Quality & DocumentationFor Heart Failure & AMI Programs

Nathalie De Michelis, Cardiovascular Program ManagerJuly 24th, 2014

2

Formal outpatient HF Clinic program• 1535 HF clinic visits

– 551 single pts

Discharge Unit & Services• for Primary HF Dx

Heart Failure ProgramInpatient and Outpatient FY 2013-2014

Inpatient visit volume• 174 PDx of AMI• 254 PDx of HF

– 254 with 2nd Dx w/ Acute HF

10.2%

34.3%

0.4%0.4%

23.2%

26.0%

5.5%

HF DC Unit

CCU/MICU DH78 ED SICUT3 T5 TELE/SDU

47.24%

0.79%0.39%

50.00%

0.39% 1.18%

HF DC Service

CARD CTSx FM IM SURG TxSx

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CV Program Design…Coordinated Care Across the Continuum (In-patient)

• ED triage (CP unit, CP/AMI & HF Algorithms)• Identifying patient population/AMI & HF program introduction • Multidisciplinary Clinical Pathways

• HF & PCI• EBT Cardiology Order Sets Please try to use

• A fib, AMI, CP, EP, HF, Cath, PCI• Initiation of patient education process by HF NP & HF Coach• State-of-the-art diagnostics• Collaborative input for advanced treatments:

• interventional, device, surgical therapies, cardiac anesthesia• Comprehensive discharge plan/case mgmt

• f/u with in a week, Home Health when eligible,….• Palliative care/end of life • Research pool

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CV Program Design…Coordinated Care Across the Continuum(Out-Patient)

• UCI Cardiac Rehab• Cardiology Clinic

• General Cardiology• EP/Pacemaker Clinic• Valve Clinic• Woman Card Clinic• Adult Congenital Clinic• CV Preventive Clinic

• HF Clinic• Open access & program follow-up

• Timely post-discharge HF recommendations to PCP• HF Program f/u of moderate-advanced HF

• IV Lasix• 48 hrs and 1 month follow-up phone calls to prevent ED Readmit

• HF & DM Chronic Disease in person Coach Care • Palliative Care Collaboration soon…HF/Palliative clinic • Research pool

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HF & AMI List

• HF/AMI List•Communication tool, between the HF Program

Manager & the care team, to assist with the identification & the care of this population

•Let me know if patients need to be added or deleted from the list below.

•Please clarify pink areas on the patient list

• Memorandum of Agreement between IM & Cardiology for HF for Heart Failure Patients• New Onset HF Admit to Card Service• Acute HF following in UCI Card Admit to Card • Other Acute HF request a Card consult

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Quality Initiatives

• Joint Commission Certified HF Program since 2008• Dr. D. Lombardo Medical Director

• OC Cardiovascular Receiving Center since 2005• Dr. P Patel Medical Director

• Multiple National & State Quality Initiatives– American Heart Association (Gold Plus HF AHA award)– American College Of Cardiology– CMS & Joint Commission Measures– Readmission Reduction Task Force

• DSRIP projects– Improvement of Primary Care in HF & DM

Disease management

• Research

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What are Hospital Quality Measures

• Measures based on:– Scientific evidence– Reflect guidelines– Standards of care or practice parameters

• Converts medical information from patient records into a rate or percentage that can be assess

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Why quality measure are important?• Use to assess:

• How well care is provided to our patient• Our performance over time• Helps improve patient care• Benchmark for outcomes & resource utilization

• (Internal, External , Public)

• Public Reporting• CMS & The Joint Commission

• Healthcare consumerism• CMS.gov (Hospital Compare), Healthgrades.com, WebMD.com, State

organizations

• Pricing, Payment and Contracting• Quality data used by insurers in negotiating contracts• Rate affect Reimbursement rate

• Pay-for-performance, VBP, Readmission Reduction Program• Physician Quality Reporting System (PQRS), HEDIS

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AMI Hospital Quality Measures - CMS, TJC • Outpatient Arrival time to ECG & Troponin for CP

• Aspirin within 24 hrs of Arrival (or clear documented contraindication)

• PCI Within 90 Minutes of Arrival for STEMI

• Fibrinolytic within 30 Minutes of Arrival for STEMI (not used at UCI)

