Ensuring Clinical Documentation Reflects Care and

32 

Loading....

Loading....

Loading....

Loading....

Loading....

Full text

(1)

Ensuring Clinical

Documentation Reflects Care

and

Ensuring Clinical

Documentation Reflects Care

and

© National Hospice and Palliative Care Organization, 2010

1

Meets Requirements

Meets Requirements

Joan Harrold MD MPH FACP FAAHPM

Presenters

Joan Harrold, MD, MPH, FACP, FAAHPM Medical Director/VP, Medical Services

Hospice of Lancaster County

jharrold@hospiceoflancaster.org Annette Kiser, MSN, RN, NE-BC

Director of Quality & Compliance Director of Quality & Compliance

Carolinas Center for Hospice & End of Life Care

(2)

Goals for Today’s

Program

Goals for Today’s

Program

Discuss documentation to meet the MedicareDiscuss documentation to meet the Medicare CoPs for comprehensive assessment and care planning

Describe tips to enhance documentation to meet the Local Coverage Determinations (LCDs) and illustrate eligibility

© National Hospice and Palliative Care Organization, 2010

3

( ) g y

Explain eligibility and documentation

requirements for the different levels of care under the Medicare Hospice Benefit

Assessment & Care Planning:

Compliance with CoPs

Assessment & Care Planning:

Compliance with CoPs

(3)

Admission, Assessments,

and Care Planning

Admission, Assessments,

and Care Planning

Election & consentElection & consent

Conduct & document initial assessmentConduct & document first comprehensive

assessment

Establish plan of care

U d t h i t

© National Hospice and Palliative Care Organization, 2010

5

Update comprehensive assessmentUpdate care plan

Conduct IDG meetings & coordinate care

Initial Assessment

Initial Assessment

§ 418.54 Condition of participation: Initial and comprehensive assessment of the patient. • IA must address immediate needs of the patient

and family

• IA forms the foundation of documentation to guide care

g

• Determines involvement of other disciplines in completing the Comprehensive Assessment

(4)

Comprehensive

Assessment

Comprehensive

Assessment

Must assess the following:

– Physical, psychosocial, emotional & spiritual needs – Nature & condition causing admission

– Functional status – Imminence of death – Medications

Bereavement needs

© National Hospice and Palliative Care Organization, 2010

7

– Bereavement needs

Assessment is a continuous process that drives updates to the plan of care

Updates to the

Comprehensive Assessment

Updates to the

Comprehensive Assessment

Update CA every 15 days and as needed with significant changes in condition or level of care

Address interventions in plan of care Disciplines must visit during the 15-day

timeframe based on need

(5)

From Comprehensive

Assessment to Plan of Care

From Comprehensive

Assessment to Plan of Care

§ 418.56 Condition of Participation:

§

p

Interdisciplinary group, care planning,

coordination of services.

• CMS considers the plan of care the most important document in hospice care

• Using data from assessments develop & update

© National Hospice and Palliative Care Organization, 2010

9

Using data from assessments, develop & update the plan of care.

• Must be interdisciplinary

Plan of Care

Plan of Care

Plan of care must address:

– Interventions to address symptoms – Scope and frequency of services – Measurable outcomes

– Drugs, treatments, supplies and DME – Patient or representative’s level ofPatient or representative s level of

understanding, involvement, and agreement with the plan of care

(6)

Plan of Care

Plan of Care

IDG should use the plan of care as a tool

– RN begins documentation of plan of care based on findings from the Initial Assessment & consults with others

– IDG members add to and update as the Comprehensive Assessment is completed – Base plan of care on patient-specific needs

© National Hospice and Palliative Care Organization, 2010

11

• No “cookie cutter” documentation.

