Helen M. Simpson Rehabilitation Hospital Leveraging IT to Coordinate Care Transitions

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1 Helen M. Simpson Rehabilitation Hospital Leveraging IT to Coordinate Care Transitions All speakers have completed commercial bias disclosure forms and do not have any conflicts of interest

2 Disclosures It is the policy of Corexcel and IMNE to ensure fair balance, independence, objectivity, and scientific rigor in all programming. In compliance with the American Nurses Credentialing Center (ANCC) and the Accreditation Council for Pharmacy Education (ACPE), it is the policy of Corexcel and IMNE that faculty disclose all financial relationships with commercial interests over the past 12 months. Corexcel s provider status through the ANCC and IMNE s provider status through the ACPE, are limited to educational activities. Corexcel, IMNE, ANCC and ANCC do not endorse commercial products.

3 Objectives Understand the importance of continuity of care as patients transition across care settings. Discuss the clinical documentation process and compliance standards for a rehab setting. Discuss ways in which IT can support clinical documentation in a rehab setting. Share examples of how IT supports a coordinated approach to care delivery in a rehab setting.

4 Presenters Melissa Gillis, OTR/L MPA Administrative Director, Physical Medicine and Rehabilitation and Rehabilitation Hospital Cynthia Brown, RN, BSN, MS Director of Clinical Informatics Jenny L. Morris, RN, BSN Clinical Informatics Specialist

5 Disclosures It is the policy of Corexcel and IMNE to ensure fair balance, independence, objectivity, and scientific rigor in all programming. In compliance with the American Nurses Credentialing Center (ANCC) and the Accreditation Council for Pharmacy Education (ACPE), it is the policy of Corexcel and IMNE that faculty disclose all financial relationships with commercial interests over the past 12 months. Corexcel s provider status through the ANCC and IMNE s provider status through the ACPE, are limited to educational activities. Corexcel, IMNE, ANCC and ANCC do not endorse commercial products.

6 Objectives Understand the importance of continuity of care as patients transition across care settings. Discuss the clinical documentation process and compliance standards for a rehab setting. Discuss ways in which IT can support clinical documentation in a rehab setting. Share examples of how IT supports a coordinated approach to care delivery in a rehab setting.

7 PinnacleHealth Harrisburg, Pennsylvania Non-profit healthcare system in Central Pennsylvania since 1873 Healthcare network includes four campuses, Family Care practices, specialty practices, outpatient surgery and Imaging centers, PinnacleHealth-Fox Chase Regional Cancer Center, Inpatient and Outpatient care, Home Health and Hospice services. 591 licensed beds 55 bed Rehab Hospital Primary service area includes 550,000 people in a five-county area Annual Statistics Surgeries: 23,000 (in our hospitals) Emergency Department Visits: 58,000 Births: 5,000 Employees: 4,500 Medical Staff: 800 active and courtesy staff

8 Impetus for Change CMS Regulatory Changes 2010 IRF-PPS Administrative Efficiency and Compliance Physician and Therapy adoption of IT Clinical Process Quality

9 Innovation via CMS SURPRISE! October 15, 2009 Inpatient Rehabilitation Facility-Prospective Payment System (IRF-PPS) Strong Documentation Requirements highlight regulatory changes for 2010 Effective January 1, 2010

10 Premises of Changes Areas of Discussion Attending Physiatrist demonstrates active involvement in Pre-Admission Process Must approve patients for admission Pre-Admission Assessment becomes part of Medical Record Post Admission Assessment 24 hours after admission Admission H&P is not enough Must demonstrate that interdisciplinary team has been part of initial itial communication Interdisciplinary Plan of Care 72 hours after admission Existing Interdisciplinary Team Conference Form meets standards Must demonstrate interdisciplinary involvement and oversight by physiatrist Documentation by Team Interdisciplinary Focus is important Must demonstrate rehab nursing and therapies are communicating among a all shifts.

