Tammy Garwick MA, RCEP, FAACVPR Richard Sukeena MS, MBA, FAACVPR Creating a Standard Individual Treatment Plan (ITP) for Cardiac & Pulmonary Rehabilitation: For Efficient Review & Physician Signature Tammy Garwick MA, RCEP, FAACVPR Richard Sukeena MS, MBA, FAACVPR

Objectives Create a standard quality ITP for Cardiac and Pulmonary Rehabilitation that meets both (AACVPR Program Certification & CMS) guidelines Develop a workflow to enhance efficiency for physician review and signature Bringing it All Together and examples of ITPs Linking the ITP and physician workflow to a department Quality Assurance plan

No Conflicts of Interest Using the Examples in this Presentations does NOT guarantee program certification by AACVPR Founded in 1985, AACVPR is a multidisciplinary organization focused on a mission, not preservation of a discipline. Central to our mission is the improvement in quality of life for our patients and their families We accomplish this by Providing educational resources and networking opportunities to enhance the knowledge and performance of our members and their programs Advocating on both national and regional levels to enhance third-party payment for cardiovascular and pulmonary rehabilitation and prevention services

62% of all current AACVPR members hold Joint Affiliate membership In good company… 62% of all current AACVPR members hold Joint Affiliate membership Update the % of membership Also # of Joint Affiliates—vs total number of Affiliates **Highlight specific Affiliate for each presentation Does anything need to be said/presented on the benefits of Joint Affiliation? Especially for those Affiliates not yet a Joint Affiliate? Seems a bit disjointed—this slide JA, next slide Ed Adv, next slide webcasts . . .

AACVPR Certification Contacts and Local Resources Members with certification questions are probably best to send an email to certification@aacvpr.org KENTUKY Audra Byers RN, BSN, CCRN, CCRP Audra.byers@lpnt.net OHIO Bonnie Clark RRT, CPT, FAACVPR Bonnie.Clark@ProMedica.org Robert Rosneck MA, RRT,CES, RCEP Robert.Rosneck@UHhospitals.org Certification Leadership Committee Chair Mark Stout MS, CCRP, FAACVPR Certification Leadership Committee Vice-Chair Susi Mathis MS, RCEP, CES, RN, CCRP, FAACVPR

OBJECTIVE Create a standard quality ITP for Cardiac and Pulmonary Rehabilitation that meets both (AACVPR Program Certification & CMS) guidelines

CMS Individual Treatment Plan (ITP) The Centers for Medicare & Medicaid Services (CMS) 42 CFR 410.49 and 410.47- cardiac rehabilitation and pulmonary rehabilitation programs Conditions of Coverage states: Components of a cardiac rehabilitation and intensive cardiac rehabilitation programs and pulmonary rehabilitation programs must include all of the following: (i) Physician-prescribed exercise each day cardiac rehabilitation items and services are furnished. (ii) Cardiac risk factor modification, including education, counseling, and behavioral intervention, tailored to the patients' individual needs. (iii) Psychosocial assessment. (iv) Outcomes assessment. (v) An individualized treatment plan detailing how components are utilized for each patient. The individualized treatment plan must be established, reviewed, and signed by a physician every 30 days.”

Latest CGS Revisions CR 4/18/18 & PR 8/24/16 ITP must be signed prior to or on the first day of billed services. ITP must be signed within every 30 days, regardless of when the 30 days fall (weekend/holidays). Physician signature required for initial, within every 30 days, and discharge

CMS Regulations Description of the diagnosis The type, amount, frequency, and duration of rehab Goals set for the next 30 days signed off by MD Intervention/Education O2 assessment and plan (pulmonary) Risk factor modification (Cardiac) Physician prescribed exercise Psychosocial assessment and plan signed off Outcome assessment Tell a story

AACVPR ITP Key Elements & Steps AACVPR Applications: Revised 3/20/2018 AACVPR ITP Key Elements & Steps Core Elements: 1.Exercise 2.Nutrition 3.Psychosocial 4.Other Core Components/Risk Factors as applicable to individual patient 5.Oxygen use and titration (required for Pulmonary Rehab application) Four Required Steps: 1.Assessment 2.Plan: Includes Goals/Interventions and Education including initial exercise prescription with mode, frequency, duration and intensity 3.Reassessment: At least one! MD signature and date is required at least every 30 days 4. Discharge Plan Does your ITP tell a complete story?

