Guided Clinical Mentorship at Inspira Health Network Lynette

Guided Clinical Mentorship at Inspira Health Network Lynette

Guided Clinical Mentorship at Inspira Health Network Lynette Newkirk, RN Administrative Director, Care Coordination & Patient Relations Inspira Health Network Michelle Wieczorek RN RHIT CPHQ General Manager, Coding and CDI Practice e4 Services Objectives Review the decision making process of Inspira Health Network in selecting a hybrid model and approach to CDI. Review the LEAN Six Sigma approach to implementing a CDI Program, including the use of an a3. Examine the Guided Clinical Mentorship Program for CDI Training. Examine the program challenges, opportunities and achievements through use of a CDI Dashboard implemented to visualize and manage the workplan. About Inspira Inspira Health Network is a charitable nonprofit health care organization formed in November 2012 by the merger of South Jersey Healthcare

and Underwood-Memorial Hospital. The Network comprises three hospitals (Vineland, Elmer and Woodbury Campuses), four multispecialty health centers and a total of more than 60 locations. 1,100 physicians and other health care providers provide evidence-based care to help each patient achieve the best possible outcome. Michelle Wieczorek, e4 GOING LEAN WITH CDI AND KEY DECISIONS Key Program Drivers for Inspira Prepare Providers for ICD-10 Improve Medicare Performance Indicators LOS CC/MCC Capture Rates CMI PEPPER Support Physician Engagement/Alignment

Strategies such as Gainsharing Strengthen Coding -Audit Ready Record Leverage Existing Infrastructure-FTE Neutral TOP 15 DRG Pairs/Triplets by Volume YTD: DECEMBER 31, 2014 CMI CC & MCC Capture MCC Capture Annual Volume Actual Bench Current Bench Current Bench 629 1.117 1.168 80% 87% 35% 42% DRG Group 291_292_293 Group Name Heart failure & shock

190_191_192 Chronic obstructive pulmonary disease 509 1.020 0.996 82% 80% 48% 41% 308_309_310 193_194_195 Cardiac arrhythmia & conduction disorders Simple pneumonia & pleurisy 344 328 0.857

1.176 0.829 1.132 65% 85% 66% 88% 33% 45% 26% 34% 314 299 234 0.812 1.183 0.900 0.823 1.214 0.916

17% 91% 30% 19% 94% 34% 17% 37% 30% 19% 42% 34% 228 2.188 2.285 7% 14% 7%

14% 64_65_66 Intracranial hemorrhage or cerebral infarction 226 377_378_379 G.I. hemorrhage 224 1.172 1.119 1.305 1.178 68% 78% 81% 87% 20% 22% 36% 27% 205

0.846 0.819 37% 31% 37% 31% 193 180 1.265 0.947 1.416 0.962 66% 17% 81% 19% 39%

17% 54% 19% 165 135 1.667 0.928 1.721 1.034 73% 66% 80% 78% 73% 14% 80% 23% 391_392 Esophagitis, gastroent & misc digest disorders

682_683_684 Renal failure 689_690 Kidney & urinary tract infections Major joint replacement or reattachment of 469_470 lower extremity 640_641 Nutritional & misc metabolic disorders 280_281_282 Acute myocardial infarction, discharged alive 602_603 Cellulitis Septicemia or severe sepsis w/o MV 96+ 871_872 hours 388_389_390 G.I. obstruction e4 Services LLC 6 CDI Schematic for Vineland and Elmer CDI Program is Live

SWOT February 24-25 SWOT Debrief and Decision to Proceed with GCM March 4 LEAN Event March 1011 LEAN Debrief and Straw Model Alignment March 17 GCM Didactic (3 Days)

April GCM Program 10 Weeks Physician Education Didactic Sessions May July January (Woodbury Focus) 7 Two Basic CDI Models HIM-Coding Based Nurse-Clinical Model RHIAs/RHITs/CCSs RNs and LPNs

Concurrent and/or Retrospective (Pre-Bill) Concurrent Focus on Improved Documentation for Coding and DRG Assignment Focus on Improved Documentation for Diagnosis Clarity, Specificity and Capture of Acuity Record is concurrently coded and validated at Discharge Often have a Quality Focus (HACs, PSIs and Core Measures) HYBRID Decreases DNFB/AR Impact Queries are often electronic, or paper based. Staff must be able to code-very challenging High reliance on encoder and other technology during reviews

