Implications of CMS’s Present on Admission Provisions in the ICU:

Making Dollars and Sense

Todd M. Grivetti, MSN, RN, CCRN, CNMLClinical Nurse Manager

Regional Neurosciences CenterPoudre Valley Hospital

Ft. Collins, CO

2008 Award Recipient

Disclosure Statement

Todd M. Grivetti, MSN, RN, CCRN, CNML Disclosure

Speaker’s Bureau – AACN Financial Interest - None

House Keeping tips Class Code – 169 Session Times – 2:15 – 3:30 pm Please turn cell phones and pagers off or

to Vibrate. Please utilize the microphones in the room

for questions.

Learning Objectives Review, Discuss, and Understand the

Present on Admission Provisions Discuss practical implications of hospital

acquired conditions Incorporate evidence-based research with

confidence to establish unit specific guidelines to eliminate hospital-acquired conditions

Develop and implement a customized POA risk assessment.

Definitions CMS – Centers for Medicare and Medicaid

Services IPPS – Inpatient Prospective Payment

System DRG – Diagnosis Related Group HAC – Hospital Acquired Conditions NI – Nosocomial Infection POA – Present on Admission

Evolution to Quality Based Payment Public Awareness

1999 – IOM’s To Err is Human is published. 2001 – IOM’s Crossing the Quality Chiasm.

Quality Reporting 2003 – CMS Begins quality reporting in-patient

initiatives. Ten Metrics

2008 – CMS Begins Quality reporting out-patient initiatives.

Seven Metrics

Evolution to Quality Based Payment

2007 – Physician Quality reporting 2008 – Outcome measures introduced

Other entities monitoring hospital quality and safety initiatives: Joint Commission Association of Healthcare Research & Quality (AHRQ) Leap Frog Health Grades State Governments Private Insurance companies Patient Safety Organizations

Evolution to Quality Based Payments

Individual contracts between hospitals and insurers

2004 - CMS/Premier begins demonstration project. Pay for Performance Hospital Quality Indicator Demonstration (HQID)

Uses national measures to test payment methods.

Deficit Reduction Act (2005) IPPS – 2008

Severity adjusted payments POA Provisions

Deficit Reduction Act - 2005 CMS selected a variety of hospital-

acquired conditions deemed to be reasonably preventable that will receive lower payment if not coded at present on admission.

If a claim includes one of the conditions falling under this policy as a secondary diagnosis without a present on admission indicator, it will be reimbursed as if the secondary diagnosis was not present, leading to reduced payment.

Hospital Acquired Conditions selected for Present on Admission Provisions

FY – 2008 Pressure Ulcers (decubitus ulcers) Catheter-associated urinary tract infections Object left in surgery Mediastinitis after CABG surgery Air embolism Blood incompatibility Vascular catheter associated infections Falls

Hospital Acquired Conditions selected for Present on Admission Provisions

FY-2009 – Conditions not selected but being considered. Clostridium difficile – associated disease Deep vein thrombosis (DVT) Pulmonary embolism Staphylococcus aureus septicemia Ventilator associated pneumonia (VAP) Methicillin Resistant Staphylococcus aureus

(MRSA) Delerium

Hospital Acquired Conditions selected for Present on Admission Provisions

Conditions NOT SELECTED for FY-2009 and will not be subjected to provisions Legionnaires disease – Not typically a HAC Wrong site or Wrong surgery

Medicare WILL NOT pay at all

Phased Implementation of POA

August 2007 – FY 08 IPPS Final rule announced: POA provision finalized

October 2007 – Short term, acute care hospitals required to begin

reporting POA codes, information not used in claims. January 2008 –

CMS begins processing POA data and provide feedback on POA reporting errors

Hospitals submitting invalid POA code receive remark code on remittance advice; claims with errors still processed.

Phased Implementation of POA

April 1, 2008: Claims that are submitted for payment that do not

contain proper POA data will be returned to the provider for correct submission of POA information.

