1. CYPRESS COLLEGE LONG TERM CARE & THE HEALTH INFORMATION PROFESSIONAL

2. 4 PRESENTED BY Khaleelah Wagner, RHIA Training Coordinator, AHIS A nderson H ealth I nformation S ystems, I nc. 940 W. 17 th Street, Suite B Santa Ana, California 91706 Phone 714-558-3887 Fax: 714-558-1302 Email: khaleelahwagner@hotmail.com or office@ahis.netkhaleelahwagner@hotmail.com office@ahis.net

3. 5 DATE & LOCATION  September 21, 2012  Cypress College Italic = HIM Student Task

4. 6 AHIMA DOMAINS  Identify:  Health Information Systems items for a Long Term Care Facility  The rules and regulations and how you stay “in touch with regulations”  Quality assurance and improvement systems and will practice documentation review  Health information systems and tasks for the HIM Department  HIM consultant reports

5. 7 AHIMA DOMAINS -2  Assist in identifying a schedule for a LTC facility that includes change of condition  Review the Change of Condition Instruction and receive guidance to conduct onsite visit with an HIM Consultant  Present data both manual and verbal

6. 8 HOW SHOULD I DO IT?  Attend a presentation by the HIM Consultant in Long Term Care  Review the ppt. and the handouts  Practice one quality of documentation review and prepare for onsite assignment  Attend onsite assignment – Prepare a summary of the key points learned, identify compliance items and best practices

7. 9 EVALUATION CRITERIA 1.Attend the LTC presentation. Identify the most important item learned. 2.Identify key tasks and evaluation of HIM Department. 3.Make a written list of organizational items that would be the same if you were in acute hospital setting, clinic, etc.

8. 10 EVALUATION CRITERIA -2 4.Practice of change of condition in classroom setting – identify questions. Use those questions and prepare a one-page summary of the Change of Condition review done onsite with the consultant. 5.Conduct change of condition for 5 residents and tabulate results. 6.Evaluate disclosure logs, HIPAA review of facility.

9. 11 EVALUATION CRITERIA -3 7.Identify the schedule of the LTC – Health Information/Record Designee. Assess the completeness and determine if carried out timely and completely. Prepare a one- paragraph summary re: your thoughts re: scheduling process. 8.Evaluate audit grid, evaluate if carried out; trend one or two of findings from audits for presentation to QA.

10. 12 EVALUATION CRITERIA -4 9.Prepare a summary of onsite visit with consultant that describes the results of the onsite visit and present the findings that identifies “system issues” and Best Practices.

11. 13 TASKS – ACTIVITY 1. Attend the LTC presentation. 2. Prepare a one paragraph summary of the most important item learned. 3.State the HIM – LTC common system/report by consultant. 4.Identify tasks in the LTC facility – HIM/Record Department that would be the same as an acute hospital setting, clinic, etc. **(have the list prepared prior to consult visits)**

12. 14 TASKS – ACTIVITY -2 5.List items to be evaluated in an LTC HIM Department. 6.Conduct Change of Condition for 4 residents and tabulate results. 7.Identify the HIM/Record Designees’ last two Change of Condition audits. Identify the deficient areas.

13. 15 TASKS – ACTIVITY -3 8.Review the schedule of audits/monitors from the HIM/Record Designee and review the Audit book re: timeliness and follow- up action. 9.Identify five items you learned and/or best practices you observed from the HIM/Record Consultant and/or the HIM/Record Designee’s work in the facility.

14. 16 EVALUATE – ACTIVITY 1. Attend the LTC presentation. 2. Prepare a one paragraph summary of the most important item learned. 3. Identify tasks in the LTC facility – HIM/Record Department that would be the same as an acute hospital setting, clinic, etc. **(have the list prepared prior to consult visits)**

15. 17 EVALUATE – ACTIVITY -2 4. Conduct Change of Condition for 5 residents and tabulate results. 5. Identify the HIM/Record Designees’ last two Change of Condition audits. Identify the deficient areas. 6. Review the schedule of audits/monitors from the HIM/Record Designee and review the Audit book re: timeliness and follow-up action.

16. 18 EVALUATE – ACTIVITY -3 7.Identify five items you learned and/or best practices you observed from the HIM/Record Consultant and/or the HIM/Record Designee’s work in the facility.

