
up contact date
Tobacco Measures
 tob10 Tobacco Use Screening
 tob20 Tobacco Use Treatment Provided or Offered
 tob30 Tobacco Use Treatment
 tob40 Tobacco Use Treatment Provided or Offered at
Discharge
 tob50 Tobacco Use Treatment at Discharge
 tob60 Tobacco Use: Assessing Status after
Discharge
Exclusions from Tobacco Measures
 The following are denominator exclusions for all
tobacco measures
LOS <=3 days or >120 days
 Patients that are cognitively impaired
 Patients with comfort measures only documented
 There may be additional exclusions for particular measures

Tob10: Tobacco Use Screening
 Denominator: All cases except exclusions as noted
in the previous slide
 Numerator:
There is documentation of the patient’s tobacco use status
within the first 3 days of admission (tobstatus2 =1, 2, or 3)
OR
 The patient refused tobacco use screening

tob20: Tobacco Use Treatment Provided or Offered
 Denominator includes those who were screened for
tobacco use and found to have used tobacco in any
volume during the last 30 days (tobstatus2=1 or 2)
 Numerator:

The patient received or refused practical counseling within the first 3
days of admission and
There is a code from Table 12.3 (pregnancy) or
 Tobstatus2=2 (light volume use) or
 Tobstatus2=1 AND
 The patient received or refused one of the FDA-approved tobacco
cessation medications in the first 3 days after arrival OR
 Tobacco cessation medication was not received AND

• There is a documented reason for not prescribing a tobacco cessation
medication
tob30: Tobacco Use Treatment
 Denominator includes cases in tob20 denominator
 Numerator:
 The patient received practical counseling within the first 3
days of admission and
There is a code from Table 12.3 (pregnancy) or
 Tobstatus2=2 (light volume use) or
 Tobstatus2=1 AND
 The patient received one of the FDA-approved tobacco cessation
medications in the first 3 days after arrival OR
 Tobacco cessation medication was not received AND

• There is a documented reason for not prescribing a tobacco
cessation medication
tob40: Tobacco Use Treatment Provided or Offered at
Discharge
 Denominator



Discharge disposition is home or not documented/unable to determine
Those who were screened for tobacco use within the first three days of admission and found to be
tobacco users in the past 30 days
Denominator exclusions

A referral for outpatient tobacco cessation counseling was not offered because the patient’s residence is not in
the USA

Tobstatus2=1 and the patient received or refused a referral for outpatient tobacco cessation counseling made by the
healthcare provider prior to discharge and tobacco cessation medications were not offered at discharge because the
patient’ residence is not in the USA
 Numerator

The patient received or refused a referral for outpatient tobacco cessation
counseling made by the healthcare provider prior to discharge



There is a code from Table 12.3 (pregnancy) or
Tobstatus2=2 (light volume use) or
Tobstatus2=1 AND
 The patient received or refused one of the FDA-approved tobacco cessation
medications at discharge OR
 Tobacco cessation medication was not received AND
• There is a documented reason for not prescribing a tobacco cessation medication
tob50: Tobacco Use Treatment at Discharge
 Denominator: cases in the denominator of tob40
 Numerator:
 The patient received a referral for outpatient tobacco cessation
counseling made by the healthcare provider prior to discharge
There is a code from Table 12.3 (pregnancy) or
 Tobstatus2=2 (light volume use) or
 Tobstatus2=1 AND
 The patient received or one of the FDA-approved tobacco
cessation medications at discharge OR
 Tobacco cessation medication was not received AND

• There is a documented reason for not prescribing a tobacco
cessation medication
tob60: Tobacco Use: Assessing Status after
Discharge
 Denominator



Discharge disposition is home or not documented/unable to determine
Those who were screened for tobacco use within the first three days of
admission and found to be tobacco users in the past 30 days
Denominator exclusions:


Patients who refused a referral to outpatient tobacco cessation counseling
treatment and do not have a diagnosis code on table 12.3 and refused tobacco
cessation medication at discharge
A follow-up contact was not made within 30 days post discharge because the
patient’s residence is not in the USA, the patient was incarcerated, contact number
was no longer valid, the patient had no phone, or the patient was re-admitted to the
hospital within 30 days post discharge or at least three unsuccessful attempts to
contact the patient were documented
tob60: Tobacco Use: Assessing Status after
Discharge
 Numerator
 A follow up contact was made between 15 and 30 days post discharge
relative to tobacco use status and