• Discharge on (or clear documented contraindication if not)• Aspirin • ACE or ARB for LVSD• Beta Blocker • Statin

• AMI 30 days Mortality rate

• AMI 30 days Readmission rate

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AMI Composite

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AMI 30 Day Readmission rate

2012-05 (0/12)

2012-06 (4/14)

2012-07 (4/13)

2012-08 (2/13)

2012-09 (0/8)

2012-10 (2/15)

2012-11 (2/15)

2012-12 (5/18)

2013-01 (1/18)

2013-02 (1/6)

2013-03 (0/9)

2013-04 (0/9)

2013-05 (1/9)

2013-06 (1/10)

2013-07 (0/14)

2013-08 (0/9)

2013-09 (0/14)

2013-10 (2/13)

2013-11 (1/18)

2013-12 (1/15)

2014-01 (2/14)

2014-02 (1/15)

2014-03 (1/4)

2014-04 (1/15)

0.00

5.00

10.00

15.00

20.00

25.00

30.00

35.00

7.3

AMI - % 30 Day Readmit% 30 Day Readmit UHC Top 25th Percentile Performance

Discharge Month

Perc

enta

ge

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Hospital compare for AMI- PCI & ASA-CP measureshttp://www.medicare.gov/hospitalcompare/search.html

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Hospital compare - HCAHPS

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HF Hospital Quality Measures % of HF patients given:

• Discharge Instructions (need all 6 items)• Diet Cardiac diet be more descriptive – i.e. 2g low salt, low fat….• Activity level• Daily Weight Monitoring Even if on Dialysis• Medications (complete reconciliation w/home & hosp. Rx

• with indication for each Rx (NEW TJC measure)• Symptom management

• Recommend pt to call if weight gain is >3lbs in a day or > 5lbs in a week• Follow-up appointment (with date and time on DC Instruction)

• Documentation of LVS function

• ACE or ARB for LVSD at discharge (or clear documented contraindication)

• HF 30 days Mortality rate

• HF 30 days readmission rate

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HF TJC & AHA GWTG Measures• DVT Prophylaxis while in hospital

• Prior to Discharge on (or clear documented contraindication if not)• Pneumococcal Vaccination• Influenza Vaccination During Flu Season• ICD Placed or Prescribed • For EF≤ 35 (exclude new onset):

• ICD Placed or Prescribed • CRT-D or CRT-P Placed or Prescribed if QRS ≥120 or QRS ≥ 150 or LBBB

• Discharge on (or clear documented contraindication if not)• Evidence-Based Specific Beta Blockers for LVSD (Bisoprolol, Carvedilol, Metoprolol CR/XL)

• Aldosterone Antagonist • Anticoagulation for Atrial Fibrillation• Hydralazine Nitrate ( for African Americans on OGMT)

• Post Discharge Appointment (including date, time, location; or home health visit)

• Follow-Up Visit Scheduled Within 7 Days or Less

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HF Hospital Quality Measures – HF Composite

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Hospital compare for HF

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GWTG Achievement & TJC Measure – Evidence-Based Beta Blockers

[TJC Target 90%]

[GWTG Target 85%]

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GWTG Achievement & TJC Measure – Aldosterone Antagonist for LVSD at DC

[GWTG Target 75%]

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GWTG Plus Quality Measure Anticoagulation for A. Fib

[GWTG Target 75%]

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GWTG Achievement Measure Follow-up at Discharge (with date, time & location)

[Target 85%]

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HF 30 Day Readmission rate

2012-05 (0/14)

2012-06 (0/17)

2012-07 (3/16)

2012-08 (2/13)

2012-09 (3/14)

2012-10 (4/14)

2012-11 (8/31)

2012-12 (9/17)

2013-01 (7/29)

2013-02 (4/19)

2013-03 (2/29)

2013-04 (6/27)

2013-05 (3/18)

2013-06 (1/18)

2013-07 (4/17)

2013-08 (3/25)

2013-09 (4/25)

2013-10 (4/21)

2013-11 (3/17)

2013-12 (3/19)

2014-01 (2/23)

2014-02 (2/19)

2014-03 (5/19)

2014-04 (7/32)

0.00

10.00

20.00

30.00

40.00

50.00

60.00

16.6

HF - % 30 Day Readmit % 30 Day Readmit UHC Top 25th Percentile Performance

Discharge Month

Perc

enta

ge

How to improve HF/AMI measures & outcomes?

