© Copyright, The Joint Commission Advanced Certification in Heart Failure Measures Pilot Test Training Part I: Monday, November 14, 2011

© Copyright, The Joint Commission 2 Objectives  Discuss the measure specifications, related data elements, and algorithms  Review the data collection tool  Provide opportunity for questions

© Copyright, The Joint Commission use thes e colo rs

© Copyright, The Joint Commission Advanced Certification in Heart Failure Quality & Safety of Care for Patients Process GWTG (B-S-G) Structure DSC Standards + ACHF Standards Outcome HF Core + ACHF Measures ACHF

© Copyright, The Joint Commission Standardized Measure Identification Process Determine measurement topic Identify measure scope and framework (domains of care) Expert Advisory Panel meets ( identify additional domains, endorse framework, identify extant measures) Additional measures solicited via 30 day public comment period & via list serves, etc. Existing evidence-based measures submitted by public/stakeholders Expert Advisory Panel review of submitted measures & recommendation of candidate measures Public/Stakeholder Comment re. candidate measures Expert Advisory Panel review of comment & final recommendation of measures Develop measure specifications & data collection tools Pilot test and reliability test of measures Expert Advisory Panel review of pilot results & measure revision TJC StaffExpert PanelPublic/Stakeholders Responsible entity : Implementation of measure set

© Copyright, The Joint Commission Timeline in Months MarAug Technical Advisory Panel (TAP) Meets Oct Nov Dec SepMayJun Jan Feb MarApr TAP reviews comments and recommendations Public Comment Measure specifications and data collection tool developed TAP reviews pilot results and finalizes measures 6-month Pilot Test Jul

© Copyright, The Joint Commission 7 ACHF Initial Patient Population  Two sub-populations: 1)ACHF Inpatient 2)ACHF Hospital Outpatient (Appendix A, Table 2.1 and Table 2.2)

© Copyright, The Joint Commission 8 ACHF Initial Inpatient Population  The population of the ACHF inpatient measures is identified using 6 data elements: –ICD-9-CM Principal Diagnosis Code –ICD-9-CM Principal Procedure Code –ICD-9-CM Other Procedure Codes –Admission Date –Birthdate –Discharge Date

© Copyright, The Joint Commission 9 ACHF Initial Inpatient Population  Patients admitted to the hospital for inpatient acute care: –ICD-9-CM Principal Diagnosis Code for HF –No ICD-9-CM Principal or Other Procedure Code of Left Ventricular Assistive Device (LVAD) or Heart Transplant –Patient Age (Admission Date minus Birthdate) greater than or equal to 18 years –Length of Stay (Discharge Date minus Admission Date) less than / = to 120 days

© Copyright, The Joint Commission ACHF Initial Inpatient Population

© Copyright, The Joint Commission 11 Excluded Populations – ALL ACHF Inpatient Measures  Patients who had a left ventricular assist device (LVAD) or heart transplant procedure (ICD-9-CM Procedure Code for LVAD or heart transplant as defined in Appendix A, Table 2.2)  Age <18 years

© Copyright, The Joint Commission 12 Excluded Populations – ALL ACHF Inpatient Measures  Inpatient Discharges > 120 days  Patients with Comfort Measures Only documented  Patients discharged to another hospital  Patients who expired  Patients discharged to home for hospice care  Patients discharged to a healthcare facility for hospice care

© Copyright, The Joint Commission 13 ACHF Initial Outpatient Population  The population of the ACHF hospital outpatient measures is identified using 7 data elements: –E/M Code –Discharge Status –Outpatient Encounter Date –Birthdate –ICD-9-CM Principal Diagnosis Code –ICD-9-CM Principal Procedure Code –ICD-9-CM Other Procedure Codes

© Copyright, The Joint Commission 14 ACHF Initial Outpatient Population  Patients seen in the clinic/hospital for outpatient care: –E/M code on OP Table 1.0 –Discharge Status anything not = 20 –Patient Age (Outpatient Encounter Date minus Birthdate) greater than or equal to 18 years –ICD-9-CM Principal Diagnosis Code for HF –No ICD-9-CM Principal or Other Procedure Code of Left Ventricular Assistive Device (LVAD) or Heart Transplant

© Copyright, The Joint Commission ACHF Initial Outpatient Population

© Copyright, The Joint Commission 16 Excluded Populations – ALL ACHF Outpatient Measures  Patients who had a left ventricular assist device (LVAD) or heart transplant procedure (ICD-9-CM Procedure Code for LVAD or heart transplant as defined in Appendix A, Table 2.2)  Age <18 years  All Discharge Status codes except 20

© Copyright, The Joint Commission 17 Monthly Sample Size Average Monthly Initial Patient Population Size “N” Minimum Required Sample Size “n”  % of Initial Patient Population size < 26No sampling; 100% Initial Patient Population required

© Copyright, The Joint Commission 18 Monthly Sample Size  Same methodology for both inpatients and outpatients –Example: 30 inpatient discharges and 52 outpatient visits for the month of November. Randomly select 26 inpatient records plus 26 outpatient records for review. The same patient record may be in both samples.

