DOCUMENTATION IN ADULT HEALTH CARE

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DOCUMENTATION IN ADULT HEALTH CARE

• Susan Almon-Matangos
• Janet Brown
• Elaine Ledwon-Robinson
• John Tracy
• November 20, 2008
• Session 1433

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FOUNDATION OF DOCUMENTATION

• Janet Brown, MA CCC-SLP
• ASHA
• jbrown_at_asha.org

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Documentation A Perpetual Challenge

• ASHA 2007 SLP Health Care Survey
• What are the greatest challenges you face in
• health care?
• 55 of respondents checked Paperwork (clinical
  and reimbursement)
• 48 insufficient reimbursement
• 45 productivity
• ASHA 2005 SLP Health Care Survey
• 53 Paperwork, insufficient reimbursement

4
Who Makes the Rules About Documentation?
5
Guidance For Clinical Documentation

• ASHA (www.asha.org/policy)
• Code of Ethics
• Preferred Practice Patterns
• Specific clinical policy documents
• Other ASHA resources
• http//www.asha.org/members/slp/healthcare/documen
  tation.htm
• Institutional policies and procedures

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Who Makes the Rules About Documentation for
Payment?

• Medicare
• Medicaid
• Private Health Insurance Plans

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How Can Documentation Be Streamlined?

• Use of templates
• Less narrative writing
• Electronic platforms
• without losing clinically relevant information!!

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ASHAs Committee on Documentation

• Goals
• Develop evaluation templates for electronic
  medical records
• Content can also be used for paper documentation
• Consensus based (not prescriptive)
• should be modified to fit the target population
  or institution and emerging evidence
• Working with Cedaron Medical to develop software
  platform, including NOMS
• Available in 2009

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NOMS and Outcomes

• National Outcomes Measurement System
• Developed by ASHA as an alternative to FIM and
  other measurements not sensitive to SLP progress
• Adult NOMS consists of 15 Functional
  Communication Measures and seven point scales
• Most frequently used FCMS
• Spoken language comprehension
• Spoken language expression
• Motor Speech
• Problem solving
• Memory
• Attention

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Outcomes and Reimbursement

• Medicares Value Based Purchasing
• Demonstrating benefit of services
• Working to incorporate this concept into new Part
  B payment
• PQRI (Physician Quality Reporting Initiative)
• Financial incentive for reporting outcomes
• Private practice SLPs may be eligible

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Status of NOMS and Its FCMS

• Recommended by
• MedPAC (Medicare Payment Advisory Commission)
• Performance Measures Accepted by
• The Joint Commission
• National Quality Forum
• Agency for Health Care Research and Quality

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Benefit of Reporting NOMS Data to ASHA

• Increases the data base of patient information
• Used for advocacy with Centers for Medicare and
  Medicaid Services
• ASHA provides benchmark information

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For More Information

• Janet Brown
• jbrown_at_asha.org
• For information about NOMS
• Jaumeiko Brown
• jbrown2_at_asha.org
• 301-296-8750

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MEDICARE DOCUMENTATION REQUIREMENTS

• John Tracy, Ph.D., M.P.H., CCC-SLP
• Salem Hospital, Salem OR
• John.Tracy_at_salemhospital.org

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Medicare Requirements

• Basic Qualifying Requirements
• Level of complexity requires services of a
  skilled clinician adequate complexity
• Services furnished under a Tx. plan of care
• Client under the care of a physician or non-
  physician provider
• Client able to make adequate progress in
  generally accepted period of time
• Services are appropriate given medical and
  therapy diagnosis reasonable and necessary

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Medicare Requirements

• Expectations
• Condition will improve with treatment
• Maximum improvement has not yet been attained

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Medicare Reporting Formats

• Initial Plan of Treatment Old 700 Form
• Identifying information patients first and
  last
• name, provider , HICN, provider name, onset
  date, start of care date
• Type of service
• Primary Dx.(pertinent medical Dx.)
• Tx. Dx. (treatment Dx.)
• Signature of professional establishing plan of
• care including professional designation
• Date established and frequency and duration

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...Medicare Reporting Formats