April 15 2008: FY09 IPPS Proposed Rule announced; CMS outlines plan

to expand POA provision to additional conditions August 2008:

FY09 IPPS Final Rule expected; expansion of condition list in POA provision likely.

October 2008: POA provision set to officially launch; reimbursement at

stake.

Practical Implications of POA

FinancialClarifying Implications

Limitations

Practical Implications of POA Indicators

General Reporting Requirements: POA indicators required for all claims involving Medicare

inpatient admissions to acute care hospitals. POA is defined as present at the time the order for inpatient

admission occurs – conditions that occur during an outpatient encounter, including emergency department, observation, or outpatient surgery are considered POA.

POA indicators is assigned to both primary and secondary diagnoses.

Issues related to inconsistent, missing, conflicting or unclear documentation must be resolved by the provider.

If a condition would not be coded and reported based on Uniform Hospital Discharge Data Set definitions and current official coding guidelines, then POA indicator would not be reported.

CMS does not require POA indicators for external cause of injury code unless it is being reported as an “other diagnosis.”

Source: CMS - HAC/POA

POA Indicator Details*POA Indicator Definition Reason for Code

Y Yes Present at the time of admission

N No Not present at the time of admission

U UnknownDocumentation insufficient to determine if the condition was present on admission

WClinically

Undetermined

Provider unable to clinically determine whether the condition was present on admission or not

1 (One)Unreported/

Not UsedExempt from POA reporting

*Every diagnosis code required to have one of five POA indicator codes

CMS Broadening the List: Private Payers Likely to Follow

“It’s not a matter of not paying for them. It’s about getting them not to happen in the first place.”

Thomas Granatir

Director of Policy & Research

Humana, Inc.

“Having a financial incentive will increase hospitals’ awareness of the need to make the systematic changes necessary to avoid these errors… We are considering making non-payments for never events a standard part of our contract.”

Charles Cutler, MD

Chief Medical Director, Aetna

Practical Implications of POA Indicators

Financial Revenue

Increased cost of nosocomial injuries or infections Increased Length of Stay (LOS) Impact on revenue cycle Number of conditions and revenue risk with 2009

IPPS rulings increasing. Accurate documentation is important Nursing care accounts for 30% of total hospital

operating budget and 44% of direct care costs. Payment systems do not account for the variable

time nurses spend with different patients or for their efforts in providing care to different types of patients.

Financial Burden – POA/NI Kilgore (2008) –

NI’s are associated with $12,197 in incremental cost.

Advisory Board (2008) Based on projections outlined in the FY08 IPPS

Final Rule CMS estimates the overall impact would be relatively modest – Expected aggregate payments to all hospitals of $20M/yr.

Advisory Board – calculates for decubitus ulcers alone, worse case scenario of $283M/year

Financial burden Zahn & Miller (2003)

Account for 18 types of medical errors could account for 2.4 million extra hospital days or $9.3B in extra charges/annually

Kurtzman & Buerhaus (2008) CMS estimates in 2007 –

Prevalence of certain HAC’s, up to 490,000 claims could be paid at lower rate under CMS-1533-FC – Once again, identifying a $20M savings in Medicare direct payments

Payment Implications: Present/Absent Decubitus

Ulcers on Admission

# Discharges,

as is

#Discharges,

exclude ulcer Codes

Cost, as isCost, exclude ulcer codes

TOTALS 259,356 259,356

$2,972,052,520 $2,688,620,270

-$283,432,250

-9.5%

Source: Advisory Board; CMS Analysis

Worst Case Scenario

Clarifying the Mechanics of No Pay Events

MS-DRGPOA

?MS-DRG

POA?

MS-DRG POA?