© Copyright, The Joint Commission Inpatient and Outpatient Settings

© Copyright, The Joint Commission 20 ACHF-01 Beta-Blocker Therapy (i.e., Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Succinate) for LVSD Prescribed at Discharge Denominator: Heart failure patients with current or prior documentation of left ventricular ejection fraction (LVSD) < 40% Numerator: Patients prescribed bisoprolol, carvedilol, or sustained-release metoprolol succinate at hospital discharge

© Copyright, The Joint Commission 21 ACHF-01 Included Populations  Discharges with ICD-9-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1, and  Documentation of LVSD < 40%

© Copyright, The Joint Commission 22 ACHF-01 Excluded Populations  Patients enrolled in Clinical Trial  Patients who left against medical advice  Patients with a documented Reason for No Bisoprolol, Carvedilol, or Sustained- Release Metoprolol Succinate Prescribed for LVSD at Discharge

© Copyright, The Joint Commission 23 ACHF-01 Data Elements Denominator:  Admission Date  Birthdate  Clinical Trial  Comfort Measures Only  Discharge Date  Discharge Disposition

© Copyright, The Joint Commission 24 ACHF-01 Data Elements Denominator:  ICD-9-CM Other Procedure Codes  ICD-9-CM Principal Diagnosis Code  ICD-9-CM Principal Procedure Code  LVSD < 40%  Reason for No Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Succinate Prescribed for LVSD at Discharge

© Copyright, The Joint Commission 25 ACHF-01 Algorithm Highlights

© Copyright, The Joint Commission 26 ACHF-01a Hospital Outpatient Beta-Blocker Therapy (i.e., Bisoprolol, Carvedilol, or Sustained- Release Metoprolol Succinate) Prescribed for LVSD Denominator: Heart failure patients with current or prior documentation of left ventricular ejection fraction (LVSD) < 40% Numerator: Patients prescribed bisoprolol, carvedilol, or sustained-release metoprolol succinate for LVSD when seen in the outpatient setting

© Copyright, The Joint Commission 27 ACHF-01a Included Populations  E/M Code for hospital outpatient encounter as defined in OP Appendix A, OP Table 1.0, and  An ICD-9-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1  Documentation of LVSD < 40%

© Copyright, The Joint Commission 28 ACHF-01a Excluded Populations  Patients enrolled in Clinical Trial  Patients with a documented Reason for No Bisoprolol, Carvedilol, or Sustained- Release Metoprolol Succinate Prescribed for LVSD in the Outpatient Setting

© Copyright, The Joint Commission 29 ACHF-01a Data Elements Denominator:  Birthdate  Clinical Trial  Discharge Status  E/M Code  ICD-9-CM Other Procedure Codes  ICD-9-CM Principal Diagnosis Code  ICD-9-CM Principal Procedure Code

© Copyright, The Joint Commission 30 ACHF-01a Data Elements Denominator:  LVSD < 40%  Outpatient Encounter Date  Reason for No Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Succinate prescribed for LVSD in the Outpatient Setting

© Copyright, The Joint Commission 31 ACHF-01a Data Elements Numerator:  Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Succinate Prescribed for LVSD in the Outpatient Setting

© Copyright, The Joint Commission 32 ACHF-01a Algorithm Highlights

© Copyright, The Joint Commission 33 ACHF-01b Hospital Outpatient ACEI or ARB Prescribed for LVSD Denominator: Heart failure patients with current or prior documentation of left ventricular ejection fraction (LVSD) < 40% Numerator: Patients who are prescribed an ACEI or ARB for LVSD when seen in the outpatient setting

© Copyright, The Joint Commission 34 ACHF-01b Included Populations  E/M Code for hospital outpatient encounter as defined in OP Appendix A, OP Table 1.0, and  An ICD-9-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1  Documentation of LVSD < 40%

© Copyright, The Joint Commission 35 ACHF-01b Excluded Populations  Patients enrolled in Clinical Trial  Patients with a documented Reason for No ACEI or ARB Prescribed for LVSD in the Outpatient Setting