• Physician Certification
• I certify the need for these services furnished
  under this plan of Tx. and while under my care.
• Signature line

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...Medicare Reporting Formats

• Initial Assessment
• HX. and medical complications
• Level of function at start of care
• Reason for referral
• Certification dates From---Through
• Prior hospitalizations or similar Tx.
• Plan of Tx
• Functional goals Goals(short term),
• Outcome(long term)
• Plan

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Medicare Documentation Formats

• Reevaluation
• not to determine progress in response to Tx.
• used when patient shows obvious change
• some communication emerging
• regressing from level of progress at discharge
• obvious change in potential during implementation
  of Tx. plan
• Documents need to moving into skilled Tx. or
• revising home program
• Follows same format as initial evaluation

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..Medicare Documentation Formats

• Progress Note
• report of progress after 10 days of therapy or
• 30 days of intervention, whichever is shortest
• can be combined with encounter note
• can be combined with recertification request
• must meet criteria for physician certification
  of
• plan including goals and plan along with need
  for skilled services
• includes progress toward goals in measurable
• statements or with instrumentation outcome
• documents changes in goals

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..Medicare Documentation Formats

• Encounter Note
• can be combined with Tx. note
• documents time in minutes for all timed and
• untimed codes and total time
• procedures(include CPT codesnot required)
• listed
• like flow sheets of old

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..Medicare Documentation Formats

• Treatment Note
• can be the same as progress note
• documents ongoing assessment
• date of treatment
• identify all interventions provided and billed
• signature and professional ID
• changes to Tx. plan including goals completed,
• deleted and new strategies between progress
• notes
• adverse reactions to treatment
• communication/consultations
• other Info.

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..Medicare Documentation Formats

• Discharge summary
• may summarize all of episode of care
• can be update since last progress note
• addresses LTGs and/or STGs using objective
  statements
• justify medical necessity for extension of
  services under cap
• identifying info as for 700 form, but list all
  visits since start of care (SOC)

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Other Medicare Guidelines

• Groups
• individual treatment Plan
• 2-4(max.) clients
• all individual documentation requirements apply
• Students
• can sign treatment notes
• notes must be countersigned by qualified
• practitioner

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Documentation Formats

• Dictation
• Handwritten
• closed form with some text
• open form with general outline
• Clinician-typed on computer
• Canned computer programs
• inflexible
• flexible
• excessive free text
• combination of drop-down menus and free text

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Planning a New System

• Needs assessment (management)
• flow of present system
• documentation system(s) in place
• type of record, storage and retrieval
• effectiveness of client/staff communication
• equipment in use
• staff focus groups
• present costs using flow and staff input

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...Planning a New System

• Identification of hardware
• wireless or wired
• coverage-signal router placement and number
• laptop or electronic notebook-portability and
• speed of access/use
• Choice of system
• no change
• canned computer-inflexible(software)
• canned computer-flexible(web based)

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...Planning a New System

• Training
• vendor training of internal trainer(s)
• vendor orientation of staff to system
• formal training by internal trainer(s)
• testing and playing with new system-staff and
• trainers consultants
• trainers on site during go-live period

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...Planning a New System

• Budgeting
• other department budgets
• hardware
• software or license fees
• loss of productivity
• training
• reduced speed and need for Doc. time
• staff work task changes

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JUSTIFYING SPEECH, LANGUAGE, HEARING, AND
SWALLOWING SERVICES

• Susan Almon-Matangos, MS CCC-SLP
• Aegis Therapies
• susan.almon_at_aegistherapies.com

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How to Justify Services

• Define medical necessity for speech-language
  pathology services to meet payer requirements
• Document the need for skilled speech-language
  pathology services

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Medical Necessity

• Explain why it is clinically necessary for SLP
  service to start now
• What functional aspect changed?
• What caused that change?
• What is likely to occur if SLP does not intervene
  now?

