Increased Weakness & Slurred Speech - HCPro questions please contact HCProcustomer service at...

©2013 HCPro, Inc. All rights reserved. These materials may not be duplicated without the express written permission of HCPro, Inc. For questions please contact HCPro customer service at 800-650-6787. 1

Fifth Time’s a Charm: Loma Linda University Medical Center

Loma Linda University Medical Center, Loma Linda, Calif.:James Pappas, MD, MBAVice President, Patient Safety & Reliability

Waheed Baqai, MPH, CPHDirector, Clinical Decision Support

2

Learning Objectives

• Explain why Loma Linda had poor public ratings• Describe how severity of illness/risk of mortality

concepts work, and how they led to physician buy-in• Define incentives to ensure physician participation

in CDI efforts• Identify case studies of non-specific vs. specific

documentation and their impact on quality metrics• List regulatory trends affecting the future of CDI,

including the Affordable Care Act and the migration towards quality

3

Increased Weakness& Slurred Speech

• ID: 61-year-old male with h/o CVA• CC: increased global weakness, slurred speech,

altered mental status• HPI: 4 a.m., found sitting on couch; can’t stand,HPI: 4 a.m., found sitting on couch; can t stand,

respond appropriately, or speak; evidence of urinary incontinence. In the ED: Unable to explain most of night’s events; patient thinks he is speaking funny despite knowing what he wanted to say.

• PMH: 1) CVA, 2) HTN, 3) DM type 2, 4) seizure disorder, and 5) drug (cocaine) abuse

4


Increased Weakness & Slurred Speech

• Vitals: T = 97 (oral), P = 90, RR = 18, BP = 197/104

• Neurological exam: Alert and oriented; slowed mentation, general right-sided weakness

A t I i i ht id d k d• Assessment: Increasing right-sided weakness and dysarthria of unknown duration, TIA versus CVA

The miracle ofmodern medicine …

5

Mortality

Hos

pita

l 1

Hos

pita

l 2

Hos

pita

l 3

Hos

pita

l 4

Hos

pita

l 5

Hos

pita

l 6

Hos

pita

l 7

Hos

pita

l 8

Hos

pita

l 9

Hos

pita

l 10

LLU

MC

Hos

pita

l 11

Hos

pita

l 12

6

Compare Overall Physician Group Ratings (San Bernardino County)

Physician Group Rating

Bay Valley Medical Group

F il P ti M di l G f S B di

LLUMC Data & Ratings

Excellent Good Fair Poor

Family Practice Medical Group of San Bernardino

Guardian Medical Associates IPA (Desert Medical IPA)

High Desert Primary Care Medical Group

Inland HealthCare Group

La Salle Medical Associates, Inc.

Loma Linda University HealthCare

New Horizon Medical Group

Oasis IPA

Physicians Healthways

7

LLUMC Mortality by Calendar Year

3.6%3.5%

Actual Expected

3.1% 3.1% 3.1%

3.3%

3.0% 3.0% 3.0%3.1%

FY 2004 FY 2005 FY 2006 FY 2007 FY 2008

CMS MedPAR: Q4 2003 to Q3 20088


Service to >26% of California

4 million people

Loma Linda UniversityMedical Center

• Adult and pediatricLevel I Trauma Center

• Four campuses

LLUMC

9

Our Story

How we did it

CDI of tomorrow

Epiphanies & PPACA

What worked

and what didn’t

The beginning

10

Clinical Documentation Improvement

• Reports to Patient Safety and Reliability

–VP Quality and Patient Safety & chief patient safety officer

• Five full-time CDSs, all RNs

• At first Medicare only

–Expanded to other DRG payers

11

CDI Focus

• Quality – not financial

• Document the severity of patients

• Win-win for physicians

• Physician education

–Teachable moments

–New environment

• Resident education – system thinking

12


CDI Successes

• Trained majority of medical staff

–Strongly encouraged by School of Medicine dean and medical staff president

Mandated education for residents–Mandated education for residents• New resident orientation

• System thinking goal

• Just-in-time training

• CDSs viewed as consultants and teachers

13

Secondary Diagnosis

• Any condition that is documented by a treating physician and is:– Clinically evaluated or

– Diagnostically tested or

– Therapeutically treated or

– Causes an increase in LOS or nursing care

Note: In addition to being documented by the physician, only one of the criteria above must be met in order for a condition to be considered a secondary diagnosis.

