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Physician Advisor & CDI
A Collaborative Team Physician Advisor & CDI Laura Shawhughes, MD, FHM October 17, 2018
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Learning Objectives At the conclusion of this activity, participants will be able to: Describe the roles and responsibilities of the Physician Advisor at Kent Hospital Discuss the ways in which a Physician Advisor and CDI team can collaborate to achieve institutional goals and metrics Understand the rationale for and benefits of CDI/PA "Case Review" sessions Give examples of methods for communication to and education for hospital medical staff including development of "CDI Documentation Tip Sheet" Identify ongoing challenges faced by a CDI/PA Team Please feel free to interrupt and ask questions, would like this to be a discussion rather than a lecture
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What is a “Physician Advisor”?
Liaison/connection between the physician providing care at the bedside and all the other invested parties Where does CDI fit into this picture?
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What is a “Physician Advisor”?
Emerging field (ACPA founded in 2014) Administrative role - part time vs. full time Evolving responsibilities Role may vary based on institutional structure/needs Consultant to and resource for physicians Peer educator Hospitalists have knowledge base and skill set that fits well role of PA Internal vs. External physician Role may change/morph over time
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What is a “Physician Advisor”?
Physician clinical expert on topics such as Length of stay Transitions of Care and Readmissions Utilization review and Level of care Quality/patient safety Regulatory compliance Denials and Appeals Contract Negotiations with Insurance Payers Clinical documentation Concurrent Level of Care Denials Retrospective DRG denials and appeals Clinical Documentation –teach physicians what to document in the medical record that will reconcile ICD-10, Coding rules/regulations, and what they learned during medical training
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My Journey to PA Residency in Internal Medicine
Employed as a hospitalist for over 10 years at 4 different hospital systems Personal interest in UR, CM, Transitions of Care, and Documentation Hospital opportunity - need for physician leadership and input Personal opportunity - career development, reduce burnout, improved work hours Mentor – Dr. O’Brien “Hospitalist” coined in 1996 and the role has rapidly expanded. Hospitalists uniquely suited for administrative roles in the hospital due to knowledge of hospital systems and personal investments in seeing hospital succeed. Hospitalist have personal connections with broad swath of medical staff because of use of consultants.
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Kent Physician Advisor Role
Liaison between the physician staff, care management/utilization review and CDI. 2 Physicians, each with ~50% of time devoted to PA role ~7 clinical shifts/month as a hospitalist Member of multiple hospital committees Administrative roles within the hospitalist group Chair Readmission Committee, Member of Performance Improvement, Utilization Review Committee (only hospital committee required in Medicare COP), Value Based Care – systems improvement, Quality Initiatives, Education to Residents/Medical Students. List making, edit hospitalist handbook, orientation to new hospitalist hires
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Current Kent PA Roles/Initiatives
Kent Readmissions Committee – Chair Utilization and Level of Care reviews Code 44/Medicare 1 Day Stay reviews Clinical High Risk Meeting (Long Stay Case Reviews, 2x/wk) Denials/Appeal Reviews CDI
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Kent CDI Physician Advisor
PA acts as a liaison between the CDI professionals, HIM, and the hospital’s medical staff to facilitate Effective documentation to support level of care Accurate and complete documentation for coding and abstracting of clinical data Capture of severity, acuity, and risk of mortality Appropriate MS-DRG/DRG assignment PA provides ongoing support and education to the medical staff regarding the need for comprehensive, quality documentation Resident program has rapidly expanded over the past few years and thus so has the documentation in the medical record that is done by trainees. It’s challenging to continuously educate these new doctors. CDI leadership and PA do a yearly presentation at resident morning report to give overview of CDI program. Positive feedback from upper level residents that topic is relevant and useful to their practice.