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...Medical Necessity Example

• Reason for Referral
• Patient was referred due to weight loss and
  coughing during meals following recent
  hospitalization for an exacerbation of COPD with
  pneumonia. Evaluate the need for dysphagia
  therapy, as the patient is at risk for
  malnutrition, dehydration, and choking

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...Medical Necessity Bad Example

• Reason for Referral
• The patient is being evaluated for speech and
  swallowing due to physician order

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...Medical NecessityAnother Bad Example

• Reason for Referral
• The patient was seen upon a nursing referral

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Medical Necessity and Diagnoses

• The medical and treatment diagnoses contribute to
  the reviewers understanding of the medical
  necessity for your service and align with the
  treatment codes.
• Medical diagnosisThe medical condition that
  caused the disorder that you are treating (such
  as CVA, Parkinsons Disease, Alzheimers
  Disease).
• Treatment diagnosisThe disorder that you are
  treating (such as dysphagia, aphasia, or
  cognitive-communicative deficit).

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...Medical Necessity and Diagnoses

• The medical history should explain this
  relationship, along with any other medical
  conditions that are pertinent to your treatment
  plan. The findings of the evaluation support the
  need for services.

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Medical Necessity and Prognosis

• The rehab potential (or prognosis) is another
  factor that supports medical necessity.
• Good, fair, poor
• For goals
• Due to __________ (motivation, cooperation,
  family support, stimulability, auditory
  comprehension skills, etc.)

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Skilled Service

• Explain what service the SLP will be providing
  that could not be provided by someone else.
• Skilled analysis of the functional deficits and
  underlying impairments
• Selection of appropriate treatment techniques
• Skilled adjustment of the treatment plan based on
  progress

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Skilled Analysis

• How do the underlying impairments impact the
  functional deficits?
• What deficits remain?
• How do the underlying impairments lead to those
  deficits?
• How can treatment be designed to lead to
  improvement?

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Skilled Adjustment

• How does the treatment plan need to be adjusted?
  Do new goals need to be added? Does the approach
  need to change?
• Modification of tasks
• Modification of environment
• Change in amount of assistance or cues provided
• Caregiver training to change approach or cueing

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Skilled ServiceExample of Skilled Analysis and
Adjustment

• Speech intelligibility remains impaired due to
  flexed neck and trunk posture and reduced volume.
  The treatment plan will now focus on
  strengthening neck muscles to allow appropriate
  head and neck posture. Goals for diaphragmatic
  breathing will be added to encourage increased
  volume of phonation and improved overall posture.

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...Skilled ServiceExamples of Skilled Treatment
Techniques

• Word finding training
• Automatic speech tasks
• Repetition/imitation tasks
• Volitional speech tasks
• Articulation training
• Thermal stimulation
• Compensatory swallowing strategy

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...Skilled ServiceMore Examples of Skilled
Techniques

• Attention/concentration tasks
• Functional problem solving strategies
• Compensatory memory strategies
• Vocal hygiene techniques
• Vocal prosthetic training
• Topic maintenance

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Skilled Service and Maintenance Programs

• The establishment of a maintenance program is a
  skilled service.
• The ongoing implementation of the maintenance
  program is not a skilled service.

47
Writing and Reporting on Goals for Skilled
Service

• Write goals that reflect the skilled nature of
  the service.
• Write statements that reflect the functional
  change in status achieved as a result of the
  service.

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Types of Skilled GoalsLong-Term Goals

• To be achieved at the end of the course of
  therapy.
• These should remain the same unless there is a
  reason to change them.
• Example Patient will use functional
  communication skills for vocational needs with
  90 accuracy without cues.

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...Types of Skilled GoalsShort-Term Goals

• To be achieved within a specific time period,
  often 30 days.
• These should change as the patient progresses
  through the treatment program.
• Example Patient will use appropriate rate in
  sentences with 80 intelligibility without cues.

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Components of Skilled Goals

• Behavioral
• Goals should be based on a specific behavior that
  can be observed and measured
• Functional
• Goals should be tied to a meaningful, functional
  outcome that is important to the patient

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...Skilled GoalsFunctional Deficits

• Goals are often written based on the functional
  deficit displayed.
• Communication (for example, speech
  intelligibility, comprehension of conversation,
  reading, writing)
• Cognition (for example, remembering daily
  schedule)
• Swallowing (for example, safe PO intake)
• Progress may be too slow for this type of goal.
• This type of goal may not prompt an in-depth,
  comprehensive treatment plan.