• If using electronic records, free text on each note to individualize documentation

Updates to the

Plan of Care

Updates to the

Plan of Care

IDG must review and revise the plan of careIDG must review and revise the plan of care at least every 15 days

Updates are necessary as conditions and needs change

Must address progress toward goalsShould guide interventions at each visitShould guide interventions at each visit

(7)

Documentation:

Important Points

Documentation:

Important Points

Documentation should be:Authentic

Concise (more is not always better)Objective

Comprehensive but pertinent

© National Hospice and Palliative Care Organization, 2010

13

Comprehensive, but pertinentConsistent

Timely

Strategies for Success

Strategies for Success

Ensure that there are no blanks inEnsure that there are no blanks in pertinent areas of forms

Ensure problems are addressed timelyDocument communication among IDG

and with attending physician

Show ongoing coordination of care withShow ongoing coordination of care with

(8)

Strategies for Success

Strategies for Success

Using goals from plan of care, document g g p ,

outcomes in assessments

Ensure physician orders are updated timelyConsistently update medication profile Show patient and family involvement in

planning care

© National Hospice and Palliative Care Organization, 2010

15

Ensure that adequate discharge planning has occurred and is documented

Referrals, communication, transfer of information

Documentation of

Prognosis

(9)

Admitted for end stage cardiac disease

Paint the Picture

© National Hospice and Palliative Care Organization, 2010

17

Admitted for end stage cardiac disease. Poor response to standard treatment.

Desires palliative care.

(10)

Admitted for end stage cardiac disease. Poor response to standard treatment. Desires palliative care. Is NYHA

Class IV with significant symptoms of angina at rest & inability to carry on any physical activity w/o discomfort.

Paint the Picture

Ejection fraction of ≤20%, significant ventricular arrhythmias, & unexplained syncope episodes.

© National Hospice and Palliative Care Organization, 2010

19

Documentation Using LCDs

Documentation Using LCDs

Documentation needs to address:

– Impairments in function & structure – Activity limitations

– Participation restrictions – Secondary diagnoses – Co morbid conditions

(11)

Documentation Using LCDs

Documentation Using LCDs

Address the patient’s activity level, self p y care, communication, and mobility

Give a historical perspective of what the patient’s ability was in the previous time period and then document current status

BUT REMEMBER…

© National Hospice and Palliative Care Organization, 2010

21

Decline eligibility

Decline necessary or sufficient

Documentation Using LCDs

Documentation Using LCDs

Use specifics to show the extent of the symptoms and limitations

symptoms and limitations

Use the term “as evidenced by” to link prognosis to specific findings

Include symptoms such as wt loss, decubitus ulcers, and edema

Explain unusual or potentially misleading p p y g findings

Co morbid conditions such as CHF, COPD and diabetes affect prognosis

(12)

Functional Assessment Tools

Functional Assessment Tools

PPS

Validated in palliative careBe sure to use correctly

ECOG

Cancer

Karnofsky

© National Hospice and Palliative Care Organization, 2010

23

Cancer

FAST

Dementia

Functional Assessment Tools

Functional Assessment Tools

Mortality Risk Index Score and the

Flacker-Ki l M t lit A t

Kiely Mortality Assessment

NH residents with advanced dementiaRetrospective cohort studies

Minimum Data Set (MDS) information

Critical: Must use tools correctly!

htt // h d /ELNEC/ df/P lli ti C AJN15

http://www.aacn.nche.edu/ELNEC/pdf/PalliativeCareAJN15.p

(13)

Focused Quality

Documentation

Focused Quality

Documentation

Examples of focused quality documentation:Documenting limits to daily activities of living for aDocumenting limits to daily activities of living for a

patient with end-stage heart disease.

Describing the extent of oxygen for a patient COPD

and shortness of breath.

Stating facts with objective information:

– “Clothing no longer fits due to weight loss” “Sl i XX b f h f d ”

© National Hospice and Palliative Care Organization, 2010

25

– “Sleeping XX number of hours of day”

– “Pain is severely limiting activities of daily living”

Comparative Documentation

Comparative Documentation

Comparative documentation:

Contrasts the patient’s present condition toContrasts the patient s present condition to

his/her prior condition

Individualizes patients by focusing on their

trajectory of decline

Presents specific information, not

generalizations

O k t ti ½ ¾ f 2 l

One week ago, pt was eating ½ - ¾ of 2 meals per day. Now eating only ¼ of 1 meal each day.