Primary DxCoronary Atherosclerosis (41401)

YCoronary Atherosclerosis(41401)

YCoronary Atherosclerosis(41401)

Y

Secondary Dx

Decubitus Ulcer Stage III

YDecubitus Ulcer Stage III

NDecubitus Ulcer Stage III

N

Secondary Dx

Cardiogenic Shock

Y

Primary Px(Aorto)coronary Bypass of two coronary arteries

(Aorto)coronary Bypass or two coronary arteries

(Aorto)coronary Bypass of two coronary arteries

DRG Assignment

Coronary bypass w/o Cardiac Cath w/ MCC

Coronary bypass w/o Cardiac Cath w/o MCC

Coronary bypass w/o Cardiac Cath w/ MCC

Basic Payment

$27,831 $20,208 $27,831

Patient 1 Patient 2 Patient 3

Source: Advisory Board – Nurse Executive Center

CMS No-Pay policy targets – High-volume, costly adverse events

Effective Oct. 1, 2008 Cases *$$ Per

Hospitalization*Total Medicare Cost*

Pressure Ulcers Stages III, IV 257,142 $43,180 $11.1 Billion

Preventable injuries – Fractures, burns, and dislocations

193,566 $33,894 $6.6 Billion

Catheter Associated UTI’s 12,185 $44,043 $536.7 Million

Vascular catheter Associated Infections

29,536 $103,027 $3.0 Billion

Surgical Site Infections 69 $299,237 $20.0 Million

Objects left inside 750 $63,631 $47.7 Million

Air emboli 57 $71,636 $4.0 Million

Blood incompatibility 24 $50,455 $1.2 Million

CMS No-Pay policy – High-volume, costly adverse events

Effective Oct. 1 2009 Cases *

Avg. charge per hospital stay*

Total Medicare cost *

Deep Vein Thrombosis or pulmonary embolism following certain orthopedic surgeries

140,010 $50,937 $7.1 Billion

Manifestations of poor blood glucose control: - diabetic ketoacidosis - hypoglycemic coma

11,4691,131

$42,974$45,989

$492.9 Million $52.0 Million

Surgical site infections acquired in a hospital following: - Orthopedic procedures, e.g., total knee - Bariatric surgery

539208

$63,135$180,142

$34.0 Million$37.5 Million

* At all US hospitals in fiscal year 2007 Source: CMS: O’Reily, AMNews, 7/14/08

Cost AvoidanceAdditional cost compared to Worst

Case Scenario

$0

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

VAP BSI MSI

MinimumMedianMaximum

Additional Cost per Infection

MSI – Mediastinitis

Aggregate Costs and Revenue at Risk of Mediastinitis (MSI)

$0

$500,000

$1,000,000

$1,500,000

$2,000,000

$2,500,000

$3,000,000

$3,500,000

Minimum Median Maximum WorstCase

Cost

111 Discharges with Mediastinitis in FY06Additional Cost of Care 8x Worst case Revenue at

risk.

Limitations – Analytical Challenges

Lack of Information Lack of specific codes

Only 6:8 of approved conditions have specific diagnosis codes in FY06

4:6 of the tentative conditions have specific diagnosis codes in FY06

Lack of POA indicators Datasets with POA indicators not available until 2009 100% coverage (entire year and hospitals) 2010

Case Scenario Ms. Lewis, an 82 year old Medicare

beneficiary is hospitalized with a diagnosis of intracerebral hemorrhage. Admitted to the ICU with neurological impairment. Requires:

Urinary catheter for acute urinary retention. Discharged from hospital after recovery. Hospital bills Medicare coding the UTI as “ICD-

9-CM-996.64 signifying it was a complication of care

Hospital is paid $8,117.05 including $1,089.91 (13%) extra for cost incurred in treating Ms. Lewis.

Changes Related to Inpatient Nursing Care Quality - ICU

ImpactUniversity of North Carolina Study - ICU

Medical University of South Carolina Data

Patients = (N) 10,606 58,473

ICU days % 48.7%

Total days % 37.8%

Total costs % 50.0% 44.9%

Deaths % 32.4%

Nursing care hours %

41.%

Outcomes of Outlier Patients (90th Percentile of costs)

Aligning Payment

Health Care Quality & SafetyNurses

&Physicians

Patient Safety Organizations Joint Commission –

www.jointcommission.org National Patient Safety Goals MissionThe mission of The Joint Commission is to

continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations.

