day1pp3 physician buyin prescott final - acdis buyin_fi… · •providers are struggling to...

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Promoting Physician Buy‐In:Communicating Key Concepts

Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRCDirector, CDI EducationHCProMiddleton, MA

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Learning Objectives

• At the completion of this educational activity, the learner will be able to:

– Discuss the challenges related to provider education in the outpatient setting

– Develop a provider education plan

– Identify key concepts to include in provider education

– Explore educational strategies to successfully communicate concepts

2018 Copyright, HCPro, a brand of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.

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What Is Engagement?

“To involve yourself or become occupied”

“An emotional connection that influences behaviors”

“To participate fully and deeply”

“Emotional involvement or commitment”

“Active support of a project”“An ability to envision how one’s own work contributes to the overall goal”

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What Do We Mean by Physician Engagement?

Engagement

“To involve oneself or become occupied; to participate fully and deeply”

o Active support of your efforts by answering queries, applying CDI teaching to documentation, seeking guidance from CDI specialists. Participating in committees and efforts to improve documentation.


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Why Is Provider Engagement Important?Our Success Is Their Success!

• A provider’s focus should be caring for the patient, not navigating the intricate world of healthcare reimbursement, quality reporting, and medical necessity.

• We can be the support structure—the resource to assist in navigating the waters. We can be the “compass.”

Meaningful use

Affordable care

organizations

MACRA/MIPS

Risk adjustment

Medical necessity

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Be the Compass;Point Them in the Right Direction

‐ Just as a navigator must rely on a compass, demonstrate to providers that you are the resource to understanding how their documentation influences the desired goals

‐ Educate the impact of documentation upon the big picture

‐ Be available for Q&A‐ If you don’t know the answer, find it‐ Share new information as you learn‐ Be “ever‐present”


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Strategies for Provider Engagement:Understand the Barriers

• Providers are struggling to survive in the new value‐based environment.

• Providers state frustration, feeling decreased autonomy. They are now employees versus controlling their own destiny.

• Although most providers are experiencing decreased reimbursement, there is a misconception that compensation is the most important driver of their satisfaction. Most desire less regulatory interference. They just want to “practice good medicine.”

•Do they see you as regulatory interference?

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Strategies for Provider Engagement:Understand the Barriers

• Providers have little understanding of reimbursement methodologies, value‐based measures, risk adjustment, and how their documentation serves to support these efforts.

• Providers are busy, stressed, and overwhelmed.

• Provider burnout rates are skyrocketing. Burnout is defined as a long‐term stress reaction marked by emotional exhaustion, depersonalization, and a lack of sense of personal accomplishment.

To be successful, we need to be seen as a resource, an assistant. If you are viewed as an impediment, or one that will slow downthe workflow, providers will be less apt to want to work with you.


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Stages of Engagement

Awareness ConsiderationDecision‐Making

“Buy‐In”

RejectionWhy should I care? Why should I work

with you?

Do I gain Anything in thisrelationship?Is it worth my effort?

Supportive relationship

Little cooperation with your efforts

We need to demonstrate our

value

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Strategies for Provider Engagement:Check Your Messaging

• They need to understand the WHY more than the HOW

• They want to see improvement measures that lead to improved patient care, versus to decreased costs and less waste

• Partner with physicians—YOU are part of THEIR team

• Messaging must clearly and consistently state expectations

• Administrative support is key to success

– C‐suite communications

– CMO, chief of staff, physician leaders

CDI specialists must be assertive, confident, and competent in their approach to providers. The provider should see them as a resource, an assistant in the process of ensuring accurate documentation to capture patient complexity.


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6 Steps to Gain “Buy In”

1. Discover & speak to your common purpose

2. Use an engaging style—speak to rewards

3. Reframe values & beliefs– Listen & address concerns to gain trust

4. Develop an engagement plan—education activities

5. Use “engaging” improvements (more carrots, less sticks!)

6. Show courage and provide backup… and number 7: outline clear

lines of expectation

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How Do We Engage Physicians?What Assumptions Have You Made?