(14)

Weak Documentation

Syndrome

Weak Documentation

Syndrome

Does not paint a picture of the patient.

W k d t ti d / h

Weak documentation uses words/ phrases like:

– Stable – No change – Doing well

Slow progressive decline

© National Hospice and Palliative Care Organization, 2010

27

– Slow, progressive decline – Appears to be losing weight

It is all in the detail!

Documentation to Paint the

Picture

Documentation to Paint the

Picture

Functional Decline

“I bilit t b l t i d d tl ” ld

“Inability to ambulate independently” could mean:

– Needs help of one caregiver (supervision, guidance, support)

– Needs assistance of two caregivers

– Needs assistance of two caregivers and assistiveNeeds assistance of two caregivers and assistive devises

(15)

Documentation to Paint the

Picture

Documentation to Paint the

Picture

Example - Functional Decline

Weak “ Impaired gait and mobility”

documentation example p g y Strong documentation example “Requires a walker to

ambulate due to leg weakness and unsteadiness Maximum

© National Hospice and Palliative Care Organization, 2010

29

example and unsteadiness. Maximum

distance is 10-15 feet.”

Documentation to Paint the

Picture

Documentation to Paint the

Picture

Functional Status Changes

“Inability to dress self” is vague and could mean:

– Patient is physically unable to dress self – Patient may be able to assist dressing self – Patient is physically capable, but is behaviorally

unable to comply with dressing activity unable to comply with dressing activity – Patient is bedbound and cannot dress self – Patient refuses to dress self

(16)

Documentation to Paint the

Picture

Documentation to Paint the

Picture

Example - Functional Status Changes

Weak “Patient unable to dress self”

documentation example

Strong

documentation example

“Patient agitated today and refused to assist with dressing self Patient usually able to

© National Hospice and Palliative Care Organization, 2010

31

example self. Patient usually able to

assist with shirt when provided verbal cues.”

Documentation to Paint the

Picture

Documentation to Paint the

Picture

Weight Loss

“P ti t l i i ht” ld

“Patient losing weight” could mean:

– Patient is eating less than before. – Patient is not eating at all.

– Patient has lost two pounds. – Patient has lost twenty pounds.

Patient appears cachectic – Patient appears cachectic

(17)

Documentation to Paint the

Picture

Documentation to Paint the

Picture

Example – Weight Loss

Weak “Patient is losing weight”

documentation example

Strong

documentation example

“Patient’s clothes appear looser. Food intake decreased by 50% in the last week and he has lost

© National Hospice and Palliative Care Organization, 2010

33 p

interest in his favorite foods. MAC decreased by ¾ inches.”

Vague Statements

– “Continues slow decline”

Documentation Weaknesses

Documentation Weaknesses

– Continues slow decline

– “Remains hospice appropriate” – “Needs more care

Inconsistent Documentation

– Nursing notes state: non-ambulatory Chaplain notes state: walked around hall

Ad i i f i t ith t

– Admission for pain management without documentation of interventions

– “First-line” documentation (nurse, aide, SW, volunteer) does not match “second-line” documentation (IDG notes, summaries)

(18)

Documentation

of Levels of Care

Documentation

of Levels of Care

© National Hospice and Palliative Care Organization, 2010

35

Documentation –

Levels of Care

Documentation –

Levels of Care

Documentation must support level of careDocumentation must support level of care billed or payment can be reduced to

Routine Home Care

Reason for higher level of care must be noted – what prompted the change?