AACVPR Upload COMPLETED, HIPAA compliant Cardiac or Pulmonary ITP ITP must be a single comprehensive document. (It does not need to be one page) ITP must be for an actual patient that has completed all required elements and steps. Assessment and reassessment data must be on the ITP Do not submit assessment tools Reassessments should include “progress toward goal” information ITP must be completed in the data collection period (2018) & Must include at least one “ACTIVE” core component Must include physician signatures and dates at initial assessment, at least one reassessment,& DC For Pulmonary Rehab, ITP must be submitted for a patient using oxygen Identify the patient’s first day of exercise and the physician signature dates for the initial assessment, each reassessment and discharge/follow-up

AACVPR Cardiac ITP Requirements EXERCISE NUTRITION Exercise Assessment •Exercise Plan Goals Interventions Initial Exercise Prescription including Mode, Frequency, Duration, Intensity Education Exercise Reassessment Exercise Discharge Plan Nutrition Assessment •Nutrition Plan Goals Interventions Education Nutrition Reassessment Nutrition Discharge Plan

AACVPR Cardiac ITP Requirements PSYCHOSOCIAL OTHER Psychosocial Assessment Psychosocial Plan Goals Interventions Education Psychosocial Reassessment Psychosocial Discharge Plan Other Core Components/Risk Factors as appropriate (diabetes, HTN, obesity, medications, tobacco) Assessment Plan Goals Interventions Education Reassessment Discharge Plan

AACVPR ITP CHECK LIST Core Elements: 1.Exercise 2.Nutrition 3.Psychosocial 4.Other Core Components/Risk Factors as applicable to individual patient 5.Oxygen use and titration (required for Pulmonary Rehab application) Four Required Steps: 1.Assessment 2.Plan: Includes Goals/Interventions and Education including initial exercise prescription with mode, frequency, duration and intensity 3.Reassessment: At least one! MD signature and date is required at least every 30 days 4. Discharge Plan

AACVPR Performance Measures (Cardiac) Improved functional capacity Optimal blood pressure control at completion <130/80 Tobacco Use Intervention Improvement in depression

AACVPR Performance Measures (Pulmonary) Improvement in functional capacity (6- minute walk) Improvement in dyspnea Improvement in quality of life

Performance Measures Assessment Tools (Pulmonary) Improvement in Functional Capacity/ Exercise Capacity (pre to post) Six Minute Walk Test (6MWT) Improvement in Dyspnea Measures (pre to post) Modified Medical Research Council Scale (MMRC) University of San Diego Shortness of Breath Questionnaire (UCSD SOBQ) Baseline and Transition Dyspnea Indexes (BDI/TDI) Improvement in Health-Related QOL (pre to post) St. George’s Respiratory Questionnaire (SGRQ) Chronic Respiratory Disease Questionnaire (CRQ) COPD Assessment Test (CAT)

OBJECTIVE Develop a workflow to enhance efficiency for physician review and signature

Examples of MD review/signature

Physician Involvement Engage your Medical Director or key referring physician(s) in creating the ITP Keep It Short & Sweet (KISS) Make the form easy for them to evaluate progress and key issues/concerns

Access to Telemetry Seat license

VersaCare GO Improvements

Submit ITP for Approval Submit ITP for Approval. ITP will then be submitted into ‘Unapproved ITP’ Queue

LSI Contacted LSI without a response

AEMR Physician Signature TASK

Bringing it All Together and examples of ITPs OBJECTIVE Bringing it All Together and examples of ITPs

AACVPR EXAMPLE ITP

PSYCOSOCIAL EXAMPLE

Your Programs ITP Look at your program ITP Does my ITP have the key elements AACVPR checklist for Cardiac and Pulmonary https://www.aacvpr.org/Portals/0/Program%20Certification/Application%20Resources/2017%20ITP%20Checklists.pdf

Table comparing ITP Documentation Requirements CMS/CGS Requirements   AACVPR Certification Requirements EXERCISE COMPONENT Core Element EXERCISE Expects the physician’s prescription for exercise to include: Mode, Target Intensity, Duration & Frequency Assessment/Plan/Reassess/Discharge Plan Interventions – Mode, Intensity, Duration & Frequency Dynamic “blueprint” monitoring the patients subjective/objective response to exercise therapy Under Plan: Goals, Intervention & Education PSYCOSOCIAL COMONENT Core Element PSYCOSOCIAL Psychosocial assessment for screening depression and plan of action based on results (signatures/dates). Description and goals OUTCOME ASSESSMENT Core Element NUTRITION Interventions/services did/did not result is benefit to the patient. Description of those outcomes and goals IE: wt. loss Respiratory Management RESPIRATORY MANAGEMENT O2 USE & TITRATION CARDIAC RISK FACTOR MODIFICATION Core Elements RISK FACTORS Includes education, counseling and behavioral intervention tailored to the patient’s individual needs, Description and goals Addressing cardiac risk factors IE: lipid lowering, sedentary lifestyle or tobacco use. ITP addresses documentation demonstrating how the risk factor were addressed (signed and dated by appropriate services are delivered) Addressing cardiac/Pulmonary Risk factors IE: Diabetes, Tobacco, Environment factors, inhaler meds, weight, hypertension and bronchial hygiene

Efficiency Why are you touching the same data more than 2 times, is it too much? Look at ways that enter the data once and it be carried to multiple points (ITP, Registry, Quality Assurance) Paper strong but process weak Work smarter, not harder When is the last time you stepped back and evaluated your process

Almost all registry information can be entered from telemetry system.