The patient is attending outpatient tobacco cessation counseling post-discharge,
or is not attending outpatient tobacco cessation counseling post-discharge or
refused to provide information relative to post discharge counseling attendance
(tobdcoun 1, 2, or 98)
And

The patient is taking the recommended tobacco cessation medication post
discharge or the patient is not taking the recommended tobacco cessation
medication post discharge or the patient refused to provide information relative
to tobacco cessation medication post discharge (tobdcmed 1, 2, or 98)
And

The patient has quit using tobacco products post discharge or the patient has not quit
using tobacco products post discharge or the patient refused to provide information
relative to tobacco use at the follow up contact (tobdcquit 1, 2, or 98)
Substance Use
 The first series of questions in the substance use
section are about screening for alcohol misuse with
the AUDIT-C
 The questions are the same as the AUDIT-C
questions in CGPI except


You are looking for screening with the AUDIT-C within the
first 3 days of admission only
Q28 has an option for patient refusal of screening during the
first three days of admission
Brief Intervention
 If the patient was screened using the AUDIT-C and the total score is
>=5, the next question is 34 (briefint)
 Following the positive screening result for alcohol use, did
the patient receive a brief intervention including any of
the following components prior to discharge?
Indicate all that apply:





1. Feedback concerning the quantity and frequency of alcohol
consumed by the patient in comparison with national norms
2. A discussion of negative physical, emotional, and occupational
consequences
3. A discussion of the overall severity of the problem
98. Patient refused/declined brief intervention
99. Brief intervention was not offered to the patient during the hospital stay
or unable to determine if a brief intervention was provided from medical
record documentation
Brief Intervention
 A brief intervention is defined as a single interaction between
the qualified healthcare professional and the patient
following a positive screening result for unhealthy alcohol
use or alcohol use disorder


A qualified healthcare professional may be defined as a
physician, nurse, addictions counselor, psychologist, social
worker, or health educator with training in brief intervention
The components of the intervention are answer options 1, 2,
and 3
Brief Intervention
 Select answer “99”
 if there is no documentation of a brief intervention
 if the documentation is not explicit enough to determine if the
specific components were included
 if it is determined that the intervention does not meet the
intent of the measure
 If the discharge disposition is anything other than 1
or 99, abstraction ends
Substance Use Disorder
 Q 35 (sudisord) Is there documentation in the
medical record that the patient has an alcohol or
drug use disorder?


Do not try to determine if alcohol or drug abuse exists from
documentation of symptoms
The health care provider must document explicitly that the
patient has an alcohol or drug use disorder
Substance Use Disorder
 Inclusion Guidelines for Abstraction:
 Alcohol or Drug dependent/dependence (may be described as
appears to have, consider, consistent with (C/W), diagnostic
of, evidence of , indicative of , likely, most likely, probable ,
representative of )
 Admission for Detoxification
 Delirium Tremens (DTs)
 Withdrawal syndrome
 Exclude:
 History of dependence
Referral for Addiction Treatment
 Q36 (addtxref) Was a referral for addictions
treatment made for the patient prior to
discharge?





1. The referral to addictions treatment was made by the
healthcare provider prior to discharge.
2. Referral information was given to the patient at discharge but
the appointment was not made by the provider prior to discharge.
4. The referral for addictions treatment was not offered because
the patient’s residence is not in the USA.
98. The patient refused the referral for addictions treatment and
the referral was not made.
99. The referral for addictions treatment was not offered at
discharge or unable to determine from the medical record
documentation.
Referral for Addiction Treatment
 A referral may be defined as an appointment made
by the provider either through telephone contact, fax
or e-mail.


