CDI Across the Care Continuum:
Impacting Quality and Reimbursement
March 2016
Proprietary and Confidential. Prepared by The Claro Group, LLC ©2016. For Internal Use Only.
No external distribution without prior written consent of The Claro Group, LLC
Objectives
►
Review new challenges facing providers, hospitals, and health systems
►
Examine the role of the medical record in the modern healthcare environment
►
Discuss the expanding role of CDI and multidisciplinary teams
►
Achieving buy‐in and success
►
Application: working with physicians
►
Data analysis strategies
Proprietary and Confidential. Prepared by The Claro Group, LLC ©2016. For Internal Use Only.
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2
New Pressures on Healthcare Providers
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3
Organizational Goals
►
These challenges have focused healthcare executives on maximizing revenue in the face of increasing pressures
►
In order to do this, hospitals must:
►
●
Get paid appropriately for what they do
●
Demonstrate high quality care at a low cost
●
Maintain or improve market share
●
Position for negotiations with payors
●
Develop successful partnerships with the medical staff
●
Plan for the future
Organizational strategies have become more complex and holistic in scope
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4
The Rise of Value‐Based Reimbursement
Volume‐based reimbursement
We are here
In addition, we are at the beginning of a significant transition in the way healthcare providers are reimbursed for the services they provide
Revenue
►
Quality‐based reimbursement
Time
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5
Importance of Clinical Documentation
►
The coded medical record is a key driver for many of the issues on the minds of hospital executives
Reimbursement
Quality Ratings –
CMS and Others
Readmissions Reduction
Compliance
Coded Medical Record
Hospital Acquired Conditions
E/M billing
►
Denials
Patient Safety Measures
Charging
Value‐based Purchasing
Clinical documentation improvement can improve the quality of the medical record
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Getting the Record Right
 The coded record remains the basis for many evaluations of patient care
 CDI bridges the gap between clinical and coding language, helping to ensure the coded medical record is an accurate depiction of the acuity of the patient and the care provided
Clinical Documentation
Coding Requirements
Based on historical practices and training, physicians/providers use clinical terms
Based on rules and regulations, coding requires specific diagnostic terms
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Traditional Focus of CDI
 Inpatient Medicare population
 Primarily focused on improving reimbursement
 Not seen as a “key” hospital initiative, many unaware of its function Proprietary and Confidential. Prepared by The Claro Group, LLC ©2016. For Internal Use Only.
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Expanded Role of CDI
►
►
The narrow focus of traditional CDI has changed considerably
●
No longer focused solely on reimbursement
●
More payors
●
More settings of care
●
A key component of many value‐based initiatives
The shift to value‐based reimbursement also requires close collaboration between the clinical and finance staff
●
The financial success of a hospital or health system relies on increasingly complex requirements for provider documentation
●
The clinical team will need to rely on advanced analytics to track progress and identify opportunities
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Example: Clinical Documentation and Readmissions
►
Readmissions are “risk adjusted”
●
The documentation of secondary diagnoses plays a major role in the risk‐
adjustment process