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...Skilled GoalsUnderlying Impairments

• Goals may also be written based on underlying
  impairments.
• Underlying impairments are the cause of the
  functional deficits.
• Phonation, breath support, vocal volume
• Auditory comprehension of words
• Memory, problem solving, reasoning
• Visual tracking
• Recall of written symbols
• Attention, concentration
• Oral motor strength, bolus manipulation, posture
• These goals are more sensitive to incremental
  progress.
• These goals prompt a treatment plan that
  addresses the reason for the functional deficit.

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...Skilled GoalsBaseline and Comparison

• It is important to show the baseline measures so
  that future comparisons can be made.
• The baseline should be the patients ability
  before intervention by the SLP.
• Each progress update should include a comparison
  of the current status of goals to the previous
  period.

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Baselines

• Documentation should show the baselines for
  specific goals and measures
• Naming ability
• Speech intelligibility
• Auditory comprehension ability
• Response to cues
• Frequency of coughing with PO intake
• Mastication time

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Sample GoalsCognitive-Communicative Deficit

• Patient will follow safety strategies for ADLs
  with 75 accuracy with written cues.
• Patient will use functional problem solving for
  safety during ADLs with 60 accuracy with verbal
  cues and extra time for processing.
• Patient will learn effective use of a memory book
  to compensate for residual memory problems with
  80 accuracy.
• Patient will use external memory aid with 80
  accuracy with verbal and tactile cues to maximize
  memory skills.

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...Sample GoalsCommunication Deficit

• Patient will respond during simple conversations
  related to daily activities with 80 accuracy
  with verbal cues.
• Patient will use short phrases to communicate
  memories of familiar objects with 75 accuracy.
• Patient will point to common objects with 75
  accuracy without cues for basic wants and needs.
• Patient will answer verbally presented
• Wh-questions with 80 accuracy with written cues
  to participate in conversation.

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...Sample GoalsSevere Cognitive-Communicative
Deficits with Sensory Stimulation

• Patient will turn head to locate and keep track
  of moving stimulus for active range of motion of
  neck with caregiver following functional
  maintenance plan.
• Patient will grunt, grimace, or smile to
  communicate with caregiver following functional
  maintenance plan.
• Patient will attend to or respond to stimulation
  appropriate for cognitive level with caregiver
  following functional maintenance plan as designed
  by SLP.

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...Sample GoalsDysphagia

• Patient will produce 25 repetitions of lingual
  exercises with resistance.
• Patient will use chin tuck with 80 accuracy
  during therapeutic feeds with SLP using pureed
  diet without cues for 100 of PO intake.
• Patient will use compensatory swallowing
  strategies for pudding thick liquids for pleasure
  feedings only with 100 accuracy with verbal cues.

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...Sample GoalsHearing Disorder with Aural Rehab

• Patient will speechread phrases at a 4-foot
  distance in a quiet environment with familiar
  speakers with 80 accuracy with cues.
• Use repetition/rewording repair strategies with
  75 accuracy without cues.

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GoalsUpdating the Treatment Plan

• Review the goals when progress updates are
  written.
• Advance the treatment plan as needed through
  considering
• Skilled analysis and adjustment
• Progress assessment
• Functional needs of the patient
• Simplify goals to address underlying impairments
  as needed.

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A SYSTEMS APPROACH TO MANAGING DOCUMENTATION
COMPLIANCE

• Elaine Ledwon-Robinson, MS CCC-SLP, B-C, ANCDS
• University of Michigan Health Care System
• eledwon_at_umich.edu

62
ASHA Survey

• Clinical, reimbursement paperwork the 1
  challenge for SLPs, followed by insufficient
  reimbursement for needed patient services
• 1st or 2nd concern in all health care facilities,
  except pediatric hospitals (ASHA 2007 Health Care
  Survey)

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Key Components

• Quality
• Timeliness

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Quality

• Maintain quality assessment embedded in a CQI
  process
• Include key report components required by
  insurers, Joint Commission, profession

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Meeting Insurer Requirements
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CQI Components

• Medical Dx
• Communication DX
• Onset Date
• Hearing Statement
• Goals/Progress reasonable and appropriate to
  communication dx