17. 19 AHIS OFFICE RESOURCES  Anne Soukup, Business Manager  Office 714-558-3887  Email bosslady@ahis.netbosslady@ahis.net  Monique Brennan, Consult / Contract Coordinator  Office 714-558-3887  Email monique@ahis.netmonique@ahis.net

18. 20 HIM CONSULTANTS  Khaleelah Wagner, RHIA  Training, Medicare, Coding, eHR Resource  All AHIS Consultants  Training – On site records evaluation, Medicare, Coding, eHR Resource

19. 21 ANDERSON HEALTH INFORMATION SYSTEMS  Anderson Health Information Systems, Inc. (AHIS) agreement:  Assists [facility/agency] in meeting the immediate and long range goals of quality improvement through consultation  Identifies the facility status, survey, quality measures

20. 22 RE-ENGINEERING OF THE HEALTH INFORMATION  AHIS has Health Information/Record Department tool for evaluation of the Department’s systems (see H.O. #1)see H.O. #1  Sample HI Department Evaluation Summary (see H.O. #2)see H.O. #2  [Facility/Agency’s] current Department evaluation tools, policies and procedures will be reviewed/recommendations made based on your input

21. 23 ANALYZE THE MEDICAL RECORDS SERVICES  Conduct an evaluation of each of the HI/Record Department’s systems and provide input as to the suggested approaches for HI/Records in coordination with the [facility/agency’s] designated staff

22. 24 ANALYZE THE MEDICAL RECORD SERVICES -2  Focus items will include: schedule, efficiency and integration into the overall Quality Assurance model (see H.O. #3)see H.O. #3

23. 25 PERFORMANCE MEASURES  Clinical Records Systems  Staff Performance Measures (see H.O. #4)see H.O. #4  Criteria represent a fairly complete outline of the duties and responsibilities of the HIM Dept staff  Written in outcome oriented terms  Tied to F-tags, Title 22 and other regulatory requirements and standards of practice in the field of HIM  Key items are introduced and trained and/or evaluated based on facility needs and the experience of the staff member

24. 26 PERFORMANCE MEASURES -2  Clinical Records Systems  Orientation and Training Checklist (see H.O. #5)see H.O. #5  Tracks progress of HIM Staff Training and Skills Mastery

25. 27 PROVIDE WORKSHOPS  For HI/Record Department and clinical staff based on identified needs (see H.O. #6)see H.O. #6  Example for records staff training – coding, new regulations/requirements, audit and monitoring systems, Daily Quality Assurance AKA Change of Condition etc. (see H.O. #5)see H.O. #5  Workshops for clinical staff may be provided based on agreed topics

26. 28 HEALTH INFORMATION/ RECORD MANUAL – AHIS  Will evaluate the current HI/Record Manual to determine if there are policies and procedures that need revision  Regulations that apply  Title 22 –State Regulations – Skilled Nursing  Federal Regulations by Center for Medicare and Medicaid Services – Omnibus Budget Reconciliation Act, OBRA – F- Tags

27. 29 REGULATIONS  Hospice, Dialysis, Sub-acute Medi-Cal Regulations  Joint Commission  OSHA  HIPAA  Fire and Life Safety  Disaster Planning  HITECH  Automated Clinical Record requirements

28. 30 HEALTH INFORMATION/ RECORD MANUAL – AHIS 2  Admission Monitor  Admission/7/14/21/30 Day Combined Monitor  Admission/7/14/21/30 Day Monitor  Admission/JCAHO Sub-Acute Monitor  Advance Directive/IHCI/Preferred Intensity of Care (PIC) Monitor  Behavior Drug Monitor  Bowel/Bladder Training Monitor

29. 31 HEALTH INFORMATION/ RECORD MANUAL – AHIS 3  Care Plan Monitor  Change of Condition/Daily Quality Assurance Monitor  Clinical Record Monitor  Combined Admission Monitor – see Admission/7/14/21/30 Day Combined Monitor  Diabetic Monitor  Dialysis Monitors  Hospice Monitor

30. 32 HEALTH INFORMATION/ RECORD MANUAL – AHIS 4  Intake/Output/Catheter Monitor  JCAHO Sub-Acute Monitor – see Admission/JCAHO Sub-Acute Monitor  Licensed Progress Note Monitor – Option I/II  Medicare/MDS Monitor  Medication Monitor  Minimum Data Set (MDS) Monitor  Nursing Assistant Flow Sheet Monitor