Some secondary diagnoses increase the probability of a readmission
–

Uses a modified HCC model
–
ICD‐9/10 Code
042
CMS refers to these select diagnoses as “risk variables”
Inpatient, outpatient, and physician office documentation is all considered
Short Label
Human immuno virus dis
Condition Category
Condition Category Label
1
HIV/AIDS
Readmissions Coefficient Code Type
1.05
I9
Capturing this condition increases the “expected readmissions” rate for a given patient
Proprietary and Confidential. Prepared by The Claro Group, LLC ©2016. For Internal Use Only.
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CDI Opportunity Across the Care Continuum
 Many successful CDI programs have now taken a more holistic approach, targeting:
•
Professional Billing
•
Facility Billing
•
Charging
•
HCCs, Capitation Payments
•
Status Determination
•
Quality Ratings
•
Denials/Compliance
•
Value‐based Purchasing
•
Readmissions
•
Hospital‐acquired Conditions
•
POA status
Care Continuum
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Benefits of CDI Across the Care Continuum
 Patient Centric
•
Complete and accurate documentation throughout the patient record
 Consistent Approach
•
One approach to clarifying documentation needs, applied across all care settings and payors
 Physician Alignment
•
Support accountable care organization and other integrated care models with improved communication and partnership with the medical staff
 Quality and Financial Benefits
•
Capture existing revenue and quality opportunities, with additional focus on value‐based reimbursement initiatives
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More Stakeholders
 Expansion of CDI across the care continuum introduces new stakeholders
Clinicians (primarily physicians)
Traditional CDI stakeholders
Finance
Nursing
Case Management
CDS Team and Coders
Outpatient Clinic/Ambulatory Surgery Staff
Quality
Physician Office Billing Staff
ED Staff
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Implementation Challenges
 CDI programs stretching across the care continuum can be difficult to implement, due to the involvement of many departments/stakeholders
 Significant effort should be put into effective change management
•
Organizational support
•
Support from leadership
•
Physician engagement
•
Alignment and buy‐in from departments not previously involved in CDI
•
Use of data
 Effective CDI programs do not achieve sustainable success as a result of the initial message or messenger, but through sustained effort
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Engaging with Stakeholders
Introductory Communication
Training
• Carefully crafted message
• Message and tone
• Tailored to the organization
• Messenger
• Right messenger
• Content
• Setting
• Frequency
Feedback and Reporting
• Monitor performance
• Provide feedback (successes and opportunities)
Publicly Reward
• Requires broad organizational support
• Ongoing involvement of leadership
Change is a process to be managed. Each step is important to achieve your goals.
Organizational change is not a one time event. It is an ongoing process
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Change Management Curve
Change Management
Much better
than before
+
Performance
High expectations
Realization of effort and complexity
Light at the end of the tunnel
X
Time
Hostility
‐
Despair
Poorly Managed Program
Effective Program
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Resistance to Change is a Significant Barrier
When pursuing transformations, organizations rarely realize the benefits or retain the value they anticipated. While there are many reasons for this, the following survey of CEO’s shows that 5 out of the top 10 business transformation showstoppers are ‘people and organizational’ issues.
Top 10 Barriers to Success
Resistance to Change
82%
Inadequate Sponsorship
72%
Unrealistic Expectations
65%
Poor Project Management
54%
Case for Change not Compelling
46%
Project Team Lacked Skills
44%
Scope Expansion / Uncertainty
44%
No Change Management Program
“Soft stuff”? Hard Impact.
43%
Not Horizontal Process View
41%
IT Perspective not Integrated
36%
PERCENT OF FIRMS
Source: Survey of CEOs Regarding Business Transformation: Barriers to Success, Conference Board,
Proprietary and Confidential. Prepared by The Claro Group, LLC ©2016. For Internal Use Only.
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Change Management: Commitment Curve
 The goal of change management, is to move stakeholders along the “Commitment Curve” throughout the lifecycle of a project Proprietary and Confidential. Prepared by The Claro Group, LLC ©2016. For Internal Use Only.
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18
The Change Commitment Curve Commitment Curve Definitions
Commitment Adoption
Understanding Awareness
Takes action and demonstrates personal commitment to the change. Brings others along with them
Accepts the change and can articulate the goals/desired outcomes, works in the “new way”
Comprehends nature, scope and intent of change (may not overtly support, but understands)
Has knowledge of scope and intent, yet is unclear how it will really impact them or what to do next
Not everyone needs to be at “commitment”!
Proprietary and Confidential. Prepared by The Claro Group, LLC ©2016. For Internal Use Only.
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The Change Commitment Curve Ways to Drive Commitment to CDI
 Executive Sponsor(s) own success of CDI program
 Highlight outcomes and benefits – the “why?”
Commitment Adoption
Understanding Awareness
 Transparent communication (macro and micro)
•
Communicate success stories and opportunities
•
Track progress with metrics/data/reporting
•
Personalize messages by audience group
•
Share plans/timelines
 Mentor department managers and other key stakeholders
•
Manage their trajectory up the commitment curve  Conduct ongoing training, not just for short periods of time
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Keys to Buy‐In: Frame of Reference Formal Definition ‐‐ A frame of reference is a complex set of assumptions and attitudes which we use to filter perceptions to create meaning. The frame can include beliefs, preferences, values, culture and other ways in which we bias our understanding and judgment.
Simple Terms ‐‐ the lens we use to view the world
Influences our attitude towards any change, such as a comprehensive CDI project
Understand your stakeholders’ frame of reference :
•
Prior experience with organizational change
•
Length of time in the organization
•
What leadership has said –privately and publicly •
•
What they have read/heard about the effort
How secure they feel in their role –
short term/long term
•
First impressions of the initiative
•
Are they data driven/quantitative
•
Personal skills and background
•
•
Personal flexibility/adaptability – resilience
Are they people/emotion drive –more qualitative
•
Hot buttons/trigger words Proprietary and Confidential. Prepared by The Claro Group, LLC ©2016. For Internal Use Only.
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Physician Engagement
 Our successful clients have achieved physician engagement as a result of effective change management efforts
 Managing the initial message:
•
Strong executive leadership (CFO and CMO)
•
Understand the physicians’ frame of reference

In general – how do physicians typically view CDI?

