Posts Tagged ‘education’

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Educational Videos: Face-To-Face Encounter

Monday, July 25th, 2011

Face To Face Encounters CY2011 Clinical Compliance

CMS was mandated by the Affordable Care Act to provide this encounter. You will be able to look on page 296 on the Final Rule to read the depth of it. But, essentially what CMS is stating is that the physician must see the patient within 90 days prior to the admission in a home health agency.  And that means that also, in seeing that patient for that face-to-face encounter, that diagnosis or that reason for seeing that patient must be directly related to the home health referral.  Now, if they don’t see them within 90 days prior to they must see them within 30 days after admission.

As of December 10, 2010 CMS is sending out a notice to the physician regarding this face-to-face encounter information.  So the home health agencies are going to have to do a lot of education with physicians.  It also requires then, that the physician provide this attestation that they have completed this face-to-face encounter, and it has to be attached to/or a part of the POC.

At Select Data we’ve created a documentation of the face-to-face encounter tool click here to download a copy of this form:  http://www.selectdata.com/wp-content/uploads/2010/12/DocumentationFacetoFaceEncounter.pdf

Summary

The face to face encounter must occur within the 90 days prior to the start of care, or within the 30 days after the start of care. While the long standing requirement for physicians to order and certify the need for home health remains unchanged, this new requirement assures that the physician’s order is based on current knowledge of the patient’s condition

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Posted in CMS, CMS Guidelines, CY2011, Educational Videos, Face to Face Encounters, Home Health, Medicare, OASIS-C, Teaching/Education, Tools | No Comments »

Adult Learning Principles: Influencing Patient Outcomes through Education

Monday, July 25th, 2011

Understanding the Principles of Adult Learning can assist clinicians to improve patient learning and can result in improved clinical and quality patient outcomes. The brain governs more than memory alone. The brain and mind allow humans to cope with stimuli, creativity, immune responses, language, reasoning, planning, analyzing, and dreaming. It allows the human to feel a myriad of emotions, store experiences, while shaping the capacity to alter behavior and thinking through awareness expansion and critical reflection. The brain is, according to Caine, 2009) biologically designed to learn and learning is a matter of building rich neural networks, but how? Each individual learns a bit differently than their neighbor yet there are 12 strong underlying principles:

  1. All learning is physiological
  2. The brain/mind is social
  3. The search for meaning is innate
  4. The search for meaning occurs through patterning
  5. Emotions are critical to patterning
  6. The brain/mind processes parts and wholes simultaneously
  7. Learning involves both focused attention and peripheral perception
  8. Learning always involves conscious and unconscious processes
  9. There are at least two approaches to memory

10.  Learning is developmental

11.  Complex learning is enhanced by challenge and inhibited by threat associated with helplessness

12.  Each brain is uniquely organized

(Caine, Caine, McClintic, and Klimek, 2009 and Caine and Caine, 1994)

The principles assist us, as clinicians, leaders, managers, to understand that there are several different processes involved. Yet, we all tend to print up some teaching materials and have the nurses leave them with the patient “for reinforcement”. Many people believe, “If I told you, you have had education”.

The best selling education books, Tellin’ ain’t Trainin’ (Stolovitch, 2011) and Sit and Get Won’t Grow Dendrites (Tate, 2004) help us to better understand Brain-Compatible strategies. Some patients may learn well with the written word, while others are spatial and auditory learners.

Future Select Data articles will explore the constructs further but here is one sample activity.

If a patient treatment has changed or is being compared or contrasted, consider using a Venn Diagram. Draw two circles that have an overlapping center like below:

Information that is overlapping in the center is that information that is alike. The information outside that space identifies differences.

A spider chart with the new treatment or new topic in the center of a circle should be drawn. Then draw “spider-like” lines coming out of the circles. These can be goals to be achieved. As the patient articulates each goal they desire to achieve, linking it to the treatment or med in the center of the chart dramatically diagrams the importance of that treatment or medication.

A pie chart can be used to classify the careplan components. Breakdowns can make the plan seem more manageable. Each component or “piece” of the pie can appear to be managed at a setting, much like a tasty lemon pie.

We will look at this topic with more depth in the future. There is a PowerPoint Presentation on the topic of Learning and Brain Compatibility that is based on the Twelve Adult Learning Principles. This presentation was presented at two state association conferences and it could be shared with clinicians.