The referral may be to an addictions treatment program, to a
mental health program or mental health specialist for followup for substance use or addiction treatment, or to a medical or
health professional for follow-up for substance use or
addiction
The referral may be made by a physician or by a non-physician
(e.g nurse, psychologist or counselor)
Referral for Addiction Treatment
 Include:







Group counseling
Individual counseling
Personal physician
Psychiatrist
Psychologist
Addictions counselor
Social worker
 Do not include:


Self help interventions
Support groups that are not considered treatment, such as AA

A referral to Alcoholics Anonymous (AA) or similar mutual support
groups does not meet the intent of the measure, select value 98 if such
a referral is given to the patient.
Medication for Alcohol or Drug Disorder
 Q37 (sudmedc) Was one of the FDA-approved
medications for alcohol or drug disorder
prescribed at discharge?




1. A prescription for an FDA-approved medication for alcohol or
drug disorder was given to the patient at discharge
3. A prescription for an FDA-approved medication for alcohol or
drug disorder was not offered at discharge because the patient’s
residence is not in the USA
98. A prescription for an FDA-approved medication for alcohol or
drug disorder was offered at discharge and the patient refused
99. A prescription for an FDA-approved medication for alcohol or
drug disorder was not offered at discharge, or unable to determine
from medical record documentation
Medication for Alcohol or Drug Disorder
 Refer to Joint Commission Appendix C, Table 9.2 for
a list of FDA-approved medications for alcohol and
drug dependence


In cases where a medication for alcohol or drug use is listed in
one source but is not mentioned in other sources, it should be
interpreted as a discharge medication. Select value 1 unless
documentation elsewhere in the medical record suggests that
the medication was not prescribed at discharge
If documentation is contradictory or after careful examination
of circumstance, context, timing, etc., documentation raises
enough questions, the case should be deemed unable to
determine, select value 99
Substance Abuse Follow Up
 Cases will go through the substance abuse follow up
questions if there is



an ICD-9 CM diagnosis code for alcohol or drug dependence (Table
13.1, 13.2) or
a procedure code for alcohol or drug treatment (Table 13.3) or
if there is documentation that the patient has an alcohol or drug use
disorder (sudisord=1)
Follow Up
 Contact may be made by phone call, discussion at a
follow up clinic visits, or by mail
 There are specific timeframes for the follow up so
please read the questions carefully
Substance Abuse Follow Up
 Q38 (folosub) Was contact made with the patient
relative to their alcohol or other drug use status
between 7 and 30 days post discharge?
 Read each answer option carefully along with the
definition/decision rules to determine the correct
response
Folosub
 1. A follow-up contact was made between 7 and
within 30 days post discharge relative to the patient's
alcohol or other drug use status

Select 1 if information relative to alcohol or other drug use
status was obtained between 7 and 30 days post-discharge
Include contact with a family member or other person who
answered the questions on behalf of the patient
 Check progress notes of clinic visits during the time period to see if
information relative to substance use status was obtained

Folosub
 2. A follow-up contact was made, but not between 7
and 30 days post discharge
Folosub
 3. A follow-up contact was not made between 7 and 30 days post
discharge because the patient's residence is not in the USA, the patient
was incarcerated, contact number was no longer valid, the patient had
no phone, or the patient was readmitted to the hospital within 30 days
post discharge, or at least 3 unsuccessful attempts to contact the patient
were documented

Also use answer 3 if




There is documentation at discharge that the patient is homeless
The patient died within 30 days post discharge
A return is received indicating the contact information is no longer valid when trying to contact the
patient by phone or mail
If the patient is readmitted following the initial hospitalization, select value 3 if the
hospitalization continued into the specified time frame for follow-up
Folosub
 99. A follow-up contact relative to the patient's
alcohol or other drug use status was not made or
unable to determine from medical record
documentation
If less than 3 unsuccessful attempts were made, select value
99
 If follow-up contact is made by letter or email and no
response is received from patient within 30 days post
discharge, select value 99
 If folosub=2, 3, or 99 you will go to tobacco follow up if
appropriate, otherwise module ends

Date of Contact
 Q39 (folosubdt) If follow up contact was made to assess
substance use post-discharge, enter the date

The field will only accept a date >=7 days and <=30 days after the
date of discharge
 If multiple contacts are made with the patient post
discharge, select the date of the latest contact where
information is received relative to substance use status.
 If contact is made through email or letter, select the date
of receipt of the patient's alcohol or drug use post
discharge status, not the date the email or letter was sent
Post-Discharge Counseling
 Q40 (sudcoun) Is the patient with an alcohol or drug
disorder or addiction attending the referred
addictions counseling post discharge?





