Going the Distance with Behavioral Health Core Measures Workflow Changes to Canopy. Go-Live: July 23, 2015

Transcription

1 Going the Distance with Behavioral Health Core Measures Workflow Changes to Canopy Go-Live: July 23, 2015

2 Learning Objectives Provide an overview of core measures and their importance Describe the enhancements made to nursing documentation Explain the functionality of the core measure tool Define the nurse s role in providing the best care to patients who are admitted to a Behavioral Health unit

3 Core Measures & Their Importance Serve as a national, standardized performance measurement system providing assessment of care in specific areas such as Hospital Based Inpatient Psychiatric Services (HBIPS) Tobacco Cessation (TOB) Initiative established by The Joint Commission (TJC) and Centers for Medicare and Medicaid Services (CMS) to improve quality, safety and performance through collaboration of providers, nursing, pharmacy, and patients Established around evidence-based practice guidelines Strive for the best outcomes

4 Reasons for Changes to Canopy Standardized care across the system by: Embedding evidence-based tools into Canopy Providing consistent documentation as it relates to core measures Ease of work flow A new tool will provide real-time feedback to all clinicians regarding documentation Allow clinicians to easily identify gaps in documentation and will provide links for immediate documentation, if applicable

5 Documentation Changes in Canopy Admission Patient's Stay Discharge Violence Risk to Self Violence Risk to Others Psychological Trauma History (Patient Abuse) Alcohol Screening Tobacco Use Tobacco Use Treatment (Practical Counseling) Education Materials Used for Tobacco Cessation Creation of Post Discharge Continuing Care Plan Transmission of the Post Discharge Continuing Care Plan

6 Documentation Changes to Canopy Admission Violence Risk to Self Violence Risk to Others Psychological Trauma History (Patient Abuse) Alcohol Screening Tobacco Use

7 Violence Risk to Self Columbia Suicide Severity Rating Scale (C-SSRS) selected as evidencebased tool to evaluate risk of violence to self Tool added to Admission Screening for nursing intake and listed as adhoc form if needed Must be completed within 72 hours of admission

8 Violence Risk to Others Timeframes have been added to current Risk for Aggressive Behavior Assessment form Both options within 6 months or longer than 6 months can be selected Must be completed within 72 hours of admission If No is selected, it is the only item that can be chosen

9 Substance Abuse Screening Timeframes have been added Substance Abuse/Use Assessment form. Need to select 1 of the 3 options provided. Must be completed within 72 hours of admission

10 Psychological Trauma History Patient Abuse Form and question titles have been changed to Psychological Trauma History Type of trauma has been updated to include new classification of abuse Must be completed within 72 hours of admission

11 Patient Strengths and Weaknesses Documentation of patient strengths and weakness has been updated to include a new comprehensive list. Must select at least 2 strengths and 2 weaknesses.

12 AUDIT PC is an evidence-based tool to evaluate a patient s history of alcohol use Alcohol Use Screening Added to Admission Screening for nursing intake and in Psychosocial Direct Admit for Social workers Listed as ad hoc form in Nursing and Social Worker folders as well If the total score is 5 or greater, you must select the Proceed to questions 6-10 button for additional questions to populate

13 Alcohol Use Screening Continued Questions 6 10 will need to be completed if a score of 5 or greater is assessed If the additional questions are answered the overall total for the AUDIT will be generated here Must be completed within 72 hours of admission

14 Tobacco Use Screening Continued A timeframe has been added to the Substance Abuse History to include Yes, within 30 days. If a patient indicates they have used Tobacco or Nicotine within the past 30 days, you must complete the details box listed above. If the patient indicates they want to quit using Tobacco/Nicotine, must document the education within 3 days of admission on the ETR.

15 Documentation Changes to Canopy Patient s Stay Tobacco Use Treatment (Practical Counseling) Education Materials Used for Tobacco Cessation

16 Tobacco Use Treatment Provided Must document the following 3 components to indicate tobacco cessation education was provided in Tobacco ETR: Recognizing dangerous situations Developing coping skills Basic information to quit

17 Tobacco Cessation Education A new custom educational tool was developed for all patients who indicate they use tobacco. Please use the education entitled Smoking Cessation Standard (Custom) when providing education materials for the patient. This information encompasses the 3 specific requirements for the measure.

18 Documentation Changes to Canopy Discharge Creation of Post Discharge Continuing Care Plan Transmission of the Post Discharge Continuing Care Plan

19 Post Discharge Continuing Care Plan A new form is currently under development to include the appropriate documentation to be sent to the next provider of care. This document will include the following components: Reason for Hospitalization Principle discharge diagnosis Indications for all discharged medications Next level of care recommendations You will also be able to fax this new form directly from Cerner to the next provider. An EPACT EASE will be distributed regarding this information. STAY TUNED FOR MORE INFORMATION TO FOLLOW

20 Transmitting Continuing Care Plan Accounting of Release form has been added to provide a place for documentation of where the information is sent to the next provider Added to Handoff Transport/Transfer form nursing Listed as an ad hoc form in the Nursing and Social Worker folders for Behavioral Health If provider does not have access to the EMR need to complete the remainder of the form outlined in red.

21 New REAL TIME Core Measures Tool Available on: Handoff Communication Inpatient Summary

22 A New Core Measure Tool Each item on the tool is tied to a documentation element within the patient s chart. Clicking on the blue Document link will automatically open the form that is requiring documentation. An alarm clock signifies the core measure is time sensitive and needs to be addressed as soon as possible

23 A New Core Measure Tool For example, clicking on blue Document for Violence Risk Self will direct you automatically to C-SSRS form. Once a response has been selected for questions #1 and #2, the tool will be updated.

24 A New Core Measure Tool When the documentation is complete the tool will be updated to reflect the documentation. The blue Documentation link will then become grayed out.