Having trouble downloading Learning and Brain Compatibility PowerPoint?

right click on the link > Then choose “Save Target As” > “Save”

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Posted in Home Health, Patient Survey, Teaching/Education | No Comments »

Educational Videos: M1010 OASIS Assessment

Monday, July 11th, 2011

Coding Compliance Completing The M1010 OASIS Assessment

If a patient was discharged from an inpatient facility in the past 14 days, then: M1010 needs to be completed.  If applicable then M1012 and M1016 needs to be completed.  Also please note that M1010 and M1016 are only to be used for diagnoses codes, and M1012 are only for procedure codes.

Most importantly, OASIS Guidelines state that “V” and “E” codes are not to be used in section M1010 and M1016.  Some examples of common V code wordings are:

  • Aftercare
  • Attention to
  • History of
  • Status of
  • Fitting and adjustment of
  • Long term use of a drug
  • Other physical therapy
  • Therapeutic drug monitoring
  • Encounter for suture removal

If there are orders and goals related to these v codes please note they must be used in the correct section in M1020 and M1022 only.
It is important to document why a surgery or procedure was performed.  Many times we don’t have a history and physical or an operative report.

Was there a fracture, osteoarthritis, or neoplasm?

It is imperative to know why the according procedure was performed as it will impact the coding process.

This will help to expedite your coding process and ensure that you are using the most correct codes possible.

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Posted in CMS Guidelines, Compliance, Educational Videos, Home Health, ICD9-CM Coding, Medicare, OASIS-C | No Comments »

Office of Civil Rights (OCR) and HIPAA

Friday, June 24th, 2011

At a recent HIPAA seminar, the Office of Civil Rights (OCR) identified that they are evaluating HIPAA audit models. The present model requests certain records, reviews, cites errors/omissions and calls for corrective action. Privacy and security of Protected Health Information (PHI) is of primary concern especially in light of social media and mandated Electronic Medical Record creation in healthcare.

Presently, organizations are reviewing their privacy and security programs. How compliant is your Compliance and HIPAA programs? Perhaps you should conduct a gap analysis.

Getting started

To conduct a review and analysis of your agency’s compliance program you must know if your program covers the required elements:

  • Complete written policies and procedures
  • Designation of a Corporate Compliance Officer
  • A training and education program regarding confidentiality, commitment to preventing fraud and abuse, and other elements of compliance
  • Communication lines to the Corporate Compliance Officer
  • Identification of compliance risk areas and a plan to mitigate risk
  • Responding to non-compliance issues
  • Policy of non-intimidation and non-retaliation against employees who identify non- compliance
  • Disciplinary policies regarding non-compliant behavior

Consider the re-signing of the organization privacy policies annually by employees. This act can become a reminder of the importance of privacy and confidentiality in the organization. Identify who will conduct regular internal audits. Conduct this present review and analysis as if it were a surveyor visit, only this time, you get to be the surveyor.

Audit the HIPAA Program

As part of the compliance audit process, be certain to evaluate the HIPAA program. Are there plan objectives? Is an audit and monitoring system in place? Who has the responsibility for completion?  Identify the audit checklist. Is it inclusive? Is there a documentation process to record findings?

Are there annual goals to improve on privacy and security in the organization? How are audit findings reviewed? How does follow up occur?

The Audit

The following checklist should be considered a guideline (not necessarily all inclusive) and would require agency individual application.