Reporting structure is variable but not usually to HIM Emphasis on VERBAL queries with a broad focus of query types (Severity, Medical Necessity and Quality Indicators in-play) Executive Summary and Recommendations MARCH 2015 A hybrid CDI Model is likely to be successful in a care management model at Vineland and Elmer campuses. Risks include Physician Engagement Strategy and Optimal Staffing to achieve a best practice CDI program. A LEAN event will help to further clarify the process changes and technology augmentation that is required to fully execute the program, including a straw model review of the proposed CDI role. Existing structures for the care management program can be leveraged today to produce the desired outcomes for the program. e4 recommends a thoughtful yet assertive timeline to achieve the best results in the current ramp up to ICD-10. Move quickly to schedule the 10 Week GCM to get it established before summer

vacations become problematic. Conduct physician education on the heels of the GCM to leverage what has been observed during the initial learning period. 9 Day One-LEAN Event 8:30 AM-8:45AM Introductions and Welcome 8:45AM-9:15AM Alignment on Goals and Objectives 9:15-10:00AM Design Overview-CDI/Care Management Straw Model 10:00AM-10:15AM Break 10:15AM-12:00PM Inpatient Coding Current State Exercise with CDI Integration in Current and Future States

12:00-12:45PM 12:45PM-2PM on Future State 2PM-2:15PM 2:15-4:30PM Lunch Concurrent Query Current State and Design Impacts Break Concurrent Query Future State Alignment Concurrent Query Gap Analysis Verbal Query Practices Electronic Queries 10 Day Two-LEAN Event 8:30-9:30AM Review a3 Drafts from Day 1 Physician Integration Current State and Future State Vision 9:30-10:45AM

Peer Advisor Role Discussion Escalation Protocols (Delinquent Records, Abandoned Queries) Verbal Query Practices Documentation and Query Guideline Development Electronic, Verbal and Written Query Workflows 10:45AM-11: 00AM Break 11:00AM-12:30PM CDI Dashboard Metrics-Future State Available Metrics Physician-Oriented Metrics Technology Augmentation 12:30PM-1:15PM Lunch 1:15PM-3:00PM Guided Clinical Mentorship Impact Assessment and Workplan Adjustments 3:00PM-3:30PM Adjournment/Next Steps 11 Clinical Documentation Improvement Program a3 1. Current State

Program 1. Attributes o Focused; Documentation Audits o Non-Clinical (HIM) o No Working DRG o Concurrent Documentation Reminders (Post-Its) o Rounding Daily on Nursing Units o Care Coordination Equipped with Documentation Tool in Soarian o Care Coordination Reviews in MIDAS; Milliman CMGs to set LOS Staffi ng and Productivity (CDI Only) o 2.5 FTEs Report to HIM o No Medical Director for CDI o 5 Day a Week Program o No ED presence Casefinding Methodology (CDI Only) o Admission Diagnosis Based o All Payer Queries o Not Part of Permanent Medical Record (Concurrent) o Retro Queries are Permanent o Free-Form Text Queries on Post-Its

o No Query Software o Retro Queries Electronic in EDM o Some Query Templates o Some verbal queries (4 questions) in Daily Rounding via Care Coordination (No HIM Rounds) o 95% Response Rate; CMI Impact Monitored and Reported to Finance Gap 4. Gaps & Counter Measures Countermeasures Care Coordinators Not Educated in CDI Concepts No APR DRG Software for SOI and ROM Current Worklist 1 to Many Guided Clinical Mentorship Program No Peer Advisor/Medical Directorship Many Systems for Care Coordinators as Part of Review Staffing -Additional Care Coordination FTEs Not Filled

OB Area Not Covered (High Risk for ICD-10) Acquire Support and Implement 2. Future State o o o o o o o o o o o Standardized Processes 7 Days a week Coverage ED Presence Working DRGs on all Reviews 2 Reviews to 1 Query Ratio (40% of cases having documentation defect to 25% in 12 Months) Minimal Retro Queries-Most Queries Verbal as part of Rounds Uniform coding and CDI queries. Electronic Queries Linked to Clinical Workflow for Physician Response APR DRGs Produced with SOI and ROM as part of Case Review