Specifically – taking into account history and prior experiences
•
Engage physicians early in the process to highlight “what’s in it for them” and why this process is an organizational priority
•
Leverage data, think empirically
•
Understand that obtaining buy‐in is a process, will not happen overnight
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Frame of Reference: Common Physician Perspective

Frequently physicians will resist initiatives (including CDI programs) that have the appearance of being focused on reimbursement

Most physicians comply with a CDI program if it is designed around
•
Quality of care data
•
Mortality ratings and data
•
Supporting resources consumed
•
Supporting length of stay
Proprietary and Confidential. Prepared by The Claro Group, LLC ©2016. For Internal Use Only.
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Frame of Reference: Common Physician Perspective

Many physicians do not fully appreciate how documentation impacts many of these measures
•

Many hospitals feel that physicians will best listen to other physicians
•

Lack of right tools/feedback
Not clear cut

We provide nurses, coders or physicians depending on each individual situation 
There are advantages with each approach 
We guide clients to have their own physician advisor and educator Common myth: physicians will only participate if there is a financial return for participation
•
We have demonstrated this to be false
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Frame of Reference: Common Physician Perspective

Some benefits to large group gatherings to spread message
•
That approach can be effective for some hospitals
•
It has the potential to create some resistance or not be as effective as other approaches


An effective message must be individually relevant •
Hard, or impossible, to be relevant to 200 individuals at the same time


Ignores or trivializes frame of reference differences between groups
E.g. Relevance for cardiologists is not the same as relevance for orthopedic surgeons
We find that data helps to provide a relevant message at the individual and small group level
•
Example: cardiology case example, service line data, and MS‐DRG data
•
Could produce embarrassment which is almost never successful in long run (must manage messaging)
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Physician Engagement
 Effective ongoing effort:
•
Maintain focus from leadership
•
Continue dialogue with the medical staff—luncheons, seminars, etc.

•
•
Involve them in their successes and solicit feedback
Provide ongoing reporting and feedback (data) on the progress of the effort

Highlight successes

Target opportunities 
Communicate these results in a transparent manner—hold groups accountable
Coach the CDS team to lessen friction