© Copyright, The Joint Commission 36 ACHF-01b Data Elements Denominator:  Birthdate  Clinical Trial  Discharge Status  E/M Code  ICD-9-CM Other Procedure Codes  ICD-9-CM Principal Diagnosis Code  ICD-9-CM Principal Procedure Code

© Copyright, The Joint Commission 37 ACHF-01b Data Elements Denominator:  LVSD < 40%  Outpatient Encounter Date  Reason for No ACEI or ARB Prescribed for LVSD in the Outpatient Setting

© Copyright, The Joint Commission 38 ACHF-01b Data Elements Numerator:  ACEI or ARB Prescribed for LVSD in the Outpatient Setting

© Copyright, The Joint Commission 39 ACHF-01b Algorithm Highlights

© Copyright, The Joint Commission 40 ACHF-01c Hospital Outpatient Aldosterone Receptor Antagonists Prescribed for LVSD Denominator: Heart failure patients with current or prior documentation of left ventricular ejection fraction (LVSD) < 40% Numerator: Patients who are prescribed an aldosterone receptor antagonist (spironolactone or eplerenone) for LVSD when seen in the outpatient setting

© Copyright, The Joint Commission 41 ACHF-01c Included Populations  E/M Code for hospital outpatient encounter as defined in OP Appendix A, OP Table 1.0, and  An ICD-9-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1  Documentation of LVSD < 40%

© Copyright, The Joint Commission 42 ACHF-01c Excluded Populations  Patients enrolled in Clinical Trial  Patients who with hyperkalemia  Patient with renal dysfunction or dialysis  Patients with a documented Reason for No Aldosterone Receptor Antagonist Prescribed for LVSD in the Outpatient Setting

© Copyright, The Joint Commission 43 ACHF-01c Data Elements Denominator:  Birthdate  Clinical Trial  Discharge Status  E/M Code  ICD-9-CM Other Procedure Codes  ICD-9-CM Principal Diagnosis Code  ICD-9-CM Principal Principal Code

© Copyright, The Joint Commission 44 ACHF-01c Data Elements Denominator:  LVSD < 40%  Outpatient Encounter Date  Reason for No Aldosterone Receptor Antagonist Prescribed for LVSD in the Outpatient Setting

© Copyright, The Joint Commission 45 ACHF-01c Data Elements Numerator:  Aldosterone Receptor Antagonist Prescribed for LVSD in the Outpatient Setting

© Copyright, The Joint Commission 46 ACHF-01c Algorithm Highlights

© Copyright, The Joint Commission 47 ACHF-07 Discussion of Advance Directives Denominator: All heart failure patients Numerator: Patients who have an advance directive documented in the medical record OR documentation of a one-time discussion of advance care planning with a healthcare provider

© Copyright, The Joint Commission 48 ACHF-07 Included Populations  Discharges with ICD-9-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1, and  Patients enrolled in a Clinical Trial  Patients who left against medical advice (AMA)

© Copyright, The Joint Commission 49 ACHF-07 Data Elements Denominator:  Admission Date  Birthdate  Clinical Trial  Comfort Measures Only  Discharge Date  Discharge Disposition

© Copyright, The Joint Commission 50 ACHF-07 Data Elements Denominator:  ICD-9-CM Other Procedure Codes  ICD-9-CM Principal Diagnosis Code  ICD-9-CM Principal Procedure Code Numerator:  Advance Directives

© Copyright, The Joint Commission 51 ACHF-07 Algorithm Highlights

© Copyright, The Joint Commission 52 ACHF-07a Hospital Outpatient Discussion of Advance Directives Denominator: All heart failure patients Numerator: Outpatients who have an advance directive documented in the medical record OR documentation of a one-time discussion of advance care planning with a healthcare provider

© Copyright, The Joint Commission 53 ACHF-07a Included Populations  E/M Code for hospital outpatient encounter as defined in OP Appendix A, OP Table 1.0, and  An ICD-9-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1

© Copyright, The Joint Commission 54 ACHF-07a Data Elements Denominator:  Birthdate  Discharge Status  E/M Code  ICD-9-CM Other Procedure Codes  ICD-9-CM Principal Diagnosis Code  ICD-9-CM Principal Procedure Code  Outpatient Encounter Date Numerator:  Advance Directives

© Copyright, The Joint Commission 55 ACHF-07a Algorithm Highlights

© Copyright, The Joint Commission Inpatient Setting

© Copyright, The Joint Commission 57 ACHF-02 Post-Discharge Appointment for Heart Failure Patients Denominator: All heart failure patients discharged from a hospital inpatient setting to home or home care Numerator: Patients for whom a follow-up appointment for an office or home health visit for management of heart failure was scheduled within 7 days post-discharge and documented including location, date, and time