14

POA (Present on Admission)

• Conditions that are POA need to be documented as such in the progress notes, e.g.:– UTI – POA– PNA – POA– Stage 2 sacral pressure ulcer – POA

• Documenting “POA” distinguishes a condition from being a HAC (hospital-acquired condition)

15

Documentation TipsRefrain From:

• “vs.,” “or,” “r/o,” “commas” to separate suspected diagnoses (e.g., SOB 2/2 PNA vs. pulmonary embolism vs. COPD)

• Use of vague terms (insufficiency, SOB, altered, chest discomfort) as diagnoses

• Use of lab values in lieu of medical conditions and/or diagnosesUse of lab values in lieu of medical conditions and/or diagnoses• Use of ARROWS↑↓, unclear abbreviations, symbols, and

shortcuts– Na ↑– K ↓– Rhabdo– Osteo– BPRPR

16


Documentation TipsDo:

• LINK symptoms to probable diagnoses: e.g., abdominal pain 2/2 possible PSBO

• Document ALL PMH: e.g., chronic diastolic CHF, CVA w/ residual of left facial droopp

• BE SPECIFIC: Type, acuity, laterality

• POA: UTI, PNA, pressure ulcers, etc.

• Acknowledge QUERIES from CDI personnel

17

3 Key Elements to Successful Documentation

1. PRINCIPAL DIAGNOSIS: Make sure your patient has a principal diagnosis and plan of care. If possible, LINK a symptom to a suspected diagnosis (reason for admission).

2. SECONDARY DIAGNOSES: Comorbiditiesand PMH with plan of care.

3. DISCHARGE SUMMARY: Needs to summarize the admission – diagnoses resolved, not resolved, being followed up, etc.

18

OUR GOAL, Through Documentation, Is To …

• Reflect the high severity of illness at LLUMC through our charting

• Show the true severity of illness of our patients compared to the national databases

• Stay compliant with regulatory agencieswhile maintaining high quality scores

• Improve outcomes by improved communication and recordkeeping

19

Why Does Data Matter?Hospital and Physician Profiling Data Is Available to the Public

20


2.113

Medicare Case-Mix Index

1.861

1.976

2008 2009 2010

21

Among the best in 7 specialties:

• Pulmonology

Best Hospitals in Riverside-San Bernardino, Calif.

U.S. News & World Report

Pulmonology • Cancer • Diabetes & endocrinology • ENT • Gynecology • Kidney disorders • Urology

2010

22

Among the best in 10 specialties:• Cancer• Cardiology and heart disease

Best Hospitals in Riverside-San Bernardino, CA

U.S. News & World Report

Cardiology and heart disease• Diabetes & endocrinology • ENT • Gastroenterology• Gynecology • Nephrology• Orthopedics• Pulmonology • Urology

2011

23

Our Story

How we did it

CDI of tomorrow

Epiphanies & PPACA

What worked

and what didn’t

The beginning

24


What Worked and What Didn’t

• Sharing nonfinancial indicators

–Case-mix index

–Observed/expected mortality

–LOS comparison

• Explaining basics

• Lots of presentations and education

–Relentlessly

25

APR-DRG 44 Intracranial hemorrhage – Severity > 64

26

APR-DRG 44 Intracranial hemorrhage – Mortality > 64

27

Hospital UB-04 Physician CMS-1500

MedPAR file: Hospital UB Claim (Medicare Provider Analysis and Review)Data is “severity adjusted” prior to public release in California

16 diagnoses 6 procedures 4 diagnoses 6 procedures 28


Incentives

• Administrative Services Agreement (ASA)

–Contract between hospital and physician groups that specifies responsibilities, duration of service, and compensationof service, and compensation

• Residents

–Will work for food

–Recognition and praise

29

Example: Department of General Surgery

• Specific surgeons with large number of queries had less than adequate response rates

• Financial incentives were offered to general surgery attending physicians if departmentsurgery attending physicians if department response rate reached 95% of CDI queries or higher

30

Pre/Post Query Response by Service

CDI Queries - Answered %Provider Group Before After

Unaffiliated 68.2 67.3Orthopaedics 78.6 84Vascular Surgery 76.9 84Neurology 84.2 86.7Neurosurgery 74.3 90OB GYN 75 91.7Head & Neck 85 92.9Surgical Oncology 70.6 93.3General/Trauma Surgery 91.9 96.4Physicians Medical Group 87.9 97.7Cardiology 91.7 98.2General Internal Medicine 87.5 100Direct Hospitalists 90 100Plastic Surgery 80 100Urology 85 100Family Medicine 87.9 100CT Surgery 89.5 100

31

AHRQ

32Outpatient Inpatient ↓↓


How Does This All Work?

