“My Patients Are Sicker”…Prove it!

When thinking of quality outcomes improvement, much focus is on the particular quality concern (such as a readmission, accidental laceration, etc.) and reducing the incidence through better practice, improved documentation or coding. But not enough attention is focused on risk-adjustment for the various quality indicators. And sadly, this is the easiest part to fix! Let’s take readmissions as an example. The threshold for an acceptable number of readmissions is set by the governing body, such as CMS or a state health department. The threshold for readmission takes into account certain secondary diagnoses that may make it more likely for the patient to be readmitted within 30 days. And the documentation today sets thresholds for subsequent years. Many institutions rightly plead their case about disproportionate share patients affecting their risk adjusted scores and are frustrated by the thresholds set, but forget how they are set. Clinically speaking, we all understand that certain chronic conditions make it more difficult to manage both the acute episode of illness and the long-term health of the patient. Having an electronic medical record should enable providers to view the entire health record of their patient and ensure they are addressing all acute and chronic conditions. But that is where the disconnect starts. Providers manage those conditions but usually do an insufficient job of documenting those same conditions. Now I can totally appreciate having too much “paperwork” and spending more time on documentation than on patient care, but listing all chronic conditions (and as specifically as possible) provides accurate data for determination of what conditions make a patient more likely to be readmitted and hence increase the readmission threshold. And I haven't even mentioned the impact on resource consumption in caring for the patients! Stay tuned for a discussion about that next time! So let’s look at one readmission cohort: COPD. Example of secondary conditions that affect the readmission threshold for COPD include history of mechanical ventilation, sleep apnea, dementia, malnutrition, stroke, certain malignancies, fibrotic lung disease, certain mental conditions and alcohol/drug dependencies. And don’t forget appropriate documentation of palliative care (v66.7/Z51.5). It is a global exclusion for readmissions for the indexed visit and for the readmission visit as well. Organizations need to ensure that providers are appropriately documenting comfort care/palliative care and that HIM staff are capturing when it meets the definition of a reportable “condition.” Please note that I am only speaking about the chronic conditions. Let us not forget the acute conditions that necessitate a longer stay and sometimes cause the admission to become an outlier. With better documentation of those secondary conditions, we can reduce the number of outlier days in some incidences. Again, stay tuned! Bringing it back to clinical documentation improvement efforts, we must think beyond diagnoses that impact case mix index, severity of illness/risk of mortality or quality outcomes. We need to evolve the discipline of clinical documentation improvement to clinical documentation completeness. Are your patients sicker and more likely to be readmitted? Prove it! Cheryl Manchenton is a Senior Inpatient Consultant and Project Manager for 3M Health Information Systems.

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