Patient Safety Organizations LeapFrog Group – www.leapfroggroup.org

Aims to reduce medical mistakes and improve the quality and affordability of healthcare.

Encourage health care providers to publicly report their quality and outcomes so that consumers and purchasing companies can make informed health care decisions.

Reward doctors and hospitals for improving their quality, safety and affordability of health care.

Help consumers reap the benefits of making smart health care decisions.

Patient Safety Organizations Agency for Healthcare Research and

Quality (AHRQ) www.ahrg.gov AHRQ Mission

The Agency for Healthcare Research and Quality's (AHRQ) mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. Information from AHRQ's research helps people make more informed decisions and improve the quality of health care services. AHRQ was formerly known as the Agency for Health Care Policy and Research.

Patient Safety Organizations HealthGrades

Leading independent healthcare ratings organization.

Provides Ratings and profiles of: Hospitals Nursing homes Physicians

Available to: Consumers Corporations Health plans and hospitals

Patient Safety Organizations HealthGrades

Hospitals HealthGrades helps hospitals understand, improve

and communicate the quality of care they deliver through a suite of products and physician-led clinical-advisory services. HealthGrades currently works with more than 400 hospitals nationwide and produces well-respected public studies of hospital quality in areas that include clinical excellence, patient safety and women's health.

Nursing Optimize Nursing Documentation Time

Appropriately leverage staff nurse time for detailed admission assessment

Must be more comprehensive Eliminate redundancies and streamline assessment

forms Provide Data for Reporting

Capture discrete data needed for reporting key quality indicators

UTI’s MRSA

Facilitate automated data collection Inform Prevention strategies

Reveal key important opportunities Select and implement appropriate interventions.

Physicians Must document NOT stage

Detailed H&P Identify Primary and Secondary diagnoses

Dual penalties for: Over-utilized diagnostics Longer times to treatment Increased costs

Increased knowledge of new coding indicator options and definitions. UB-04 Data Specifications manual ICD-9-CM Official Guidelines for Coding and Reporting

Evidence Based Research on

Implications of POA

Implementing Changes based on best practices

Data collection tools - Processes

Available at www.ihi.org Measurement tools

Critical part of measuring and implementing changes Measurement for change should not be confused with

measurement for research. IHI reports:

Despite numerous local improvements in various elements of ICU care, many promising improvements remain unused, fragmented, isolated and dispersed

Implementing system wide model of care and developing skilled, coordinated, and collaborative care teams, organizations can establish new systems of ICU care that will produce better clinical outcomes, lower costs, improved satisfaction, better coordination of care and enhanced communication with all hospital areas and departments.

Source: Institute for Healthcare Improvement – http://www.ihi.org/topics/criticalcare

Measurement for Learning & Process

Improvement vs. ResearchMeasurement for Research

Measurement for Learning and Process Improvement

PurposeTo discover new knowledge

To bring new knowledge into daily practice

TestOne Large “Blind” Test Many sequential, observable

tests

BiasControl for as many biases as possible

Stabilize the biases from test to test

DataGather as much data as possible, “just in case”

Gather “just enough” data to learn and complete another cycle

DurationCan take long periods of time to obtain results

“Small tests of significant changes” accelerates the rate of improvement.