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Team Work- PA Supporting CDI
CDI targeted case reviews Documentation Tip sheet Development Query Template Development CNE Diagnosis Criteria Development Clinical Validation Case Review Physician Education Resident Education Query Reply Assistance - identified in daily physician query report sent to leadership and department heads Physician Query Escalation Process Reviews CDI Query Reply Metrics with Medical Staff (Monthly reports sent to CMO and department heads) DRG Denials and Appeals chart reviews Support Target Metric = Physician query reply within 72 hrs > 90% Physician education re: documentation, update as diagnostic criteria change (sepsis, ETOH abuse/dependence) Physician education – 1 on 1 in person, by , group settings, tip sheets Team effort - CDI and PA use complimentary skills and knowledge to support our agenda
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CDI/PA Case Reviews Scheduled twice weekly clinical case reviews to identify documentation and/or query opportunities CDI RNs present cases 30-60min time allotted on Tuesday and Thursday Via conference call or in office PA also available by for any additional case review questions Need to include slide with Case review format for educational purpose
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CDI/PA Case Reviews Support CDI in improving the accuracy, clinical validation, consistency, and quality of documentation in the MR to support the SOI/ROM and care provided to the patient. Educational opportunity for PA Allows for PA to provide concurrent, real time feedback to CDI RNs and to providers
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CDI/PA Case Reviews – Presentation Format
Acct# Name: Unit location: Admit date: DRG Title: DRG Number: A/LOS: PDX: Brief Hx: Reason for Admit: Risk factors, Signs and Symptoms and Treatment
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CDI/PA Case Reviews No MCC/CC identified, SOI/ROM 1/1 PDX uncertain
Question on if or how to query Clinical clarification of a diagnosis, lab, or test result. Clinical validation diagnosis assistance MD peer to peer support needed for education e.g. query reply, documentation consistency, diagnosis criteria Which topics or queries to discuss/prioritize Clinical clarification example – lactic acidosis definition (vs. hyperlactatemia) Review discussions include: clinical clarification, query opportunity identification and guidance, MD query replies that may identify PA opportunity for peer education, LOS issues for PA from UR/CM perspective. Any questions about how/why we do case reviews? Anyone doing them at their institutions and willing to share format/insights?
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CDI Tip Sheet Each month, a CDI RN is asked to create a documentation “Tip Sheet" to present to the hospitalists and residents at monthly meetings and by to the surgery department Prior to distribution, the PA reviews and provides input from the physician perspective Monthly topics are identified by query volume, denial targets, PA suggestions from peer discussions, new coding guidelines, etc. and approved by the CDI supervisor If needed, CDI, PA and Coding specialists meet to review final edits prior to presentation/distribution Goal: 1 page, concise review, high yield, easily digestible
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CDI Tip Sheets – Past Topics
Query Types (Clinical Validation, Additional Diagnosis, Abnormal Result, Conflicting Dx, etc.) Clinical Validation Queries Alcohol Abuse/Dependence/Withdrawal Pneumonia Hypertension Heart Failure Clinical Validation Queries – doctors in a rush, gotten use to queries and being asked to document or redocument diagnoses without closely reading what the query is really asking
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CDI Tip Sheet - Example Clinical Validation Query - remind docs to take a closer look to make sure the clinical evidence/indicators are there to support a documented diagnosis. Docs used to queries to add dx to the medical record, but they have gotten really good at documenting sepsis, respiratory failure – maybe over diagnosing?
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CDI Tip Sheet - Example Used also to re-mind/reeducate on the “definition” of respiratory failure Doctors have gotten pretty good at documenting all the diagnoses they were missing and queried on in the past – but now ? Overdiagnosing/documenting without clinical indicators to support the documented diagnosis
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Successful Outcomes from a collaborative team
CDI program success meeting 100% CNE CDI metrics Physician Query reply rate within 72 hrs > 90% ( July high of 94%) Development of CNE clinical definition of Respiratory Failure. More word to do on denial focused diagnoses (Sepsis, Encephalopathy) Clinical Validation Education and Query Development to decrease audit risk Increased Physician and Leadership engagement for query reply from specialty providers (Surgical service lines) Private Attending query reply significantly improved with collaboration PA/CDI case reviews= increased diagnosis validation and query opportunity and identified possible LOC/LOS issues for PA from UR/CM perspective role.
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Challenges Physical Location of CDI staff
Are queries the most effective way to improve documentation? CDI vs. Coding queries Hospital metrics, Timely response Culture Change – Provider Buy In Professionalism – Query as part of the Medical Record Denials/Appeals Residents, Staff Turnover – ongoing education Time – PA role spread thin Sepsis (Clinical Validation) Provider buy in – surgical specialties, pathology queries post discharge, community physicians Denials/appeals – payers using different clinical criteria/definitions
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Challenges Do you have physician advisors at your institution?
How are you collaborating with your PA? Do you have suggestions or examples or initiatives that have worked at your institution? What challenges or issues are you wrestling with?
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PA Resources “The Physician Advisor’s Guide to Clinical Documentation Improvement” (ACDIS, 2014) American College of Physician Advisors – CDI Committee RAC Relief Google Group RACmonitor ICD10monitor “Report on Medicare Compliance” (HCCA)
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Questions? Thanks to Mary Behbehani, Jen Couri, and all of the CDI staff My mentor/former colleague, Dr. Jill O’Brien Thank you! Please feel free to contact me with additional questions. Laura G. Shawhughes, MD, FHM Physician Advisor to Utilization Review, Care Management, and CDI Hospitalist x31420 (Desk) (cell)
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