  • Is the Compliance plan, particularly the HIPAA portion, in compliance with the HIPAA Security Rule? Has an assessment been conducted regarding environmental/operational impact on PHI?
  • Can the organization identify how it protects access to information? Is there a policy re access to PHI and “need to know?”
  • Can patients obtain their information in a timely manner? Can information be provided in electronic format, as required by HITECH. Has a security risk analysis been conducted?
  • Have security measures been implemented to reduce the risk? What are those measures?
  • Have the Compliance, Privacy, and Security risk analysis available for an OCR audit or questions from an accrediting surveyor.
  • At the very least, for privacy, look at the following:
  • Can patients/guests view PHI? See computer screens? Is there any place on the premises that PHI is readily available?
  • Is PHI posted on wall boards where those who have “no need to know” have access to the info?
  • Is PHI left on desks? Are computer screens left on when the user steps away?
  • Are recycling bins used? Is there a BAA with that recycling vendor?
  • Are all BAAs in place with all vendors and in compliance with HIPAA HITECH?
  • Communication:
  • Is PHI faxed? Is there a confidentiality/disclosure statement on each fax coversheet?
  • Does the online system require level logins?
  • Are screen savers activated in a short period of time?
  • Are emails used with PHI? Are the emails encrypted?
  • Are phone calls used to give and receive PHI? How is the individuals receiving or giving info identified and confirmed?
  • Responsibility:
  • Can each employee identify when PHI enters their area of responsibility?
  • Who handles PHI? Where is it stored? What is the back up process? What is the length of storage? Is it secure? How do you know it is secure?
  • Have all employees been trained in privacy? Has security at the specific employee level been conducted? Is compliance training mandatory? Is it conducted annually?
  • Is there a protocol for new employees? Is there a protocol regarding confidentiality upon employee departure?
  • Are BAAs in place holding contractors accountable for PHI protection?  Have you seen their policies, procedures, and processes?
  • Reports:
  • Are reports created that have confidential information? Are they circulated to only those with “need to know” rights?
  • Have the reports been reviewed to reduce the amount of sensitive information, if possible? Could de-identified information be substituted?
  • Is transmission of report information secure?
  • Security:
  • Is there a written policy to protect PHI? Is there policies re computer screens in view with PHI? Are there policies re passwords?
  • Are there policies re storage of data and how backup tapes and storage devices are accounted for and monitored?
  • Has every station been evaluated as to protection of PHI and view and accessibility to information by those who do not have clearance to that station.
  • Technical Security:
  • Does the technical team periodically verify the technological security is in place and working appropriately? Can the technical team identify if an unauthorized user has accessed PHI? What safeguards are in place to protect against unauthorized access?
  • Is technology in place to verify identity of users?
  • Are passwords and IDs routinely changed per a schedule?

OCR Investigations and Review:

If you have a breach that triggers an investigation by OCR, be certain to promptly respond as to what happened, how it happened, what was done to mitigate outcomes, and what has been implemented to prevent a future occurrence.  Be certain to identify the fact you have a full Compliance Program in place. Identify that all employees have routine education re Compliance and HIPAA.

If documents are requested, your counsel may request confidentiality for those documents being sent to OCR. Create and maintain a log of events, complete with dates, times, and people involved throughout the entire investigation process. Save all electronic documents. Keep statements by all employees involved in the incident and the investigation. Obtain counsel’s advice as to phone conversations with OCR as written correspondence maintains an investigation trail.

Focus on internal compliance. If there is a HIPAA breach, there must be remediation/education regarding the process and the prevention of a reoccurrence.

Summary:

  • Keep your plan objectives current.
  • Identify who is responsible for the audits and establish times and how findings will be transmitted.
  • Have corrective action plans in place.
  • Include documentation of audits, results, and remediation/corrective action/education
  • Report findings to the BOD, leadership, and counsel.
  • If there is an OCR audit/investigation have a team established to quickly respond, pull data, analyze, and report.
  • Have an ongoing risk analysis performed as specified by policy. Be certain the risk analysis encompasses the technical requirements of the Security Rule.
  • Be certain the Risk Analysis is well documented. Be certain the plan for mitigation of any adverse findings is in place.

Like the clinical documentation rule, “if it wasn’t documented you did not do it,” so it is true here also. Document each step of the plan. If ever there is an audit, the fact a full compliance plan is in place in your agency including a HIPAA Privacy and Security review, can speak volumes about you and your organization.

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Posted in Compliance, HIPAA, Legislation | No Comments »

Utilizing Best Practices for Patients with Heart Failure

Thursday, May 19th, 2011

Best practices are expected when providing quality home health care to heart failure patients.  According to the American Heart Association, there are over 5 million cases of heart failure (HF) in the US, with an average 500,000 cases, diagnosed annually. It ranks as the primary and secondary diagnoses for all hospitalizations over the age of 65. The financial burden is in excess of $40 billion, annually, in direct and indirect costs.
Heart failure patients are among those most visited in home health care and among the five most prevalent diagnoses of homecare patients (per VNAA Chronic Care Clearinghouse). A cardiac assessment is often the primary nursing skill for homebound patients diagnosed with heart failure and involves specific knowledge of nutrition, pharmacotherapy, exercise, coping skills, and risk management.  Because caring for cardiac patients is frequent, many agencies rely on the clinician’s expertise regarding assessment and planning, yet research is suggesting the establishment of agency protocols is in order.