Documentation Coding Billing

Reimbursement

Quality Ratings

OROR

• It all starts with documentation• Clinical documentation

improvement (CDI) helps with documentation

NonspecificNonspecificDocumentation

InaccurateInaccurateCoding

ReducedReducedBills

LessLessReimbursement

PoorPoorQuality Ratings

OR…OR…

33

Which Documentation Matters?

• H&P

• Progress notes

• Consult notes

• H&P

• Progress notes

• Consult notes

• Operative andprocedure reports

• Discharge summaries

Physician documentation is key!

• Operative andprocedure reports

• Discharge summaries

Physician documentation is key!34

Coding & Billing:How Exactly Do DRGs Work?

• Diagnosis-related group (DRG) is a system to classify hospital cases into one of approximately 500 groups, also referred to as DRGs, expected to have similar hospital resource use– Groups are based on common illnesses and/or procedures (e.g., appendectomy)– Developed to replace cost-based reimbursement with a “case rate” type

paymentC DRG t i l d• Common DRG systems include– Medicare severity (MS-DRG)

• Used since 1982 for Medicare payments

• Each MS-DRG has a relative weight (RW) ranging from 0.16 to 24.28 used to calculate case-mix index (CMI)

– All patient refined DRG (APR-DRG)• Proprietary and developed by 3M• Includes severity of illness (SOI) and risk of mortality (ROM), each with 4 levels

• DRGs are assigned by a "grouper" program based on ICD diagnoses, procedures, age, sex, discharge status, and the presence of complications or comorbidities

35

APR-DRGs: Severity of Illness (SOI)

–Examples of severity designations for secondary diagnoses:

Severity 1 Severity 2 Severity 3 Severity 4Chest pain, ACS A-Fib Cardiomyopathy AMIAltered mental status, ALOC

Malnutrition, mild Malnutrition,moderate

Malnutrition, severe

Dyspnea, SOB, hypoxia, hypoxemia

Acute blood loss anemia

Encephalopathy Hepaticencephalopathy

Ischemiccardiomyopathy, CAD

Whipple’s disease Small bowel obstruction

Acute respiratoryfailure/vent dependence

Obesity Obesity, morbid (w/ BMI)

Skull fracture w/coma > 1 hour

Sepsis, line sepsis, shock, SIRS

36


Determining the APR-DRG

• APR-DRGs are determined, for a specific episode of care, through the incorporation of clinical and patient-specific data as illustrated below

Principal diagnosis

Secondary diagnosis

Procedure codes Gender Age Discharge

status

314 APR-DRGs

Pre-MDC 25 MDC

ungroupable

Grouper logic and coding rules

37

Healthgrades®One of the top online directories for physicians and hospitals

• Healthgrades uses a process of risk adjustment to compare hospitals fairly

• Based on the mortality and complication rates, hospitals are ranked accordinglyhospitals are ranked accordingly

• Hospitals received 5 star (best), 3 star (as expected), or 1 star (poor) ratings

38

A typical patient would have a 72.47% lower risk

★★★★★★★★★★yp p

of dying in a 5-star rated hospital compared to a 1-star rated hospital

The Thirteenth Annual Healthgrades Hospital Quality in America Study Author: Kristin Reed, MPH; Coauthor: Rick May, MD

Major Contributors: Carol Nicholas, MSTC, writing, editing, and publishing; Harold Taylor, PhD, and Alex Brown, statistical analysis

http://www.healthgrades.com/business/study/quality.aspx

39

Quality Scores & Physician Profiles Matter

• Payers use claims data (billing/coding) to create quality scores/ranks

–Preferred provider contracts and referrals are based on this informationbased on this information

–High-cost, low-quality providers are the hardest hit

• Customers (your potential patients) use these websites to make decisions on where to access care

40


Our Story

How we did it

CDI of tomorrow

Epiphanies & PPACA

What worked

and what didn’t

The beginning

41

• Physicians listen to other physicians

–Challenge of not having a physician adviser

• Incorporate healthcare reform into why CDI matters

Epiphanies and PPACA

matters

• Cannot stop:

–Continuing staff education

–Compliance reviews and 3rd-party audits

42

Knee Replacement – Case 1

• Female 79Y• Elective admission for “RIGHT KNEE DEGENERATIVE JOINT DISEASE”• Highest level of care: Acute• Discharge diagnoses