1. The patient was referred and is attending the referred
addictions treatment
2. The patient was referred and patient is not attending
addictions treatment
3. The patient was NOT referred to addictions treatment.
98. Patient refused to provide information relative to post
discharge counseling attendance
99. Not documented or unable to determine from follow-up
information collected.
Post-Discharge Counseling
 If addtxref was answered 4, 98 or 99, sudcoun will be
auto-filled as 3
 The follow-up information about addictions
counseling post-discharge must relate to the follow
up contact date you entered in q39
 If the first counseling session has not occurred at the
time of the post discharge follow-up and the patient
plans to attend, select “1”.
Prescribed Medication
 Q41 (sudcmed) Is the patient with an alcohol or drug
disorder or addiction taking the prescribed medication
post discharge?





1. The patient was given a prescription and is taking medication
post discharge for an alcohol or drug use disorder as prescribed
2. The patient was given a prescription and is not taking medication
post discharge for an alcohol or drug use disorder as prescribed.
3. The patient was NOT given a prescription for medication to
treat an alcohol or drug use disorder.
98. Patient refused to provide information relative to post
discharge medication use.
99. Not documented or unable to determine from follow-up
information collected
Prescribed Medication
 The question will be auto-filled as “3” if sudmedc was
answered 3, 98, or 99
 If the patient is contacted more than once during the
7 to 30 day time frame post-discharge, select the
value that corresponds to the compliance with
medication use status obtained at the latest point in
time
 The medication use information must relate to the
follow-up contact date selected by the abstractor
Alcohol Use Status
 Q42 (alcdcquit) What is the status of the patient's
alcohol use at the time of the post discharge followup contact?

1. The patient has quit or reduced their alcohol intake.

2. The patient has not quit or reduced their alcohol intake.
3. Not applicable, the patient does not use or does not have
unhealthy alcohol use.
98. The patient refused to provide information relative to
alcohol use status at the follow up contact.
99. Not documented or unable to determine from follow-up
information collected.



Alcohol Use Status
 Quit is defined as not using alcohol in the 7 day
timeframe prior to the follow up contact date.
 The use status information must relate to the follow
up contact date selected by the abstractor
 If alcohol is not the substance of interest for follow
up (i.e. no documentation of unhealthy alcohol use,
alcohol use disorder, or alcohol addiction, select “3”

You cannot choose “3” if alcscor>=5, there is a
diagnosis code from Table 13.1 or a procedure code
for alcohol treatment from Table 13.3
Drug Use Status
 Q43 (sudcquit) What is the status of the
patient's drug use at the time of the post
discharge follow-up contact?





1. The patient has quit using drugs.
2. The patient has not quit using drugs.
3. Not applicable, the patient does not use drugs.
98. The patient refused to provide information relative to drug
use status at the follow up contact.
99. Not documented or unable to determine from follow-up
information collected
Drug Use Status
 Quit is defined as not using alcohol in the 7 day
timeframe prior to the follow up contact date.
 The use status information must relate to the follow
up contact date selected by the abstractor
 If the patient was not identified during the hospital
stay as having a drug disorder or addiction and drug
use is not the substance of interest for follow-up,
select value 3

You cannot select “3” if alcdcquit=3 or if there is a
diagnosis code on Table 13.2 or a procedure code for
drug treatment from Table 13.3
Substance Use Measures
 sub10 Alcohol Use Screening
 sub20 Alcohol Use Brief Intervention Provided or




Offered
sub30 Alcohol Use Brief Intervention
sub40 Alcohol and Other Drug Use Disorder
Treatment Provided or Offered at Discharge
sub50 Alcohol and Other Drug Use Disorder
Treatment at Discharge
sub60 Alcohol and Drug Use: Assessing Status after
Discharge
Substance Use Measures
 The following are denominator exclusions for all
substance use measures
LOS <=3 days or >120 days
 Patients that are cognitively impaired
 Patients with comfort measures only documented
 There may be additional exclusions for particular measures

sub10: Alcohol Use Screening
 Denominator: includes all cases except those with
exclusions as noted in the previous slide
 Numerator:
The patient refused screening for alcohol misuse during the
first three days of admission
OR
 The patient was screened for alcohol misuse with the
AUDIT-C within the first three days of admission and the
total score is a valid number