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...CQI Components

• Prognosis
• Patient/Family Education/Participation Statement
• Total Number of Visits
• Plan

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Timeliness
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ASHA Code of Ethics

• Principle 1, Rule K Individuals shall
  adequately maintain and appropriately secure
  records of professional services rendered
• Principle 1, Rule M Individuals shall not
  charge for services not rendered

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Staff Survey 2006

• Are current documentation methods, reasonable,
  appropriate in terms of time?
• 23 yes 77 no
• Do you have outstanding reports?
• 85 yes 15 no

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...Staff Survey 2006

• Do you take work home?
• 77 yes

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Initiative

• To unpeel the problem of documentation overload,
  identifying solutions to allow staff to meet
  departmental documentation timeline mandates

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Timeliness Standards Evaluation Reports

• Outpatient evaluation, report must be signed,
  distributed, in electronic chart within 30 days
  of evaluation (UMHS)
• Inpatient evaluation within 1 working day
• Swallow evaluation same day
• (SLP,UMHS)

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Timeliness Standards Tx Reports

• Inpatient document each session within 24 hours
• Outpatient Follow Medicare guidelines for
  treatment encounter notes, progress notes and
  re-certification
• (SLP, UMHS)

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Generating Solutions

• Formed work groups to increase standardization of
  reports, develop templates
• Initiated use of electronic in-boxes to elicit
  physician certification/re-certification of tx
  plans

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Monthly Audits

• Instituted monthly random audits
• Provide monthly data for each staff member re
  meeting timeliness criteria

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Performance Evaluation Timeliness Standard

• 96-100 Exemplary
• 92-95 Meets/Proficient
• 85-91 Approaching
• lt85 Not Met
• (UMHS)

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Challenge Changing the Culture

• New staff
• Senior Staff

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Change Management Changing the Culture

• MYTHS
• Change wont be disruptive
• Change will be quick to implement (Scott and
  Jaffe)

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...Change Management

• 70 of change initiatives fail (Beer and Nohrin
  in Harvard Business Essentials)
• In a major initiative, 20 support it 50
  fence-sit 30 oppose (Price Pritchett in Harvard
  Business Essentials)

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Stages of Reaction

• Shock, denial
• Defensive retreat
• Acknowledgement, mourning
• Accept and Adapt (Jick in Harvard Business
  Essentials)

84
Anchoring Changes

• Understand the culture that promotes current
  behavior, in order to help people transition to a
  new culture
• Anchoring a change in a culture the last step
  in the change process, requiring much
  communication, and sometimes, staff turn-over
  (Kotter)

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Continuous Incremental Change

• The alternative to abrupt, intermittent change
• Antennae up for impending changes
• Maintain staff in change mode
• Change made routine

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Importance of Managing Change

• Include in performance evaluation
• Adapting to change responds positively to
  change, showing willingness to learn new ways to
  accomplish work
• For senior staff, willingness to innovate and
  identify new ways to accomplish work

87
Staff Survey 2008

• Are current Documentation Methods reasonable in
  terms of time
• Yes 25 Variable 9 No 66
• (2006) (23) (77)

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Survey

• Do you take work home
• Yes 67 (2008) 77 (2006)
• How much time spent at home per week?
• 15 minutes - 1.5 hours 37.5
• 1.6 hrs -3 hrs 37.5
• gt 3 hours/week 25.0

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...Survey

• Outstanding Reports
• 67 no 33 yes (2008)
• 15 no 85 yes (2006)

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University of Michigan Health Systems Survey
Results
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Survey

• Self-rating of stress re maintaining report
  timeliness
• Mean of 6.94 on 10-point scale
• Range 4.5 to 9.5

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Future Goals Timeliness Standards

• Work to streamline reports and reduce stress
  factor of meeting timeliness deadlines

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Future Goals

• Consolidate timeliness gains and update timelines
• Assess impact of direct text entry for accuracy
  dangers of cut and paste, including propagation
  of errors, loss of overview (Ash et al.,2004
  Weir et. al., 2003 Hirschtick, 2006)

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Mission Ongoing