– 715.36 Loc osteoarth NOS-l/leg Admitting, principal, POA– 401.9 Hypertension NOS POA– 272.4 Hyperlipidemia NEC/NOS POA– 244.9 Hypothyroidism NOS POA– 365.9 Glaucoma NOS POA– V02.54 Meth resis Staph carrier Exempt– V15.82 History of tobacco use Exempt

• Procedures– 81.54 Total knee replacement– 00.39 Other computer assisted surgery– 04.81 Injection of anesthetic into peripheral nerve for analgesia

• LOS 3 days• FEDERAL DRG: 470 MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER

EXTREMITY W/O MCC• APR-DRG: 302 Knee joint replacement• Discharge Disposition: Home

43

Knee Replacement – Case 2

• Female 72Y• Elective admission for “715.96 LEFT KNEE OSTEOARTHROSIS”• Highest level of care: Acute • Discharge diagnoses:

– 715.36 Loc osteoarth NOS-l/leg Admitting, principal, POA– 250.60 DMII neuro nt st uncntrl POA– 357.2 Neuropathy in diabetes POA– 401.9 Hypertension NOS POA

424.0 Mitral valve disorder POA424.1 Aortic valve disorder POA397.0 Tricuspid valve disease POA

– 278.01 Morbid obesity POA– V85.42 BMI 45.0–49.9, adult Exempt– 780.97 Altered mental status POA– 300.4 Dysthymic disorder POA– 244.9 Hypothyroidism NOS POA– 272.4 Hyperlipidemia NEC/NOS POA

• Procedures– 81.54 Total knee replacement– 04.81 Injection of anesthetic into peripheral nerve for analgesia

• LOS 3 days• FEDERAL DRG: 470 MAJOR JOINT REPLACEMENT OR REATTACHMENT OF

LOWER EXTREMITY W/O MCC• APR-DRG: 302 Knee joint replacement• Discharge Disposition: (SNF)(ECF)(Intermediate Care)

493.90 Asthma NOS POA285.9 Anemia NOS POA625.6 Fem stress incontinence POA530.81 Esophageal reflux POAV10.3 Hx of breast malignancy ExemptV15.3 Hx of irradiation Exempt

44


• Elective admission• APR-DRG: 302 Knee joint replacement• Total diagnoses: 7• Total procedures: 3

• Elective admission• APR-DRG: 302 Knee joint replacement• Total diagnoses: 19• Total procedures: 2

Case 1 Case 2

Side-by-Side Comparison

p• LOS: 3 days• Charges: $89,085• DRG GMLOS: 3.3• DRG relative weight/CMI: 2.0866• Severity: 01 Minor• Mortality risk: 01 Minor

p• ICU LOS: 3 days • Charges: $70,784• DRG GMLOS: 3.3• DRG relative weight/CMI: 2.0866• Severity: 03 Major• Mortality risk: 02 Moderate

Question: How does a patient (Case 2) use the same resources in the hospital as a similar patient (Case 1) and end up with a higher severity score?

Answer: Physician documentation.45

Supreme Court (Mostly) Upholds Affordable Care Act (ACA)

Constitutional Discussion Supreme Court DecisionIndividual mandate: Can the federal government compel individuals to purchase health insurance?

Upheld under Congress’s power to impose taxes

Medicaid expansion:Is the ACA’s Medicaid expansion a violation of states’ rights?

Medicaid expansion upheld; federal government may not withhold all existing Medicaid funds if states forgo expansion

Severability:Should the remainder of the ACA stand if a portion is struck down?

The remainder of the law can stand

46

ACA’s Original Coverage Expansion Plan

32 Million Newly Covered Lives through Medicaid Expansion and Exchanges

Coverage Expansion Proceeds—Perhaps Not as Originally Envisioned

133%133% 400%400%Percent of

Federal Poverty Level

Medicaid Expansion

Health InsuranceExchanges

15 M newly covered lives

???? Each state now has the choice of whether or not to expand Medicaid …

17 M newly covered lives

47

Changing Incentives

• ACA “required” establishment of shared savings program January 1, 2012

• “This program is intended to encourage providers of services … to create a new type of health care entity … an ‘Accountable Care Organization (ACO)’ that agrees to be heldAccountable Care Organization (ACO) that agrees to be held accountable for improving the health and experience of care for individuals and improving the health of populationswhile reducing the rate of growth in health care spending. Studies have shown that better care often costs less [Dartmouth] because coordinated care helps to ensure that the patient receives the right care at the right time, with the goal of avoiding unnecessary duplication …”