31. 33 HEALTH INFORMATION/ RECORD MANUAL – AHIS 5  Pressure Sore/Ulcer/Skin Conditions Monitor  Rehabilitation Monitor  Respite Care Monitor  Restrictive Device/Restraint Monitor Therapy Monitor  Treatment Monitor  Weight Monitor/Weekly Weight Monitor/Weight Log

32. 34 HEALTH INFORMATION/ RECORD MANUAL – AHIS 6  AHIS will offer recommendations for policy/procedure updates/changes when indicated and when new regulations or interpretations are identified. AHIS will advise on current changes in our own manual and assure [facility/agency] is informed

33. 35 ASSIST  With implementation of [facility/agency’s] policies and procedures, as applicable  Adapt the Medical Record Consulting processes that would compliment the Corporation’s policies and procedures  NEED TO BE KEPT CURRENT RE: _____________ CHANGES THAT AFFECT HIM/RECORD SYSTEMS

34. 36 CORPORATE QUALITY IMPROVEMENT PROCESS  Will collect information based on predetermined topics and criteria, provide a summary, conclusions and analysis for problem solving and follow up  Coordination will be carried out with the interdisciplinary team members

35. 37 CORPORATE QUALITY IMPROVEMENT PROCESS -2  AHIS will utilize [facility/agency’s] Quality Indicators / Measures for care documentation  [Facility/Agency] to provide guidance to AHIS in this area to assist with coordination  Sample Medical Records Compliance Study (see H.O. #7)see H.O. #7

36. 38 QI INDICATORS FOR DOCUMENTATION  AHIS = manual of Quality Improvement Documentation and Outcome indicators  Will assist in maximizing the use of eHR automated tools that are available  Informed Consent Monitor (see H.O. #8)see H.O. #8  DPH – AFL letter (see H.O. #9)see H.O. #9

37. 39 EXAMPLES OF REPORT & TRENDING  Consultant will review and explain  Sample consultant’s report (see H.O. #10)see H.O. #10

38. 40 COMPUTERIZATION  Will evaluate the record tasks related to computerized systems  eHR Checklist – partial (see H.O. #11)see H.O. #11  Document Management System Checklist – partial (see H.O. #12)see H.O. #12

39. 41 CONSULTANT COORD. & MTG. ATTENDANCE  AHIS will attend meetings as designated and arranged corporate-wide participation

40. 42 RESOURCES  Provide health information management resource materials

41. 43 HEALTH INS. PORTABILITY & ACCOUNTABILITY ACT  HIPAA Security Rule  Part of the Health Insurance and Portability and Accountability Act 1996  Administrative Simplification  Privacy Rule enforceable April 14,2003  Security Rule enforceable April 20, 2005

42. 44 HIPAA -2  Will provide the basic part of HIPAA as a part of the consultation services. AHIS has experts in the area of Transaction Code Sets, Privacy and Security

43. 45 HIPAA -3  Under separate agreement, AHIS can provide an outline for HIPAA assessment, training & implementation  Privacy  Transaction and Code Sets  Security  National Provider Number  Attachments  AND MORE---

44. HIPAA II  HITECH – deals with the privacy and security of electronic data, i.e., encryption 46

45. 47 NEWS & TRAINING

46. 48 OFFSITE ASSISTANCE & TRAINING  Some training maybe appropriate to be provided via Webinar  AHIS will provide Webinar training and/or offsite training via phone and instructional material  Can establish training for online computerization…if arranged

47. 49 OFFSITE ASSISTANCE & TRAINING -2  Webinar Schedule  Dates  TBD  Time  TBD

48. 50 MANUALS (Electronic/Copy)  Health Information / Record  Administrative  Quality Assessment / Indicator  Dialysis  Psychiatric  HIPAA

49. 51 QUALITY THROUGH CONSULTATION  Our intent is to enhance skills, reduce costs and increase efficiency  Find better ways of doing things  Increase automation  Assist to meet legal expectations, reduce risks  Assist with compliance  HAVE FUN!

50. 52 JOIN THE CONSULTING WORLD… IT’S FUN!