1. 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

2. 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

3. 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

4. 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 . . .

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

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

7. CMS Individual Treatment Plan (ITP)
The Centers for Medicare & Medicaid Services (CMS) 42 CFR and 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.”

8. 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

9. 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

10. 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?

11. 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

12. 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

13. 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

14. 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

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

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

17. 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)

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

19. Examples of MD review/signature

20. 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

21. Access to Telemetry Seat license

22. VersaCare GO Improvements

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

25. LSI
Contacted LSI without a response

27. AEMR Physician Signature TASK

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

29. AACVPR EXAMPLE ITP

30. PSYCOSOCIAL EXAMPLE

31. Your Programs ITP Look at your program ITP
Does my ITP have the key elements
AACVPR checklist for Cardiac and Pulmonary

33. 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

34. 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

37. Almost all registry information can be entered from telemetry system.

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

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

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

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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%

48. 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%

49. 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. 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!

50. QUESTIONS & DISCUSSION
THANK YOU
QUESTIONS & DISCUSSION

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