All levels require ongoing documentationAll levels require ongoing documentation to show the patient is appropriate for

(19)

Documentation: Routine

Home Care

Documentation: Routine

Home Care

Must document continued eligibility to g y support recertification

Need to explain symptom management versus resolution of symptoms – give creditDocument all interventions required to

maintain comfort – medications, spiritual

© National Hospice and Palliative Care Organization, 2010

37

, p

support, other non-pharmacologic measures

Levels of Care – Inpatient

Respite

Levels of Care – Inpatient

Respite

§ 418.204 Special coverage requirements. (b) Respite care.

– (1) Respite care is short-term inpatient care provided to the individual only when necessary to relieve the family members or other persons caring for the individual.

– (2) Respite care may be provided only on an – (2) Respite care may be provided only on an

occasional basis and may not be reimbursed for more than five consecutive days at a time.

(20)

Levels of Care – Inpatient

Respite

Levels of Care – Inpatient

Respite

No regulation on frequency of useNo regulation on frequency of use

Be sure reason for respite care is notedFrequent use may send red flags to

RHHI/MAC

Scheduled (same time every month) can also raise concern

© National Hospice and Palliative Care Organization, 2010

39

also raise concern

Levels of Care –

Continuous Care

Levels of Care –

Continuous Care

§ 418.204 Special coverage requirements. • Nursing care may be covered on a continuous basis up

to 24 hours a day during periods of crisis as necessary to maintain an individual at home.

• May use homemaker and/or hospice aide services to supplement, but nursing care must be provided for more than half of the period of care

(21)

Levels of Care –

Continuous Care

Levels of Care –

Continuous Care

Documentation for Continuous Care:

• Describe the crisis in detail and the patient/family’s desire to remain at home

• All staff should document their time on a 24-hour log to show a minimum of 8 hours of care in a 24 hour period in order to bill for CHC.

• Hourly staff notes are preferred to best document crisis.

© National Hospice and Palliative Care Organization, 2010

41

• Establish a new POC detailing the problems, interventions and expected outcomes. Staff visit notes should include the issues identified in the POC.

Levels of Care –

Continuous Care

Levels of Care –

Continuous Care

Provide details in documentation

Document all previous attempts to relieve symptoms

– Example: Pain unrelieved despite increase in scheduled dose and multiple breakthrough doses of pain medication

Describe frequency, severity, intensity and associated

symptoms

– Example: Grimacing with frequent chest pain; shortness of breath more pronounced with coughing

more pronounced with coughing

Document all interventions utilized to relieve patient’s

discomfort

– Example: Medications, oxygen, positioning, massage, bathing, music, lighting, verbal support, nebulizers, fans, suctioning, etc.

(22)

Levels of Care –

Continuous Care

Levels of Care –

Continuous Care

Record all teaching to the patient, family orRecord all teaching to the patient, family or caregiver

Document coordination with attending physician

Physician order for CHC must be in placeShow collaboration among team members

© National Hospice and Palliative Care Organization, 2010

43

Show collaboration among team members

Levels of Care –

General Inpatient

Levels of Care –

General Inpatient

General Inpatient (GIP) may be appropriate p ( ) y pp p for pain control and symptom managementNot to be used for caregiver breakdownMust require an intensity of care directed

towards pain control and symptom

management that cannot be managed in any other setting

other setting

(23)

Levels of Care –

General Inpatient

Levels of Care –

General Inpatient

Documentation for GIP:

D ib th ti t‘ diti d th ti t/f il

• Describe the patient‘s condition and the patient/family problems in detail.

• Explain clearly why the issues cannot be managed in the home setting, or at routine level of care if in a facility.

• Daily staff visits are appropriate in all settings so the

h i i t i f i l t f

© National Hospice and Palliative Care Organization, 2010

45

hospice can maintain professional management of the patient

• Document the coordination of care between the hospice and the facility providing GIP.

Levels of Care –

General Inpatient

Levels of Care –

General Inpatient

Documentation for GIP:

• POC should be revised detailing the problems, interventions and expected outcomes.