Utilization of PDCA in ICU’s… AND Beyond

Aim: (overall goal you wish to achieve) Every goal will require multiple smaller tests of change Describe your first (or next) test of change: Person responsible When to be done Where to be done

Plan List the tasks needed to set up this test of change Person responsible When to be done Where to be done. Predict what will happen when the test is carried out

Measures to determine if prediction succeeds Do

Describe what actually happened when you ran the test Check OR Study

Describe the measured results and how they compared to the predictions

Act Describe what modifications to the plan will be made for the next cycle

from what you learned

Source: Institute for Healthcare Improvement

Sample Measures - ICU Critical Care –

Average ICU Length of stay ICU mortality rate Percent of patients/families satisfied with care Average days on mechanical ventilation Percent of patients with VAP Percent of patients with CLBSI Percent of patients admitted with Pressure

ulcers Percent of patients admitted with UTI’s Percent of patient falls

Best Practice for preventing falls

Optimal Assessment Prompt Critical Thinking

Assessment driven prompts Serious injury risk screening Immediate post-fall diagnostics

Targeted Care Mandates Bolster Patient Toileting protocols

Safe toileting schedule Mandatory assisted toileting

360-Degree Support Enfranchise Patients and families

Teach-back Protocol Patient-Centered technologies Family education tools

Innovations for Complex Patients Deploy Cost-Effective Alternatives for Observation

Multiple room monitors High-Risk Video Surveillance

Best Practice for Preventing Pressure Ulcers

Complete Head-to-toe assessment Assess for risk using the Braden scale and

reassess during status changes Order nutrition consult Turn and position patient every two hours Use moisturizers on dry skin Don’t massage bony prominences Protect skin of incontinent patients from

moisture

Nursing directives on measuring cost, quality, and

intensity of nursing care Develop ways to predict which patients

are at risk of developing HAC on admission to the hospital and provide interventions to decrease adverse events before they occur

Identify relationships between nurses and patients to better understand the effects of nursing intensity, direct nursing costs, expertise, academic preparation, skill mix, and other nurse-specific characteristics on outcomes of care.

Nursing directives on measuring cost, quality, and

intensity of nursing care Create methods to compare inpatient

nursing performance across hospitals to identify inequities between nursing intensity, performance, and reimbursement rates

Place renewed focus and attention on patients with high cost, high resource use, and extended length of stay, who expend a disproportionate amount of days, dollars, and deaths at US hospitals.

Welton, 2008: JONA Vol. 38, No. 7/8.

Established Protocols for Prevention Pressure Ulcer Prevention Guidelines

New Jersey Hospital Association NO ULCERS N – Nutrition and fluid status O – Observation of skin

U – Up and walking or turn/position L – Lift, don’t drag skin C – Clean skin and continence care E – Elevate heals R – Risk Assessment S – Support surfaces

Established Protocols for Prevention VHA – Volunteer Hospital Association

Fall Prevention Toolkit High Risk room set up Medication Review Toileting schedules Increased Observation (Rounding, video monitoring) Visual identification Protective devices Bed/chair alarms Mobility aids

Established Communication Tools SBAR

S – Situation B – Background A – Assessment R – Recommendations

Purpose – Provides framework for communicating between members of the health care team about a patient’s condition. Easy to remember. Concrete mechanism useful for framing any

communication, especially critical ones. Allows for easy and focused way to set expectations for

what will be communicated and how between members of the team.

Transforming Care at the Bedside (TCAB)

Through IHI and the Robert Wood Johnson foundation Framework for change Improved communications Improved and redesigned work areas Improved care practices to identify & prevent:

Pressure ulcers UTI’s DVT’s Falls

POA Identification

Methodology and Hospital Acquired Complication reduction

Risk Assessment

Pre-Determined comprehensive analysis

programs PDCA’s Simplified database analysis Utilization of Infectious Disease

department to assist with Reporting methods

UTI’s CLBSI VAP

Dissemination of data to staff Graphs (monthly, quarterly, annually)

Creating action plans to correct issues.

PDCA or PDSA – Process Flow

Director evaluates for scope and validity

of issue

* PDCA?

more than department issue?

Director presents to Process

Improvement Team

*PI Team decision on

PDCA

PDCA initiated

Director decides on appropriate

resolution and explains “no”

decisons

Director maintains oversight of the

process

Issue resolved?

