Elizabeth Bonetti, RN, MA, MS

Using Data to Recharge Your CDI Program

HISTORY

• Community hospital

• Member NYPHCS

• ADC 300-325

• Urban setting

HISTORY

• Shared resource model

– Case managers assumed CDI function

– Physician and hospital staff education

• Coding opportunities

– Department development

HISTORY

• Physician education

• Audits and re-bills

• Multiple false starts!!!!

WHY NOW?

REALITY: PAYMENT RESTRUCTURING MS-DRGS

• Pay for performance: Direct– Coding/outcomes (P4P)

• Pay for performance: Indirect– Consumer choice– Selective contracting

• No pay for poor performance: – Adverse events not POA

• Recovery Audit Contractors (RAC) 2010:– Readmissions– Bundled $

American Journal of Medical Quality: “Medicare’s Value-Based Payment Initiatives: Impact on and Implications for Improving Physician Documentation and Coding,” by Alan H. Rosenstein, MD, MBA, Michelle O’Daniel, MSG, MBA,Susan White, PhD,Ken Taylor

HOSPITAL DATA REPORTS

• MS-DRG coding impact – Coding complexity– Financial impact projections

• NYS DRG severity impact • Severity-adjusted LOS report

– Opportunity assessment

• Adverse event incidence and impact • CMS/JC quality indicator report• HealthGrades report

– Actual to expected mortality/complication rates– Patient safety ratings

WHAT IS IMPACTED?

• Revenue

• ALOS

• Patient flow

• Medical necessity and DRG denials

• Quality data reporting

• Risk management

ADMINISTRATIVE SUPPORT

• CEO

• CMO

• CFO

• Finance

• Clinical chairmen

• Nursing leadership

• Clinical pharmacy

• IT

• Compliance

• Case management

• HIM

PHYSICIAN INCENTIVES

• Improves patient outcomes• Emotional: Loyalty/pride/respect• Competitive: Peer pressure• Awareness/accountability:

– Reputation– Contracting– OPPE

• Financial:– Billing– P4P incentives– Market share

American Journal of Medical Quality: “Hospital Report Cards: Intent, Impact, and Illusion,” by Alan H. Rosenstein, MD, MBA

Medical Economics: “When Health Plans Don’t Want You Anymore”

PROGRAM PLACEMENT

Assistant vice president

Clinical documentation improvement

Coding Patient

placement Social work

Senior vice president, chief financial officer Executive vice president, chief medical officer

Denials management Case management

Health information management

DEVELOPMENT

• Opportunity for improvement – Assessment

– DRG benchmark report

• Business plan

• Vendor selection

• Physician buy-in

• Staffing—type of workers

• Collaboration with HIM

• Tools

• Reporting—monthly benchmarks

PHYSICIAN BUY-IN—WHAT’S IN IT FOR ME?

• Salaried vs. voluntary physicians

• Education at routine meetings

• Tied to professional billing

• Meet the physician for 1:1 reviews

• Achievement certificates

• OPPE reporting

This certificate is awarded to

DateSignature

DateSignature

Jennifer Smith, MD

in recognition of excellent clinical documentation:

“CHF, acute on chronic with systolic dysfunction; respiratory failure

secondary to pulmonary edema”

CERTIFICATE OF EXCELLENCE

METHODOLOGY/TOOLS

• Work environment

• Laptops—concurrent entries– 3M coding software and Sunrise Record

Manager

– CDI database

– EMR

• Pocket guides—physician billing guidelines

METHODOLOGY/TOOLS

• Physician query sheets/electronic query

• Policies/processes

• Weekly coding/CDS leadership meetings

• Strategic postings

• Verbal rewarding and candy

• Physician achievement certificates

• Validation of $$ reported

A NEW START

A branding all its own!