• The staff progress notes should include the issues identified in the POC

(24)

Strategies for Success

Strategies for Success

Continuous home care and GIP

Ensure that documentation addresses the symptomsEnsure that documentation addresses the symptoms

that led to the crisis and the need for a higher level of care.

Provide & document discharge planning from the

beginning of the level of care change.

When the patient stabilizes, move the patient to

routine home care level

© National Hospice and Palliative Care Organization, 2010

47

routine home care level.

Conduct medical record review at specified times to

ensure criteria are met.

Remember: Caregiver breakdown is not a reason for GIP (Final Rule of the 2008 Hospice Wage Index)

(25)

Case Study #1

Case Study #1

84 year old male

Diagnosis: Alzheimer’s DementiaDiagnosis: Alzheimer s Dementia

Co morbidities: Renal insufficiency, Irritable bowel

syndrome, Delirium

Difficulty swallowing

Wife reports 30 lb loss in the last 6 monthsPant size changed from an XL to Medium Holds food and medications in his mouth

© National Hospice and Palliative Care Organization, 2010

49

6/24/09 Wife reports change in diet to softer foods

because of his dysphagia

7/2/09 MD note states Mr. Doe is high risk for

aspiration

Case Study #1 (Cont.)

Case Study #1 (Cont.)

Incontinent bowel and bladder

R i i t ith d i b thi

Requires max assistance with dressing, bathing,

toileting, and grooming

Requires up to three showers/day to manage

incontinence and diarrhea

Having hallucinations and restlessness“Getting meaner” per wife

Yelling out during the nightg g gSafety risk

MD discontinued Coumadin because of “given life

expectancy” and safety concerns with potential falls

(26)

Case Study #2

Case Study #2

83 year old female

Diagnosis: Cerebrovascular Accident (CVA)Diagnosis: Cerebrovascular Accident (CVA)Co morbidities: COPD, Chronic bronchitis,

Depression, Anemia

Dependent on facility staff for all ADLsIncreased agitation and pain – meds titratedIncreased difficulty taking liquids and food

© National Hospice and Palliative Care Organization, 2010

51

y g q

Lethargic at times, refusing medications, and combative

6/6/09 Congested, aspiration suspected, more wheezing, mouth droop, right hand weakness

Case Study #2 (Cont.)

Case Study #2 (Cont.)

6/08/09 O2 Sat 82% on 2.5 lpm, rate increased6/24/09 Hospice medical director consulted due6/24/09 Hospice medical director consulted due

to unmanaged pain

– Roxanol increased to 15 mg q 2 hours prn • 6/30/09 periods of apnea and gurgling

– Lethargic, increased congestion, rales bilaterally – Fever of 101.4 degreesg

(27)

Documentation Examples

Documentation Examples

Summary Note in Medical Record

– Alert w/confusion. Fair appetite with recent wt loss. Recent falls. Dyspnea at rest. Changes in activities. • Stronger Note

– Alert. Confused, oriented to person only. Fair appetite. Recent wt. loss. Current wt. 104, previous wt. 107 one month ago Recent falls due to unsteady gait and OOB

© National Hospice and Palliative Care Organization, 2010

53

month ago. Recent falls due to unsteady gait and OOB w/o assist. Dyspnea at rest, 02 prn. Withdrawing from activities, refuses to go to dining room.

More Documentation

Examples

More Documentation

Examples

Note on Physician’s Plan of Care:

– Patient doing well at this time. Vital signs stable.Patient doing well at this time. Vital signs stable. Able to ambulate in home. Appetite good.

Maintaining weight. Complaints of nausea relieved with antiemetics and diet. Pain controlled to patient’s satisfaction. • Important Data Omitted:Important Data Omitted:

– PRN pain med increased recently. Had

increased N/V necessitating change in diet and increased use of antiemetic. Decreased intake to less than 2 meals/day

(28)

Please, Sir,

I want some more.

Please, Sir,

I want some more.

