By Brian Murphy
Note: This is the second in a two-part series on how mid-revenue cycle professionals can successfully operate in population health. View part 1 here.
Population health is the current buzzword in healthcare. But do you know how to succeed in these environments?
Population health initiatives often stall due to silos within the organization. These are typically not the silos we think of: Turf wars, or “not my job” complaints, but silos of separation between various members of the population health team who don’t understand how their work overlaps and is dependent on the other.
Your organization’s population health team might include quality improvement professionals, transitional care management (TCM), registry, and the contracting department. Without good coordination, you might experience the following:
- Quality improvement specialists may not possess the knowledge on how to appropriately query a physician to impact quality measures, per ACDIS/AHIMA guidelines
- Transitional care management (TCM) nurses and schedulers who fail to schedule patients for annual wellness visits and followups
- A contract department rep who doesn’t understand that documentation can impact risk contracts and result in more favorable payments from Medicare Advantage
Getting the right documentation for population health is not just important for risk adjustment. It can impact readmissions, which in turn impacts IPPS revenue. Capturing diagnoses can also help extend length of stay and improve morality measures when these patients are admitted.
Success in population health requires these teams to work in concert and toward the same goal. “It’s a communication issue—these departments might know each other, but they just don’t know how they can help one another,” says Sandra Love, RN, CCDS, CCDS-O, CPC,
Senior Manager of CDI, Norwood.
Eight strategies to succeed in population health-based CDI
Following are eight strategies you need to succeed in a population health environment.
- Obtain buy-in from your chief stakeholders. These are your chief medical officers, both for the hospital and the broader network. “They have to be in line before you get other physicians engaged. They’re going to be looked to by other physicians for guidance,” Love says. CMOs help push physicians to get done what needs to be done, for example documentation to help with risk adjustment.
- Secure support from your chief technology officer/IT physician. You may need to build a dashboard to monitor care gaps or best practice advisories for preventative measures, for example. This may including additional technical support in the creation of templates and tools within the EHR.
- Perform an assessment of current documentation habits. This might for example include an assessment of how documentation impacts organizational Healthcare Effectiveness Data and Information Set (HEDIS) measures. HEDIS is a comprehensive set of standardized performance measures designed to provide purchasers and consumers with the information they need for reliable comparison of health plan performance. HEDIS measures relate to many significant public health issues, such as cancer, heart disease, smoking, asthma, and diabetes.
- Report on assessment findings and make recommendations based on findings. For example, you might find that the organization has a deficiency in telehealth, performing audio visits that are ineligible for risk adjustment capture (a simple solution is to implement a video component). Often physicians will document symptoms, or medications, as well as a referral to see a specialist, without documenting a specified diagnosis. Or you may find that physicians will fail to document clinical support. For example, they might write “chronic kidney disease,” and for clinical support only document “CBC” This presents a significant audit risk.
- Attack the silos in your organization. Once you have buy-in, the right tools, and the lay of the land for what needs improvement, make sure your team is on the same page and advancing down the same path. Removing the silos that separate quality, coding, TCM, and contracting won’t be easy, but ultimately it will pay off in improving the health of your members and organizational quality and reimbursement.
- Practice preventative medicine. If you have diabetics, get them scheduled for A1C checks. For patients with high blood pressure, get them scheduled for routine blood pressure checks. Mammograms, colonoscopies, AWVs, and more are all part of HEDIS measures. “All of these are to help decrease further decline of chronic conditions or other associated risk factors,” Love says. “It’s preventative medicine.” Start with your TCM department.
- Use CDI reviewers for prospective visit reviews. CDI staff with a clinical mindset (typically an RN, or a clinically-savvy HIM/coding professional with sufficient record review experience) can pre-review the chart of a patient coming in for an annual wellness visit for HEDIS improvement opportunities. For example, patients who fall into the statin quality measure might not be able to take statins due to myalgia. Failure to document that diagnosis will affect the denominator, HEDIS measure, and ultimately care outcomes. A CDI specialist could flag that record, and the physician document that to move that patient into an exclusion that would remove them appropriately from the measure.
- Work with your payers. Payers will be able to tell you which patients are part of your contracts, and which aren’t. They are an untapped resource that you should be using. For example, payers can provide lists of patients who have significant diagnoses that have not been addressed for the calendar year. “You have to have good communication, a good lawyer or a good team that works with contracting to get that set up,” Love says. “You just have to get it initiated.” With patience and effort you can obtain a rich lode of data.
- HEDIS Measures (CMS): https://www.cms.gov/Medicare/Health-Plans/SpecialNeedsPlans/SNP-HEDIS
- Transitional Care Management (AAFP): https://www.aafp.org/family-physician/practice-and-career/getting-paid/coding/transitional-care-management.html
- 2022 star ratings methodology (CMS): https://www.cms.gov/files/document/2022-star-ratings-technical-notes-oct-4-2022.pdf
About Sandra Love
Sandra is the senior manager of CDI at Norwood in Austin, Texas. She has more than 17 years of nursing experience and 10 years in CDI, previously serving as the manager of outpatient clinical documentation excellence at Atrium Health Wake Forest Baptist in Winston-Salem, North Carolina. At Wake Forest Love assisted with the implementation of an outpatient CDI program and developed two pediatric CDI programs. She is a recognized pediatric leader in the industry and has spoken at multiple conferences. Love was also a member of the ACDIS Events Committee and ACDIS Leadership Council. She is currently seeking her Master of Nursing in Executive Leadership at Grand Canyon University. Contact her at email@example.com.
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