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How to improve HF/AMI measures?

• Treating all present health issues• Make sure well compensated when DC

• Education during hospital stay- Patient should be familiar & competent with:

• Condition• Medication• Symptom Management• Life style change• Importance of follow-up ( to prevent no show)

• Proper Documentation of Guideline therapy • or explicit contraindication– i.e. ACE & ARB contraindicated at this time due to worsening renal function– i.e. Not on anticoagulation for A. Fib due to active GI bleeding

• Proper Documentation of conditions & procedures • as it affect Coding

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How to improve HF/AMI measures?

• Use Disease Specific Order Set

• Proper Discharge– Medication Reconciliation– All needed components are on Discharge instructions– The discharge summary document must contain

• Provider contact information• Discharge date • Discharge Diagnosis• Updated summary of the patient’s hospitalization.• Pending labs, test and imaging• Other follow-up issues for next provider• Complete set of discharge instructions

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Discharge Process• Proper transition of care

– Early follow-up (7 days post dc with PCP & needed specialties)• Give Date & time of appointment before discharge

– Prompt transfer of hospitalization information • to PCP or to next care provider

– Access to care and medication– Refer to Home Health, Cardiac Rehab, Telemonitoring– Refer to free UCI Patient education classes.

• HF, Heart Diet, DM, HTN

• The discharge summary creates the Discharge instructions• Be certain the nurse provides the patients with the FINAL version• must notify nurse if there are any last minute changes • Go over the instructions with the patient/family

• Fax/e-fax/mail discharge summary to the next care provider

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Discharge note –Core Measures

Please complete on all AMI

&

HF (chronic or acute)

Mem

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Memory Aids

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Memory Aids

UC Irvine HealthThe importance of Clinical Documentation

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Why should we care?Documentation drives:• The levels of coding, billing and reimbursement• Measure Compliance

• Severity of Illness (SOI) and Risk of Mortality (ROM)• Measures by which healthcare organizations & healthcare providers are

evaluated and ranked

• Stay competitive in the market • Insurance Companies’ Contracting• General public shopping for care

• Due to trend of greater transparency & availability of clinical performance data, on internet websites (e.g. Healthgrades, hospital compare)

• Prevention of random audits by the government• and serves to support the care provided by a healthcare provider in such

an event

• Reduce liability in the event of legal action

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Surfing for Quality of Care and Prices

http://hospitalcostcompare.com

Hypertension Without Major Complications

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Hospital & Physician Report CardsHealthgrades.com Medicare.gov/hospitalcompare

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One thing leads to the next

• Documentation• ICD Code• DRG (Diagnosis-Related Group)• Severity adjusted DRG• Severity of illness & Mortality data

Outcomes + Accurate Documentation = Quality

Observed mortality

Expected mortality(From severity adjusted DRGs)

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What is a DRG and how does it work?

• Identifies the "products" that a hospital provides

• DRGs have been used in the US since 1982 to determine how much Medicare pays/reimburses the hospital for each "product“

• It is similar to a known recipe:

• Each DRG has a relative cost weight & expected LOS

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DRGs

• DRGs that are associated with a higher frequency of mortality are frequently under documented in regard to severity of illness • i.e. heart failure, pneumonias, urinary tract infections, & malignancies

• Example:• Patients have who that have respiratory failure and cardiac arrest

• Most go into Hypotensive shock and have com. respiratory failure • So if would document these

• it would change the MS-DRG • and improve predicted mortality measures

Inherently, the MSDRG system penalizes rushed documentation

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SOI, ROM, CC & MCC

• Every patient we treat get assigned a SOI & ROM rate based on the documentation between 1 and 4 .

-1: Minor - 2: Moderate -3: Major -4: Extreme

• Secondary Diagnosis Coding Rule and impacts:• DRG Assignment, Severity of Illness/Risk of Mortality Reporting; and

Organization and Physician Profiling, evaluation and ranking.