More cases

More examples

More questions

© National Hospice and Palliative Care Organization, 2010

55

Documentation Pearls

Documentation Pearls

Gather a comprehensive, useful historyAssess the patient

Overall and based on the diagnoses

Describe the patient

Overall and based on the diagnoses

Use prognostic tools accuratelyp g y

(29)

Documentation Pearls

Documentation Pearls

Ensure the Plan of Care is more than “report”

In IDT and in documentation

Train SWs, chaplains, and aides to document pt appearance on every visit

Especially differences and changes

© National Hospice and Palliative Care Organization, 2010

57

Ensure that information in summaries and worksheets is supported by visit

documentation.

Hospice Documentation

Mantra

Hospice Documentation

Mantra

Documentation to support

the terminal illness is an

every day, every note

practice

practice.

(30)

NHPCO’s Regulatory Team

NHPCO’s Regulatory Team

Judi Lund Person

Vice President, Compliance and Regulatory Leadership

Jennifer Kennedy

 Regulatory & Compliance Director  NHPCO Regulatory Committee

M b f ll h i h id

© National Hospice and Palliative Care Organization, 2010

59

 Members are from all over the country with a wide variety of experience

Regulatory Assistance

Regulatory Assistance

Contact NHPCO’s Regulatory Department:

Regulatory Assistance Line: 703-647-8516

Regulatory Assistance Line: 703-647-8516

Email: regulatory@nhpco.org

Web: www.nhpco.org

 Click on the NHPCO Regulatory & Compliance Center.

(31)

Resources

Resources

• Conditions of Participation –

http://edocket.access.gpo.gov/2008/pdf/08-1305.pdf • Interim Interpretive Guidelines –

http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/ SCLetter09-19.pdf

• Local Coverage Determinations –

http://www.cms.hhs.gov/mcd/index_article_bycontractor_criteria. asp

© National Hospice and Palliative Care Organization, 2010

61

• Cahaba GBA – Hospice Resources –

https://www.cahabagba.com/rhhi/education/materials/quick_hos pice.htm

Bibliography

Bibliography

• CMS. (1983, DEC 16). § 418.202 Covered services.

Retrieved May 2009, from Centers for Medicare & Medicaid S i

Services:

http://edocket.access.gpo.gov/cfr_2008/octqtr/pdf/42cfr418.20 2.pdf

• CMS. (2009, APR 24). CMS 1420-P.Retrieved May 2009, from Centers for Medicare & Medicaid Services:

http://edocket.access.gpo.gov/2009/pdf/E9-9417.pdf

• CMS. (2004, DEC 3). Medicare Benefit Policy Manual-Chap 9.Retrieved May 2009, from Centers for Medicare & Medicaid S i

Services:

http://www.cms.hhs.gov/manuals/Downloads/bp102c09.pdf • CMS. (2005, NOV 22). Subpart B. Retrieved May 2009, from

NHPCO:

(32)

Bibliography

Bibliography

• Marrelli, T. A. (2005). Hospice and Palliative Care Handbook: Quality, Compliance, and Reimbursement, Second edition.

/

Philadelphia: Elsevier/Mosby.

• MedPAC. (2007, NOV 8). Retrieved May 2009, from

http://www.medpac.gov/transcripts/1107_hospice_access_JM _pres.pdf

• OIG. (2008, March 31). Hospice Beneficiaries' Use of Respite Care.Retrieved May 2009, from Health and Human Services: http://oig.hhs.gov/oei/reports/oei-02-06-00222.pdf

© National Hospice and Palliative Care Organization, 2010

63

• OIG. (2009, September). Medicare Hospice Care for

Beneficiaries in Nursing Facilities: Compliance with Medicare Coverage Requirements. Retrieved March 2010 from Health & Human Services: http://oig.hhs.gov/oei/reports/oei-02-06-00221.pdf

Figure

Updating...

References

Updating...

Related subjects :