Pathophysiology

Heart failure may occur when damage is done to the heart preventing it from adequately pumping blood to tissues to meet required metabolic needs. Because the circulatory system carries oxygen and necessary nutrients, a decreased blood flow limits needed tissue nourishment, resulting in compensation by the body as it seeks balance or homeostasis. The body is forced to stimulate the sympathetic nervous system to increase both the heart rate and blood pressure to meet oxygen and nutrient requirements. The kidneys will assist, by a process of  vasoconstriction, within the tubules, to increase blood pressure and secondarily retaining and reabsorbing sodium to increase vascular pressure that will aid in also raising blood pressure. In the short term, this is effective. However, long term effects include cardiac decompensation and increased symptoms of heart failure.

Symptoms frequently seen during exacerbations

Per HHQI, Best-Practice Disease Management: Heart Failure Intervention Package, expect to see

  • Shortness of breath
  • Decreased urination
  • Chest pain or heaviness
  • Increased weakness or fatigue
  • Edema of the feet, ankles, hands, abdomen, or sacrum (anasaca)
  • Increase in weight of 2-3 pounds in 24 hours or 3 pounds in one week
  • Dry hacking cough or cough producing a white foamy sputum
  • Orthopnea (the number of pillows needed propped up to breath comfortably)
  • Paroxysmal nocturnal dyspnea (feeling of smothering or fullness in the chest when lying down and resolves when standing up).

An effective in-home prevention and treatment plan helps the patient control symptoms. It also helps control the costs associated with heart failure by reducing the need for emergent and/or inpatient care. Since heart failure patients are among those most often seen in emergent and inpatient settings, a home health clinical specialty heart failure program is necessary for cardiac patients to reduce this incidence. This care is a focus of CMS. New Survey Protocols, effective May 1, 2011, focus on data gathering and outcomes seen, as opposed to the focus on structure and process orientation of past surveys. Care planning and delivery with resulting outcomes of all patients will be the focus, but because heart failure is of growing incidence, expect scrutiny.

As the OASIS process measure begins to produce data, one can expect to see the evaluation and adjustment of processes brought to the forefront. Agencies must consider a specialized episode  and disease management plan for heart failure patients under care. This program will assist the agency reach its goals clinically, operationally, and financially.

The CMS OASIS data items were created to measure processes of care in several areas to reflect Institute of Medicine (IOM) goals and Medicare Payment Advisory Commission (MPAC) recommendations. It was felt there is a need to focus on high-risk, high-volume, chronic conditions seen in the home health setting and although CMS indicates that the integrated OASIS-C process items are optional practices, it is believed by industry specialists and content experts that identified best practices are critical to providing efficient quality home health care with expected/predictable outcomes.

Evidence-based  best practices


The rationale behind process data elements is to encourage agencies to incorporate evidence-based practices (EBP) into processes. One definition of EBP is to use the best scientific evidence available as a tool to guide clinical decision-making for the purpose of attaining the best outcomes.

Research supports that a combination of proper acute care discharge planning and post discharge care for patients with heart failure can significantly reduce hospital readmission rates, improve quality of life, and reduce cost of care. Heart failure evidence-based standards of care per the American College of Cardiology/American Heart Association (ACC/AHA) include:

  • Assessment for fluid retention via monitoring weight and abdominal girth.
  • Assessment of activity level, perceived dyspnea, fatigue, reduced exercise tolerance, sleep patterns, and patient’s activity that triggers dyspnea.
  • BP standing/sitting, heart rate (HR), respiratory rate (RR), jugular venous distention (JVD) every visit.
  • Assess edema and instruct the patient as to obtaining daily weight and complete a patient assessment of abdominal and peripheral swelling, focusing on feet/ankles, hands, sacrum, scrotal area, and abdomen.
  • Complete auscultation of heart and lung sounds; identify S3 or S4. Assess for new or recurrent dysrhythmias or murmurs. Per HHQI “changes in heart rhythm can lead to poor cardiac output and worsening heart failure. Note: Extra sounds can be a warning of impending heart failure exacerbation.”
  • Assess lung sounds to identify any changes or note wheezes, crackles, rhonchi, or diminished breath sounds.
  • The physician may well monitor serum electrolytes/renal function every 6 months.
  • Assess appetite. Expect the physician to order a low-fat, low-sodium diet; fluid restriction. When assessing appetite, look for signs of abdominal fluid retention such as feelings of abdominal fullness and early satiety. Refer to girth baseline and successive measurements.
  • Assess for orthopnea and paroxysmal nocturnal dyspnea. Verify number of pillows used when lying down. Both of these symptoms are usually intermediate signs of fluid retention and per HHQI, “intervention at this point could still prevent re-hospitalization.”
  • A thoracic impendence reading (ZO) may be ordered. Fluid status changes can signify need for intervention and possibly prevent a hospitalization.
  • Assess urinary output. Decreased output could signal impending signs of renal failure or heart failure decompensation, as the body attempts to raise blood pressure.
  • Assess diabetes control, if applicable.
  • Assess psychosocial coping and note symptoms of depression. Assess family and support systems. Depression intervention may be necessary to maintain optimum self care-management.
  • If ordered, encourage regular walks progressing to 1 hour per day 3-5 days per week..
  • Smoking: Discourage first-hand and second-hand smoke.

Agency Administrators


Administrators who are looking to establish a cardiac program in their agency should review the HHQI “Best Practice Disease Management: Heart Failure.” This Nurse Track is a Best-Practice Disease Management intervention package that supports the implementation, education, and application of current assessment and symptom management modalities with clinical processes to decrease active symptoms in heart failure patients. It discusses providing a structured plan for care, and supports EBP.  The package describes nursing actions that support an effective disease management program.

The administrator should also include an assessment of current standards of care in relation to the number of visits incurred as well as type and depth of  education provided to patients, along with early intervention for symptoms of heart failure. Once the assessment plan is completed, a review of nursing education gaps assessed, agency-wide education must occur to ensure that all clinicians are familiar with best-practice standards and provide opportunity for feedback. After that education is provided and the standards are implemented, outcomes should be analyzed, and ongoing auditing for compliance should be established to ensure the best practice standards are maintained.

Guidelines in Best-Practices for Administrators

There are many programs available regarding best-practices for care of patients with heart failure. The HHQi site offers RNs a free 2.0 Continuing Nursing Education units after completion of the 115 minute five activities for the Heart Failure Track. In addition, there are tools and podcasts to aid in reducing hospitalizations as well as a Decision Support Tool: Heart Failure

Once the program is underway, data analysis becomes an important practice allowing the administrator to review statistics and trends within the agency-specific patient populations. For the administrator planning to survive present and anticipated future changes in regulation, care delivery, and reimbursement models effective decision-support software providing data aggregation, benchmarking, and analysis opportunities for operational management will be essential.

Administrators should monitor specific patient populations for trending and analysis that include:

  • Hospitalization rates by diagnoses
  • Disciplines utilized within an episode
  • Visit patterns and scheduling
  • Number of days from SOC before therapy began care
  • Average number or recertifications
  • Therapy utilization for energy conservation training
  • Changes in patient education between SOC and recertification episode

In addition to monitoring heart failure outcomes through OASIS-C data, reduced hospitalization rates, compliance with the structured heart failure disease management program the agency should find ways to motivate personnel to continue use of the enhanced heart failure education. Administrators should be certain a specific skilled staff competency review regarding heart failure symptoms is administered regularly.

Best practices disease management programs can be very successful as seen in Dominion Care Home Health agency in San Antonio, TX. Their acute care hospitalization (ACH) rate declined from 41% to 28% after initiating such a program. With pay for performance in our future, newly instituted Survey Protocols, and higher expectations for improved patient outcomes, a disease management program targeting heart failure is a must.

Sources:

www.homehealthquality.org

HHQI Best Practice Intervention Practice, 8SOW-PA-HHQ07 467 App, 1/2008

www.qualitynet.org

http://mhcc.maryland.gov/consumerinfo/hospitalguide/hospital_leaders/best_practices/hf..h

www.chronicconditions.org/ClearingHouse/cat/Heart%20Failure,61.aspx

Heart and Ling Sounds by 3M

http://solutions.3M.com/wps/portal/3M/en_US/Littmann/stethoscope/education/heart-lung-sounds

Decision Support Tool: Heart Failure Publication # 8SOW-PA-HH05.187

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