© Copyright, The Joint Commission 58 ACHF-02 Included Populations  Discharges with ICD-9-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1, and  A discharge to home, home care, or court/law enforcement

© Copyright, The Joint Commission 59 ACHF-02 Excluded Populations  Patients discharged to locations other than home, home care, or law enforcement  Patients enrolled in Clinical Trial  Patients with a documented Reason for No Post-Discharge Appointment Within 7 Days

© Copyright, The Joint Commission 60 ACHF-02 Data Elements Denominator:  Admission Date  Birthdate  Clinical Trial  Comfort Measures Only  Discharge Date  Discharge Disposition  ICD-9-CM Other Procedure Codes

© Copyright, The Joint Commission 61 ACHF-02 Data Elements Denominator:  ICD-9-CM Principal Diagnosis Code  ICD-9-CM Principal Procedure Code  Reason for No Post-Discharge Appointment Within 7 Days Numerator:  Post-Discharge Appointment Scheduled Within 7 Days

© Copyright, The Joint Commission 62 ACHF-02 Algorithm Highlights

© Copyright, The Joint Commission ACHF-03 Care Transition Record Transmitted Denominator: All heart failure patients discharged from a hospital inpatient setting to home or home care Numerator: Care transition record transmitted to a next level of care provider within 7 days of discharge with a copy in the medical record containing ALL of the following components:

© Copyright, The Joint Commission ACHF-03 Care Transition Record Components  Reason for hospitalization  Procedures performed during hospitalization  Treatment / services provided  Condition / functional status at discharge  Discharge medications  Follow-up treatment / services needed  Caregiver / social support  Next level of care provider contact info  Post-discharge appointment info 64

© Copyright, The Joint Commission 65 ACHF-03 Included Populations  Discharges with ICD-9-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1, and  A discharge to home, home care, or court/law enforcement

© Copyright, The Joint Commission 66 ACHF-03 Excluded Populations  Patients discharged to locations other than home, home care, or law enforcement  Patients enrolled in Clinical Trial

© Copyright, The Joint Commission 67 ACHF-03 Data Elements Denominator:  Admission Date  Birthdate  Clinical Trial  Comfort Measures Only  Discharge Date  Discharge Disposition  ICD-9-CM Other Procedure Codes  ICD-9-CM Principal Diagnosis Code  ICD-9-CM Principal Procedure Code

© Copyright, The Joint Commission 68 ACHF-03 Data Elements Numerator:  Care Transition Record -Condition or Functional Status at Discharge  Care Transition Record -Designated Patient Caregiver or Social Support  Care Transition Record -Discharge Medications  Care Transition Record Given to Patient/Caregiver  Care Transition Record -Follow-up Treatment and Services Needed  Care Transition Record -Location, Date, and Time of Post-Discharge Appointment

© Copyright, The Joint Commission 69 ACHF-03 Data Elements Numerator:  Care Transition Record -Next Level of Care Provider Contact Information  Care Transition Record Present  Care Transition Record -Procedures Performed During Hospitalization  Care Transition Record -Reason for Hospitalization  Care Transition Record- Treatment/Services Provided  Discharge Date

© Copyright, The Joint Commission 70 ACHF-03 Algorithm Highlights

© Copyright, The Joint Commission 71 ACHF-03 Algorithm Highlights pt2

© Copyright, The Joint Commission 72 ACHF-03 Algorithm Highlights pt3

© Copyright, The Joint Commission 73 ACHF-08 Post-Discharge Evaluation for Heart Failure Patients Denominator: All heart failure patients discharged from a hospital inpatient setting to home or home care AND patients leaving against medical advice (AMA)

© Copyright, The Joint Commission 74 ACHF-08 Post-Discharge Evaluation for Heart Failure Patients Numerator: Patients who have a documented re-evaluation conducted via phone call or home visit within 72 hours after discharge addressing ALL of the following components: –Heart failure symptoms –Weight and fluid status –Diet and sodium intake –Medication compliance and adverse drug reactions –Activity

© Copyright, The Joint Commission 75 ACHF-08 Included Populations  Discharges with ICD-9-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1, and  A discharge to home, home care, or court/law enforcement  Patients who left against medical advice (AMA)

© Copyright, The Joint Commission 76 ACHF-08 Data Elements Denominator:  Admission Date  Birthdate  Clinical Trial  Comfort Measures Only  Discharge Date  Discharge Disposition  ICD-9-CM Other Procedure Codes  ICD-9-CM Principal Diagnosis Code  ICD-9-CM Principal Procedure Code

© Copyright, The Joint Commission 77 ACHF-08 Algorithm Highlights

© Copyright, The Joint Commission 78