Report to Process Improvement Team

Consider using PDCA when:

A process already exists, but needs to be improved and you’re not sure on how to improve it.

The process must be studied to understand how all the parts fit together.

Changing the process could be expensive and hard to reverse.

Improvement ideas don’t readily come from literature or benchmarking.

Simple problem solving has shown itself ineffective

If any of the below apply, Use the Decision Support Process

VIC/Public/Forms/Decision Support

The idea introduces a new program or service providing care for patient groups not previously served by PVHS.

The new process would provide treatment of existing patient groups through a new technology.

The process includes the purchase of an existing business not currently owned by PVHS.

The idea dramatically extends an existing service/program that increases capacity for capturing additional volume for PVHS.

The idea expands an existing program into a geographic market not previously served by PVHS.

One year time limit on PDCA team commitment

Quality Resources is available for consultation for decision support.

If the process improvement impacts patient safety, consider consulting with Quality Resources first.

* Review the statements that apply. Make a determination for using PDCA or business proposal process.Note: When the need for quick turnaround outweighs the risk of making changes without thorough upfront analysis, involvement of relevant Directors and SMG

is required.

Issue is identified and presented to director

Explain decision or escalate to

SMG

No

No

Yes

Yes

No

Yes

No

Yes

PDCA Decision Process

Share information with stakeholders

POA Surveillance - Goals

POA - Surveillance

POA Surveillance

POA Surveillance

Run Charts

Source: Institute for Healthcare Improvement

Flow Charts

Source: Institute for Healthcare Improvement

Flow Charts

Source: Institute for Healthcare Improvement

Cause & Effect Charts - Fishbone

Cause & Effect - Process

Source: Institute for Healthcare Improvement

SummaryThe Centers for Medicare and Medicaid Services will

no longer pay for additional costs of care related to Hospital Acquired Conditions such as pressure ulcers and nosocomial infections, falls, pneumonia, objects left in after surgery, transfusion reactions, and air embolisms.

Hospitals must strongly implement methods to identify best practices, utilize evidence base research, and educate clinical staff on the importance of nursing care as it pertains to improved clinical quality, improved outcomes, and improved reimbursement rates.

Thank YouContact Information

Todd M. Grivetti, MSN, RN, CCRN, CNMLtmg4@pvhs.org

grive2400@aol.com

References Advisory Board Company. 2008. Hospital Acquired Conditions: Implications

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Glance, L., Osler, T., Mukamel, D., Dick, A. 2008. Impact of the Present on Admission Indicator on Hospital Quality Measurement: Experience with the Agency for Healthcare Research and Quality (AHRQ) Inpatient Quality Indicators. Medical Care. 46 (2) 112-119.

Iezzoni, L. 2007. Finally Present on Admission but Needs Attention. Editorial. Medical Care. 45 (4). 280-282.

References Kilgore, M., Ghosh, K., Beavers, M., Wong, D., Hymel, P., Brossette,

S. 2008. The cost of Nosocomial Infections. Medical Care. 46 (1) 101-104.

Kohn, L., Corrigan, J., Donaldson, M. 2000. To Err is Human: Building a Safer Health System. Institute of Medicine Executive Summary.

Kurtzman, E., Buerhaus, P. 2008. New Medicare Payment Rules: Danger or opportunity for nursing? AJN 108 (6) 30-35.

Needleman, J. 2008. Is What’s Good for the patient Good for the Hospital: Aligning Incentives and the Business care for nursing. Policy, Politics & Nursing Practice. 9 (2) 80-87.

Unruh, L., Hassmiller, S., Reinhard, S. 2008. The Importance and Challenge of Paying for Quality Nursing Care. Policy, Politics & Nursing Practice. 9 (2) 68-72.

Welton, J. 2008. Implications of Medicare Reimbursement Changes Related to Inpatient Nursing Care Quality. JONA 38 (7/8) 325-330.