How to follow up on unanswered queries

When to query and when not to
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Example Physician Data
 Using analytics:
 Identify opportunities for improvement
 Investigate the specific area of process breakdown
 Intervene to change behaviors or alter systems
 Track the results
 This table shows the average number of hours it takes to obtain a response to a query
 This type of analysis can help pinpoint areas where the CDI process is breaking down because of delayed response to queries
Average Physician
Year 1
Current Period
Response Time (hours) 6/15 ‐ 10/15 11/15 ‐ 1/16
Hospital A
40
East
47
Hospital B
West
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
January 2016 Performance Meter
Nov '15
Dec
Jan'16
51
37
34
36 hrs or l es s
Good
30
39
39
36 hrs or l es s
Moni tor
Goal
44
36
Hospital C
St. Ann's
40
41
34
51
37
36 hrs or l es s
Moni tor
Hospital D
New Albany
N/A
62
N/A
65
60
36 hrs or l es s
Focus
Meter Reference
Good: 36 hrs or less
Monitor: 36 ‐ 48 hrs
Focus: greater than 48 hrs
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Example Physician Data
Percentage of Queries Responded to in 72 Hours or Less
Number of Provider
Medical/Surgical
9/15 ‐ 1/16
Responses 9/15 ‐ 1/16
LAI, GRACE A
Surgical
54
85.2%
MCKINNON, MARIE
Medical
20
70.0%
B
C
CHAUNCEY, ADRIANNA
Medical
19
94.7%
ASTIK, GOPI D
Medical
17
94.1%
E
SCHLICK, CARY
Surgical
17
94.1%
F
FANG, SHANNA
Surgical
16
56.3%
G
GILLESPIE, JEREMY
Medical
16
93.8%
H
SOBOLEWSKI, REBEKKAH
Surgical
16
68.8%
I
CHAPMAN, MARGARET
Medical
15
93.3%
J
BHANDARI, ABHISHEK
Medical
14
50.0%
K
DEFOE, MAYA
Medical
14
100.0%
L
KORNFELD, MICHA
Medical
14
42.9%
M
LANDLER, MATTHEW P.
Medical
14
100.0%
N
BENNETT, NOEL
Surgical
13
92.3%
O
BOYD, DARREN
Medical
13
46.2%
P
CHIEC, LAUREN
Medical
13
92.3%
Q
PROVENCHER, HEATHER
Medical
13
53.8%
R
TRIBBLE, KATHERINE
Resident
13
92.3%
S
AGULNEK, ABBY N.
Medical
12
75.0%
T
COLEMAN, DAVID
Medical
12
91.7%
U
JONES, AMANDA E.
Medical
12
66.7%
V
KO, CHRISTIN
Medical
12
83.3%
W
PHYSICIAN UNASS, Medical
12
75.0%
X
TANG, LAUREN T.
Medical
12
75.0%
Above Providers
383
79.6%
1,754
72.2%
All Providers
Goal
9/15
10/15
11/15
12/15
1/16
100.0%
64.3%
100.0%
N/A
0.0%
N/A
N/A
100.0%
100.0%
0.0%
100.0%
N/A
100.0%
0.0%
50.0%
N/A
N/A
N/A
100.0%
50.0%
N/A
N/A
0.0%
100.0%
74.0%
67.1%
83.3%
100.0%
100.0%
100.0%
N/A
N/A
83.3%
75.0%
100.0%
N/A
100.0%
40.0%
100.0%
100.0%
0.0%
N/A
100.0%
100.0%
100.0%
100.0%
100.0%
50.0%
66.7%
0.0%
81.0%
72.1%
94.1%
N/A
100.0%
N/A
100.0%
N/A
100.0%
62.5%
100.0%
66.7%
N/A
100.0%
100.0%
100.0%
50.0%
100.0%
55.6%
100.0%
100.0%
N/A
50.0%
66.7%
50.0%
50.0%
80.9%
74.2%
78.9%
N/A
91.7%
92.3%
100.0%
N/A
100.0%
50.0%
N/A
60.0%
100.0%
40.0%
N/A
N/A
N/A
100.0%
0.0%
N/A
60.0%
100.0%
83.3%
100.0%
100.0%
N/A
83.3%
75.4%
80.0%
50.0%
100.0%
100.0%
100.0%
56.3%
100.0%
N/A
83.3%
0.0%
100.0%
33.3%
100.0%
N/A
50.0%
0.0%
100.0%
87.5%
50.0%
100.0%
33.3%
100.0%
100.0%
100.0%
75.9%
70.3%
72 Hours or Less
Meter Reference
Good: 90% +
Monitor: 80% ‐ 90%
Focus: less than 80%
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Additional Data Mining Strategies: Inpatient Population
 Second‐level review for the inpatient population focused on:
•
Low severity DRGs with a long LOS •
Long LOS in a case without a MCC or CC
•
Deaths in low severity DRGs
•
Deaths in cases without an MCC or CC
•
Patients discharged to Hospice without an MCC or CC and a long LOS
•
Transfers from another facility without an MCC or CC and a long LOS
•
Admits from a nursing home without an MCC or CC and a long LOS
•
Patients over 85 without an MCC or CC and a long LOS
 Breakdown of metrics by physician, physician group, and specialty
 Advanced statistical analysis, such as frequency of specific MCC or CC capture
 Use the results of these reviews to target specific physicians, departments, or processes for improvement
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Additional Data Mining Strategies: Outpatient Population
 Accurate status assignment
•
Identify long LOS observation cases for opportunities to flip to inpatient
 Accuracy of charging
•
This can be a very large project in itself
 Correct E/M leveling
 Correct E/D leveling
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Summary
►
Pressures on health systems: revenue, quality, cost, compliance, others
►
The coded record is the basis for many evaluations of patient care, including reimbursement and many quality measures
●
►
As quality and reimbursement become more intertwined, managing the accuracy of the medical record is increasingly important
The importance of clinical documentation stretches across the care continuum
●
This opens new opportunities but also creates new challenges
●
More stakeholders to manage as part of the CDI process
►
Achieving buy‐in is a process
►
Utilize data to target opportunities and further support organizational efforts
Proprietary and Confidential. Prepared by The Claro Group, LLC ©2016. For Internal Use Only.
No external distribution without prior written consent of The Claro Group, LLC
31