• Documentation of Diagnosis with severity (Acute, Acute on Chronic or chronic) instead of signs and symptom• assist with CC/MCC, SOI & ROM

• Important to document in detail the CCs• All co-morbidities (Condition present on admission) • All complications (Condition that develop after admission)

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Cardiac Diagnosis(Dx with** are not counted if patient expires)

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Respiratory Diagnoses(Dx with** are not counted if patient expires)

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Case Example 55 y/o female LOS 11 days - expired

When ≥ 3 different organs are affected start to see MCC

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Heart Failure DRGs Comparison

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3MMS DRG 285 AMI, expired w/o CC/MCC Dx suggestion to consider

M= Affect DRG S=Affect Severity R=Affect Mortality

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MSDRG are assigned a mortality risk model

• Using specific variable descriptions

• The mortality is than calculated and give us:• our expected morality rate versus actual observe mortality

• The goal is to have high expected rate for low observe rate

• This rate is used in our data and benchmarking

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Case example risk model 901:

Assigned MSDRG of 285- AMI, expired without Comorbidity or Complication (CC)/Major CCMortality model 901

Variable Description

Model Grou

p BetaOdds Ratio

95% Lower Confidence

Interval

95% Upper Confidence

Interval P-ValueIntercept 901 4.452Vent on Admission Day 901 1.938 6.943 6.137 7.854 0.000Cardiac Arrest 901 1.816 6.149 4.943 7.649 0.000Shock 901 1.589 4.897 4.290 5.590 0.000Aortic Aneurysm Dissection/Rupture 901 1.520 4.571 2.763 7.561 0.000Female, Age >= 85 901 1.418 4.127 3.541 4.811 0.000Male, Age >= 85 901 1.393 4.026 3.404 4.761 0.000Male, 80 <= Age < 85 901 1.195 3.304 2.738 3.987 0.000Endocarditis 901 1.027 2.793 1.924 4.054 0.000Female, 80 <= Age < 85 901 0.979 2.661 2.187 3.238 0.000Other Pulmonary 901 0.887 2.428 1.571 3.750 0.000Male, 75 <= Age < 80 901 0.795 2.214 1.817 2.697 0.000Female, 75 <= Age < 80 901 0.769 2.159 1.743 2.674 0.000CC Metastatic Cancer 901 0.760 2.137 1.658 2.756 0.000Hypotension 901 0.724 2.062 1.784 2.384 0.000Vfib 901 0.702 2.018 1.573 2.587 0.000Ischemic Stroke 901 0.631 1.879 1.350 2.615 0.000AMI Subsequent 901 0.576 1.779 1.232 2.569 0.002Female, 65 <= Age < 75 901 0.563 1.756 1.470 2.097 0.000Severe Brain/Spinal Conditions 901 0.562 1.754 1.479 2.081 0.000Renal Disease/Failure 901 0.521 1.683 1.533 1.848 0.000Male, 65 <= Age < 75 901 0.473 1.605 1.362 1.891 0.000Acute Liver Disease 901 0.441 1.554 1.234 1.956 0.000Sepsis 901 0.437 1.549 1.272 1.886 0.000Admit Source = Transf From Skilled Nursing/Long Term Care 901 0.435 1.546 1.211 1.972 0.000CC Fluid & Electr Disorders 901 0.351 1.421 1.289 1.566 0.000CC Peripheral Vasc Disease 901 0.261 1.298 1.163 1.449 0.000Aortic Stenosis 901 0.243 1.274 1.114 1.458 0.000CC Coagulopthy 901 0.230 1.259 1.075 1.476 0.004Admit Source = Transf From Acute 901 0.225 1.253 1.136 1.381 0.000Male, 31 <= Age < 51 901 0.467 0.627 0.477 0.824 0.001

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UCI Q1 2014 Clinical Outcome reportRisk-Adjusted Mortality

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AMI case exampleOriginal attestation sheet

SOI of 3 and ROM of 3 (Major)DRG 285 - Acute myocardial infarction, expired w/o CC/MCCDRG payment $9117.25

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Documentation correction

Patient chart documentation improvement that affects SOI & ROM: Pleural effusion only (would affect SOI)

Add Acute Diastolic Heart Failure (would give it a CC, and affect DRG, SOI & ROM)

Intubated Instead on a mechanical ventilator (would give it a MCC)

Fluid overload & Hyperkalemia Instead Fluid & Electr Disorders (hyperkalemia) (would affect ROM)