Medicare Fact Sheet, 3/31/1148


The “Whole Bet” in the Accountable Care Act

49

DeceleratingPrice Growth

• Federal, state budget pressures constraining public payer price growth

• Payments subject to quality, cost-based risks

Four Forces Shaping Future Margins

Continuing CostPressure

• No sign of slower costgrowth ahead

• Drivers of newcost growth largely

• Commercial cost shifting stretchedto the limit

non-accretive

Shifting Payer Mix• Baby boomers entering Medicare rolls• Coverage expansion boosting Medicaid

eligibility• Most demand growth over the next

decade comes from publicly insured patients

Deteriorating Case Mix• Medical demand from aging population

threatens to crowd out profitable procedures

• Incidence of chronic disease, multiple comorbidities rising

50

The Bottom Line …

We will be held ‘accountable’– Pay for performance (P4P)– A move to absolute transparency

There will be less money–Shared savings–Bundled payments

• Convenient comparison to your peers

51

2021 Not So Pleasant

Future State Untenable Without Major Change

2.2% Projected operating

margin

4.0%

G l

The 4.0% Margin Imperative

Current margin

Goal

-16.9%

Includes effects of:Includes effects of:• Price growth trends• Cost growth trends• Payer mix shift• Case mix

deterioration

• Significant long-term capital needs across the board

• Tax-exempt debt unsuitable for financing IT, physician integration investments

• Retained earnings required to fund greater portion of capital

• Financial volatility demands higher margin to compensate for increased risk

52


How to Succeed in the Brave New World (of Healthcare)

1. Maximize revenue capture

2. Excel under performance risk

3. Standardize clinical care pathways

4. Redesign inpatient care models

5. Secure surgical market share

Inaction not an option

53

Our Story

How we did it

CDI of tomorrow

Epiphanies & PPACA

What worked

and what didn’t

The beginning

54

Medicare Mortality

4.06

4.68 4.835.08

3 63.86

Expected Observed

2.83

3.48 3.373.6

3.09

2008 2009 2010 2011 2012

55

• Healthcare reform is happening– There will be no secrets– There will be less money

• The barrier between hospitals and physicians

In Summary …

• The barrier between hospitals and physicians must come down– Both must cooperate to document appropriately– Physicians must seize this opportunity

• See your CDI team as a tool to help you at the point of care (POC)

56


Hospital-Acquired Conditions

• Central line–associated bloodstream infections (CLABSI)

• Ventilator-associated pneumonia (VAP)

• Urinary tract infection (UTI)• Urinary tract infection (UTI)

• Patient Safety Indicators (falls, pressure ulcers, failure to rescue, OB complications, retained objects)

57

CDI’s Role in Quality

• Coordination with other departments

–Care management (case managers, discharge planners, social work)

HIM (queries after discharge)–HIM (queries after discharge)

–Quality

–Finance

58

• Identify conditions that are POA – make sure documentation is in patient record

• Identify and notify quality department of potential serious errors (medication, surgical,


potential serious errors (medication, surgical, other treatment), especially if it is reportable

– Calif. – Never 28 reportable within 5 days or $100 per day fine

– The Joint Commission – reportable sentinel events

– CMS – restraint deaths

59


• Identify cases with infectious disease issues

• Identify cases for concurrent review

• Identify cases where there is insufficient/scant documentation that would be part of clinicaldocumentation that would be part of clinical processes of care abstraction

60


CDI and Quality

• CDI will be on the front line in education of MDs and other disciplines for ICD-10 documentation requirements

• CDI will have an increasing importance in theCDI will have an increasing importance in the new healthcare environment

• CDI will be the “extra” eyes and ears for quality measurement and increasing regulatory scrutiny

• CDI will be a link between the medical staff and other departments working in the regulatory environment

61

Current Challenges

• C-suite support• Accountability

• Resources• Resources• Communication

throughout the organization• 2nd law of thermodynamics

62

Thank you. Questions?

James M. Pappas, MD, MBAW h d B i MPH CPH b i@ll d

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the workbook.

Waheed Baqai, MPH, CPH, [email protected]

63

Increased Weakness & Slurred Speech - HCPro questions please contact HCProcustomer service at...

Documents

Transcript of Increased Weakness & Slurred Speech - HCPro questions please contact HCProcustomer service at...