Outcomes per patient Add comments, summary to physicians Links to program data

OBJECTIVE Linking the ITP and physician workflow to a department Quality Assurance plan

Program Data Able to define time Able to run specific reports Able to see trends

Defining Quality Assurance (QA) A way to ensure that defined standards are met. The first step toward Quality Improvement. Nursing Quality Management A system for evaluating performance, as in the delivery of services or quality of products provided to customers or patients. American Medical Dictionary

Quality is monitored & continually improved! Quality Process? Quality is monitored & continually improved! Structure: system goals/resources/accrediting or regulatory standards (defined benchmarks) Politics: local, state and national Process: activities of both providers/services Outcomes: actual results of the service line & patient activities

Why Focus on Quality? CSG Audit Cardiac & Pulmonary The top denial reasons associated with this review: Physician-prescribed exercise Cardiac risk factor modification Psychosocial assessment Outcomes assessment An individualized treatment plan Lack of physician Signatures/Dates

Implementation of a QA Review Team members met to discuss initial program areas for QA review 2. Insight from Medical Director/Hospital Compliance department 3. Target areas were chosen to review (IE): - untoward events - physician response time to 30 day reports - chart documentation standards (CMS/AACVPR/System) - Patient Falls 4. QA team developed a chart review checklist for QUARTERLY data collection 5. Benchmarks were established for each of the report areas (trends, history, MD, director) 6. Each site developed action plans for standards not meeting benchmarks

Examples of quality assurance checklist and reviews Patient Name: ______________________ Diagnosis: _______________ Discharge Date: __________ Reviewer: ____________________Facility: _________________ Case Manager: ____________   Appropriate diagnosis and signed/dated physician referral Initial ITP signed prior to patient’s start (signed by the medical director/physician) Falls Risk Assessed (noted on Face Sheet) and color coded & did the patient fall in rehab Patient risk stratified (CR) and reported a disease specific re-admission while enrolled (CR/PR) Staff identified patient’s quantifiable , realistic individualized goals with timeline All ITP 30 day progress reports and discharge reports /summaries (D/C sent within 2 weeks of discharge/signed) are completed and returned on time– (Unmet/in-progress outcomes should have comments) All patient daily session reports are completed and have a minimum of three EKG strips/SaO2 levels, body weight, blood sugar level (during first 2 wks and periodically thereafter), supervising physician, staff signature and time/date HVI Medication Reconciliation form completed pre and post Ex Rx: comments on iITP, ITP (30 day reassessment) and Discharge should include adherence to the required elements of mode, frequency, duration, intensity (address changes in THR), exercise progression (refer to hand-out on “s” drive), O2 usage/titration and special needs 30 day ITP reports/reassessments include: exercise, psychosocial, nutrition/weight management and other sub-optimal outcomes. Include exercise progression update, frequency, duration and O2 usage/titration and/or address special needs. All reports must include physician signatures/dates Comments/Summary area of ITP 30 reports should include clinical/health changes or issues, education/attendance issues and address any other sub-optimal risk factors on ITP or lack of progression

Cardiac Rehabilitation QA Report II. Completeness of Physician Response Report Turnaround Time: The cardiac rehabilitation staff will track all phase II cardiac rehabilitation patient physician response reports turnaround time for both the fourth and eighth weeks, while the patients are enrolled in the program. Numerator = # of 30 day physician reports that are returned within 30 days of previous 30 day report Denominator = Total # of charts reviewed Benchmark: 100%   First Quarter Second Quarter Third Quarter Fourth Quarter # returned in 30 days 44 41 43 45 reports reviewed 100% 95%

Cardiac Rehabilitation Report (cont’d) III. Phase II Patient Chart Review: Appropriate diagnosis and documentation standards are being met on phase II cardiac rehabilitation charts. Numerator = # of phase II charts reviewed that are compliant with outlined standards Denominator = Total # of charts reviewed Benchmark: 100% Comments & Action Items: 1st Quarter: 1 chart missing exercise session #24 and 1 chart missing staff signature/time/date 2nd Quarter: No supervising physician and session # on 2 charts ACTION: At weekly huddle discuss missing items and set-up a review of charts by staff to review charts prior to forwarding to MR   First Quarter Second Quarter Third Quarter Fourth Quarter Compliant 10 7 9 8 Patient charts reviewed 12 11 83% 64% 82% 67%

Program & Staff Accountability! EXAMPLE ACTION PLANS Completeness of physician response turnaround time: 95%, benchmark 100%: Action plan: 1. new fax machine designated for rehab area purchased may eliminate lost reports. E-mail reminder 2. ask medical director to inform rehab staff when out of office and identify covering physician ahead of time Patient chart reviews: 50%, benchmark 100%: 1. staff to review JCAHO “do not use” abbreviation list 2. employ system of checks/balances when filing daily reports 3. staff use QA checklist to review all charts prior to quarterly audit (staff review charts) Case Manager responsibility Program & Staff Accountability!

QUESTIONS & DISCUSSION THANK YOU QUESTIONS & DISCUSSION

ITP Samples Tammy & Rich will be available with samples in the Vendor Area for REVIEW