Single Solution User Interface for Care Management and CDI Reviews Daily Huddles (CDI and Coding) o o o o OB Areas Require Coverage Technology Augmentation Integrated Solution Medical Staffinput into Query Guidelines and Policies Peer Reviews (Physicians) Prepare Budget Justification to Procure Need IT to Create 1: 1 Worklist Look to reduce; consolidate into single solution in future state Create second wave of training 6 weeks after first. Incorporate in Future State 5. Metrics Metric Current

FTES (Medicare Only) TBD Days Covered Per Week Percent of Patients Covered Query Response Rate CMI 5 40% Inc. Retro 95% (Retro) 1.387 CC/MCC Capture (Medicare) 3.Ideal State Best Practice 5.3 (Pure CDI) 7 100% 95%

1.5 85% 6. Action Plan Action Item Procure APR Grouper Create New Worklist Model: Physician Oversight nd Determine 2 Wave of GCM Training Primary Resources Michele/Michelle Nancy/Lynette Betty/Lynette/Michele Lynette/Michele Due TBD April 23, 2015 April 23, 2015 Complete 12

Straw Model Lynette Newkirk, Inspira EXECUTING THE PROGRAM Inspira Care Coordination Overview Geographical & Physician Specific Care Coordinators Discharge Planning, Progression of Care, UR review for Federal Payers, CDI. Utilization Review Coordinators Medicare Advantage programs, all Commercial programs, CDI COACH team Transitions of Care Chronic disease management Registered Nurses and Community Paramedics Drug and Alcohol Abuse Certified Drug and Alcohol Counsellors MSW High Risk Discharge Planning Consensus - Approach Go fast Go enterprise wide (Woodbury had existing CDI Program that ultimately disbanded in lieu of new Care

Management CDI Approach) Train ALL 45 FTEs in Care Management on CDI to Integrate into Role Blend HIM FTEs into program (FTEs allocated to commercial payers) GCM Content 5 Modules e4 Services LLC 18 Program Stakeholders and Governance Inspira Steering Oversight Committee Program Oversight CFO, CPO, COO, Director Corporate Compliance, Director HIM, Administrative Director Care Coordination e4 , CC, HIM Steering Group Operations, Tools, Techniques, Training Coding and HIM Impact Care Coordination Departments Practice and Subject Matter Expertise Issues

Woodbury Director & Vineland Manager &Social Work Director Visualize the Workplan Task View of Each Area of Work Plan are Visible Make it WorkPhysician Engagement Physician Training Medical Staff Dept. meetings, office practices, elbow to elbow Train Hospitalist Team UR Committee Meeting , Gain Sharing Meeting Make it RealOperations Impact Operationalize the efforts: 7 day per week Care Coordination 24/7 ED Coverage Front load the process:

ED CC assign Principle Diagnosis Assign Working DRG Daily Physician Led Interdisciplinary Rounds: CC documents clinical catches in CDI worksheet embedded in Soarian Visible to all who access record Huddles Daily and Weekly Queries are permanent part of medical record ( ICD-10):

e4, Corporate Compliance , CC, and Coding Supervisors included in development Physician does not have to double document Physicians are expected to complete real time ( tracking compliance) Accessible for Coders CDI Tracker in Share Point Process metrics and productivity Query Response Rate DRG Impact CDI Impact Tool and Tracker Michelle Wieczorek, e4 and Lynette Newkirk, Inspira

IMPACTS AND OPPORTUNITIES Average Length of Stay YTD and Goals ALL PAYER Campus YTD 12/31/14 LOS Goal LOS 2014 YTD 9/21/15 LOS Goal LOS 2015 Vineland 4.13 4.23 4.15

4.08 Elmer 3.84 4.23 3.70 3.88 Woodbury 4.46 4.38 4.43 4.48 Medicare Campus YTD 12/31/14 LOS

YTD 9/21/15 LOS Goal LOS 2015 Vineland 5.08 4.81 4.93 Elmer 4.41 4.11 4.47 Woodbury 5.22 4.99

5.32 Woodbury is only June and July for 2014 2015 Network Goal is 1.45% % of Net Rev includes IP/OP Work In Progress 4th GCM will Commence in Q 1 2016 DRG Reconciliation Process Improvements Physician Escalation Protocol APR DRGs Improved Trackers Single Solution-Multi User THANK YOU FOR YOUR ATTENTION

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