Sub20: Alcohol Use Brief Intervention Provided
or Offered
 Denominator:
 Patients screened with the AUDIT-C within the first three days
of admission with a total score of >=5
 Numerator:

The patient received brief intervention that
includes all 3 components
OR

The patient refused brief intervention
sub30: Alcohol Use Brief Intervention
 Denominator:
 Cases included in the denominator of sub20
 Numerator:

The patient received brief intervention that
includes all 3 components
sub40: Alcohol and Other Drug Use Disorder
Treatment Provided or Offered at Discharge
 Denominator:



Cases with a diagnosis code on Table 13.1 or 13.2 or a
procedure code on Table 13.3 or documentation that the
patient has an alcohol or drug use disorder
Discharge disposition is home or UTD
Denominator exclusions:
A referral for addictions treatment was not offered because the
patient’s residence was not in the USA
 A prescription for FDA-approved medication for alcohol or drug
disorder was not offered because the patient’s residence was not in
the USA

sub40: Alcohol and Other Drug Use Disorder
Treatment Provided or Offered at Discharge
 Numerator:
The referral to addictions treatment was made by the
healthcare provider prior to discharge
OR

The patient refused the referral for addictions treatment and
the referral was not made
OR
 A prescription for an FDA approved medication for alcohol or
drug disorder was given to the patient at discharge
OR
 A prescription for an FDA approved medication for alcohol or
drug disorder was offered at discharge and the patient refused

sub50: Alcohol and Other Drug Use Disorder
Treatment at Discharge
 Denominator: cases included in the denominator of
sub40
 Numerator:
The referral to addictions treatment was made by the
healthcare provider prior to discharge
OR
 A prescription for an FDA approved medication for alcohol or drug
disorder was given to the patient at discharge

Sub60: Alcohol and Drug Use: Assessing Status
after Discharge
 Denominator:



Cases with a diagnosis code on Table 13.1 or 13.2 or a procedure code
on Table 13.3 or documentation that the patient has an alcohol or
drug use disorder
Discharge disposition is home or UTD
Denominator exclusion:

A follow-up contact was not made between 7 and 30 days
post discharge because the patient's residence is not in the
USA, the patient was incarcerated, contact number was no
longer valid, the patient had no phone, or the patient was readmitted
to the hospital within 30 days post discharge, or at
least 3 unsuccessful attempts to contact the patient were documented
Sub60: Alcohol and Drug Use: Assessing Status
after Discharge
 Numerator:


A follow up contact was made between 7 and 30 days post discharge relative to alcohol or other drug use status AND
One of the following: (sudcoun 1, 2, 3, or 98)
 The patient was referred and is attending the referred addictions treatment or
 The patient was referred and is not attending the addictions treatment or
 The patient was not referred to addictions treatment or
 The patient refused to provide information relative to post discharge counseling attendance
And

One of the following:(sudcmed (1, 2, 3, or 98)
 The patient was given a prescription and is taking medication post discharge for an alcohol or drug use disorder as
prescribed or
 The patient was given a prescription and is not taking medication post discharge for an alcohol or drug use disorder as
prescribed
 The patient was not given a prescription for medication to treat an alcohol or drug use disorder or
 The patient refused to provide information relative to post discharge medication use
And

At least one of the following
 The status of the patient’s alcohol use at the time of post-discharge follow up contact is
 The patient has quit or reduced alcohol intake, or

The patient has not quit or reduced alcohol intake or
 The patient refused to provide information relative to alcohol use status at the follow up contact
 The status of the patient’s drug use at the time of post-discharge follow up contact is
 The patient has quit using drugs or
 The patient has not quit using drugs or
 The patient refused to provide information relative to drug use at the follow up contact
Read and Review
 Please be sure to read questions, answer options and
definition/decision rules carefully
 Review medical record documentation carefully to
determine whether it meets the intent of the
question
 Consult with your Regional Manager when you have
questions
 It is important to do a proper review in order to let
the facility know where improvements must be made
in order to meet measures