11 Documentation Opportunities Post Acute Care Coordinator moves to EMR on Acute Therapist documentation within EMR on Acute and then Inpatient Rehab Nursing documentation re-design to meet inpatient rehabilitation needs. All time stamped encounters needed for regulatory compliance are posted in EMR Interdisciplinary Plan of Care in Weekly Team Conference within EMR Use of Electronic Signatures by team

12 Rehab Approval Process Automated the Post Acute Care Coordinator (PACC) assessment PACC nurse notifies physician via consult Physician completes approval on-line Resource center is notified via the tracking board to initiate the insurance approval process Resource center auto faxes a system generated report to the insurance provider

13

14

15 Tracking Board

16 Rehab Report

17 Admission to Rehab Hospital Facilitate transition of care from acute care to the rehab hospital Sharing of historical information between therapy disciplines Prompts to complete required nursing documentation Decrease documentation time charting the shift and admission assessments so that Nursing can focus on functional assessment documentation

18 Facilitating Transition of Care

19 Rehab Clinical Summary

20

21

22 Shared Historical Information

23 Worklist: Required Documentation

24 Abbreviated Nursing Assessments

25

26

27 Functional Assessment Consistency across disciplines with functional assessment Correlation between therapy and nursing documentation and the functional level Accurately reflects functional ability Clinician providing the care completes the documentation Easily view the trend of patient s s functional level

28

29

30

31 Plan of Care/Team Conference To facilitate coordination of care utilizing the interdisciplinary plan of care: Shared Problem List and Outcomes Nursing assigns medical mgmt problems Therapy assigns functional problems Communication between disciplines Physician approval of Plan of Care Review of plan at Team Conference

32

33

34

35 Physician Alert to Review Plan of Care

36 Team Conference

37 Regulatory Requirements Charge for service at the point of care Automatic calculation of therapy units Real Time display of therapy hours. Summary of Care Document upon Discharge from Rehab

38

39 Total Therapy Time

40 Summary of Care

41 Outcomes of Project Clinical Process Quality Streamlined Audit of patient encounters including timeliness Standardized procedures for therapist initial evaluation on Acute and Inpatient Rehab. Functional documentation algorithm embedded in EMR Clinical Outcomes Consistent tracking of 3 hour rule and reasons for missed therapy Two deficiency free certification surveys through Joint Commission in past 18 months

42 Outcomes of Project: Review by Contracted Auditor

43 Future Plans Physician documentation of H&P and progress notes in Soarian Explore replacing the current system with Soarian in the outpatient rehab sites Continue to enhance documentation and processes to comply with regulatory changes

44 Questions?

45 Download the Free Chapter Chapter 2 PinnacleHealth: Leveraging Documentation and Embedded Workflow Technology to Coordinate Care across a Health System Part of the new series, Technology in the New World of Healthcare, from Siemens Healthcare.

46 Contact Hour Credits In order to receive contact hours for today s session: If you are eligible and would like to receive credit, please follow the instructions for completing the evaluation. The instructions will appear on your screen momentarily. Or you can click on the evaluation link located on the bottom of your viewing console. Once you have completed the evaluation, you will have the ability to print out your certificate for Continuing Nursing Education Credits of 1.0 contact hour offered by Corexcel. For those of you in a group setting: If you are viewing this webcast in a group setting and would like credits, you may do the following: If you are not already registered, please be sure to register to view the playback of this event. You can access the playback through the or through the follow-up that will be sent to all registrants. The playback will be available within a few days after the conclusion of the live event. Once you complete the evaluation and are eligible for credits, you may print your certificate. These instructions will also be included in the follow-up to all attendees. Copyright 2013 Siemens Medical Solutions USA, Inc. All rights reserved.

47 Upcoming Siemens Webcast Topics Contact Information: Gail E. Latimer, MSN, RN, FACHE, FAAN, Vice President, Chief Nursing Officer, Siemens Healthcare Missed a webcasts? To view previous webcasts or to learn more on how healthcare IT can help tackle the challenges clinicians face today visit Siemens Clinical Gateway at: Copyright 2013 Siemens Medical Solutions USA, Inc. All rights reserved.

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