Also to affect DRG, SOI &ROM Prior to arrest could document: Com Respiratory failure Hypotension shock Coma

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Coding attestation post documentation

SOI of 4 and ROM of 4 (Extreme)DRG 283- Acute myocardial infarction, expired w MCCDRG payment $22597.06 (+ $13479.81)

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Documentation & coding

• Coders are limited in what they can code• They are not allowed to “interpret”

• i.e. Hgb 5.0 ≠ to anemia• Document anemia with specific type, acuity & cause

• V Fib, Chest compression, defibtillation, epi …Cardiac arrest/Code• Bacteriemia sepsis• No response no noxious stimuli Coma

• Document suspicions to the highest degree known

• Fail documentation often happen when unable to obtain a test or specimen• Document what the treatment is based on the clinical picture

• I.e “Suspect G-pneumonia, ….Rx.. given, as unable to obtain a sputum specimen.”

• Do not under-state discharge diagnoses

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Heart Failure Documentation

• r/o differential diagnosis if n/a anymore• i.e. COPS vs HF VS PN. HF is or is no longer the differential

diagnosis for SOB/Volume Overload • “Likely”= possible coding of that condition

• Determine if it is Right or Left Heart Failure• RHF = gets coded as 428.00 Unspecified HF , no code exist

for RHF• Document cause of RHF i.e. RHF 2/2 Cor Pulmonale • iF RHF alone need to meet all measures

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Heart Failure Documentation

• Specify to type • Combine Systolic and Diastolic• Diastolic• Systolic

• Do not use systolic alone. Patients with systolic HF also have diastolic HF

• Specify the acuity• Acute• Chronic• Acute on Chronic most acute HF patients

• Specify the etiology/cause if available (…HF 2/2…)• Ischemic, Afib, HTN, Valvular,…

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Heart Failure Specificity• If the type is not document event if acuity is

• It gets coded as 428.00 Unspecified HF • i.e. Acute HF = 428.00 Unspecified HF

• A documented EF is not a diagnosis of HF• EF 30% ≠ not coded as systolic

• CHF exacerbation ≠ not coded as acute

• 428.00 Unspecified HF ≠ do not count as a comorbidity

• New HF definition such as HFpEF, HFreF ≠ not coded

• Example proper documentation:• Chronic Systolic LV dysfunction 2/2 Ischemic Cardiomyopathy• Acute Diastolic LV dysfunction 2/2 Afib with RVR • Acute on Chronic Systolic LV dysfunction medication noncompliance• Right Heart Failure d/t acute Pulmonary HTN 2/2 Cor Pulmonale

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ACS/AMI-Severity issues

• Consist of 3 major clinical entities in a continuum• Unstable angina• NSTEMI• STEMI• Caution with documentation of:

• ACS alone = gets coded as UA• MI type 2 demand ischemia gets coded as generic AMI (so needs to meet guidelines)

• Otherwise to not document MI. Only Elevated troponin, demand ischemia 2/2….

• Severity issues• Identify new LBBB• Location of MI• Identify cardiogenic shock• Identify acute or chronic systolic HF when it is present• Hypotension ≠ not codable as cardiogenic shock• Low BP is not cardiogenic shock• Multi organ failure ≠ not codable

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STEMI & PCI documentation

• If LBBB, Document if new or old. • If NEW = STEMI (needs to meet all AMI Measures)

• Document clearly if 1st ECG is STEMI or NSTEMI– Be consistent through-out the chart

• If PCI delay document:” PCI delay due to…”– Pt atypical presentation into the ED – r/o aortic dissection prior PCI – Pt hemodynamic and clinical instability requiring stabilization – Difficult access to coronary arteries – Difficult vascular access – Insertion of IABP prior PCI (w/i 90 min of arrival) – Cardiopulmonary arrest (w/i 90 minutes of arrival) – Initial patient/family refusal – Pt wished to delay/wait before starting PCI (initially withheld consent) – Emergent testing required prior PCI – Other [write]

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Summary

• Documentation become our data • key measure of performance

• Correct documentation is critical to improving performance• It allows you to see where actual problems lie

• Diagnostic statements must be explicitly stated• Symptoms, orders, treatments, X-ray evidence does not replace a

diagnosis

• Benchmarking allows to compare performance against the expected averages

THANK YOUQuestion?