NETPRESENTER

• Clinical documentation program– Accurate provider and hospital profiling is now

possible

– Instant feedback on practitioner documentation to reflect severity of illness

– Coming events: Physician/staff education seminars

– Documentation team is now in place; contact Jennifer at Ext. xxxx or Brenda at Ext. xxxx for more information

Physician query

• Bright color

• Inserted in progress notes

• CDI contacts

• Compliant

METHODOLOGY/TOOLS

• Rollout

– Physician rounds

– Disease based vs. unit based

– Emergency department

• Coder identified opportunity (retro)

• Electronic query solution

COMPLIANCE

• Policy review

• Process review

• Query review

• Reports

CD TEAM EDUCATION

• Team-building methodology – All attended coding review/

updates

– Graduation

– Celebrations

– New staff orientation

– Bimonthly education/sharing

EDUCATION

– Across all disciplines

– Grand rounds

– Resident lectures

– Strategic postings

– 1:1

– Unit-based small conferences

– Physician rounds

– Discharge summary review

– EMR utilization

Reports drive success and improvement

MONTHLY FINANCIAL DASHBOARD

 Month/year Reviews  

MD queries  

(+) DRG changes   Variance

Type of reviews # % # % # %  

Concurrent opportunities

Retrospective opportunities

Re-bill records

Severity of illness (SOI)

No opportunity

TOTAL

• Senior finance leadership dashboard—monthly and annual tracking

• Case-specific validation

• Annual budgeted revenue expectation

• Tracked for attaining annual target

ANNUAL FINANCIAL DASHBOARD

 

Type of Reviews

# Reviews

% DRG change

Variance #

Reviews % DRG change

Variance #

Reviews % DRG change

Variance #

Reviews % DRG change

Variance

Concurrent Opportunities

108 63% $184,206 26 65% $68,762 35 97% $186,721 313 76% $1,063,587

Retrospective Opportunities

41 44% $83,196 33 45% $54,622 37 51% $119,249 193 46% $443,922

Rebill Records

2 100% ($7,756) 0 0% $ - 2 0% ($13,956) 11 67% $22,739

Severity of Illness

10 na na 25 na na 47 na na 107 na na

No Opportunity

17 na na 34 na na 54 na na 177 na na

TOTAL 178 69% $259,646 118 37% $123,384 175 49% $292,014 801 63% $1,530,248

Apr May June YTD

CDI CLINICAL DEPARTMENT DASHBOARD

  Apr May June 2nd Q

Clinical department

# reviews

% DRGchange

Variance #

reviews % DRGchange

Variance #

reviews % DRGchange

Variance #

reviews % DRGchange

Variance

Family medicine

27 82% $39,940 24 50% $14,657 29 100% $ 38,316 80 77% $92,913

Internal medicine

137 68% $192,698 91 57% $96,846 140 94% $ 245,572 368 73% $535,116

OB/GYN 3 100% $10,887 0 0% $0 3 0% $ - 6 33% $10,887

Pediatrics 3 100% $6,072 1 100% $7,911 0 0% $ - 4 67% $13,983

Surgery 8 62% $10,049 2 100% $3,970 3 100% $ 8,126 13 87% $22,145

TOTAL 178 69% $259,646 118 55% $123,384 175 83% $ 292,014 471 69% $675,044

• Clinical department leadership dashboard—monthly and annual tracking • Departmental CMI and revenue impact • Specific physician monitoring included

PHYSICIAN-SPECIFIC DASHBOARD

September 2010

Family medicineattending MD

Cases reviewed

Queries MD response MD agreement $$ variance

      Yes No Yes No  

John McParland 10 22 0 1 1 ($4,277)

Mary Eagan 12 2 2 0 2 0 $8,524

Steve Seifried 22 4 3 1 3 0 $24,123

Andrew Smith 15 1 1 0 1 0 $2,100

Total 59 9 8 1 7 1 $30,470

• OPPE indicator

• Physician response and agreement rate

• Case-specific data available on request

CDI STAFF DASHBOARD

October 2010

Family medicineattending MD

Cases reviewed

Queries MD response MD agreement $$ variance

      Yes No Yes No  

Jennifer Smith, RN 325 45 42 3 40 2 $77,240

Annaliza Gonzales, RN 375 66 60 6 59 1 $107,830

Elizabeth Jones, RN 280 42 40 2 38 2 $52,231

Sally Jones, RN 288 38 35 3 32 3 $45,455

Total 1268 191 177 14 169 8 $282,756

• Staff productivity monitoring

• Staff QA monitoring

• Staff feedback

DASHBOARD—IN DEVELOPMENT

• By DRG– Education opportunity by service line

– Opportunity for hospital improvement

THE ULTIMATE GOAL

• Balance cost and quality

COSTQUALITY