• Do physicians learn in the same manner as you do?

• Do physicians make decisions differently then other professionals?

• Are physicians motivated by the same concepts as you?

• Do physicians have the same priorities as you?

• Are all physicians alike?

We don’t need to walk like an Egyptian … but we do need to think like a physician!

Medical training has conditioned most physicians to be CONVERGENT learners, or independent, hands‐on learners. They learn by DOING, hands on experimentation, simulations and other practical applications of knowledge.


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Step 1: Introduce the Concepts, Demonstrate the ValueWhat Is the Purpose of the Medical Record Anyway?

Provider’s View

– Communication/patient safety

– Malpractice protection

– Professional billing

Your View

– Communication/patient safety

– Malpractice protection

– Professional billing

– Medical necessity of care

• Denial prevention

– Risk adjustment

• HCC capture/risk scores

– Quality outcome measures

The provider needs to see the world

through your eyes ...

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Concepts:What Do the Providers Need to Understand?

• Match the concepts to the focus of your program goals• Match the concepts to the provider’s motivations• Keep them as simple (or as complex) as the provider requires• Be specific & concise• Pace yourself—prioritize to highest impact


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Concept 1:Complete Documentation EqualsAccurate Code Assignment, Which Equals …

Provider Documentation of Diagnoses & Plan of Care

Assignment of ICD‐10Diagnosis Codes & CPT Codes

Influence:DRG AssignmentDenials‐Medical Necessity‐Clinical ValidityProfessional E&MQuality Scores‐Hospital (HVBP)‐Provider (MACRA, MIPS)Severity of Illness (SOI)Risk of Mortality (ROM)Patient Risk Score (RAF)

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Concept 1:The Value of Focused Documentation

• Accurate documentation not only demonstrates complexity under HCC methodology, but can also:

– Positively affect inpatient MS‐DRG payments

– Support medical necessity of setting

– Positively affect provider professional fees

– Positively affect quality measures

– Positively affect publicly reported data

• Physician Compare

• Hospital Compare

• Private rating companies


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Concept 1:Reporting Diagnosis Codes

• Regardless of the setting, the documentation should describe the patient’s condition, using terminology that includes:

– Specific diagnoses

– Symptoms (that are linked to diagnoses when possible)

– Problems

– Reasons for the encounter

• There are ICD‐10‐CM codes to describe all of these

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Concept 2:Coding Professionals & Code Assignment

Coding is a very exact discipline where the clinical documentation must exactly match the coding terminology for a code to be assigned.

There are strict guidelines and direction related to:

– When the documentation is sufficient to assign a code

– Which code to assign with which clinical indicators

– How to sequence the codes (identification of the principal diagnosis)


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Concept 2:Clinical Versus Coding Language

Healthcare providers typically document care using “clinical” terms, symptoms, differential diagnoses, orders, and

test results

Code assignment requires specific

language to allow a “match” between the documented verbiage and a diagnosis code

CDI function sits here

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Concept 3:CDI Program Purpose

• CDI specialists assist in obtaining complete and accurate documentation by: – Facilitating and obtaining appropriate provider documentation within

the health record for the clinical conditions and treatments that are required for accurate representation of severity of illness, expected risk of mortality, and complexity of patient care

– Exhibiting thorough knowledge of clinical documentation requirements as they relate to the classification systems, MS‐DRG assignment, and clinical conditions and treatment needs of the patient population

– Educating members of the patient care team and others regarding documentation guidelines

AHIMA. "Guidance for Clinical Documentation Improvement Programs." Journal of AHIMA 81, no.5 (May 2010)


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Concept 4:Publicly Reported Data

• Publicly reported data contains aggregate data that is focused on healthcare services of facilities and providers

• Much of this data is obtained from coded or administrative data obtained from hospital billing practices and through chart abstraction and record review

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Concept 4:Quality Measure Data

• Quality measure data is a growing industry focus and is available through several organizations, including:

– The Healthcare Effectiveness and Data Information Set (HEDIS)

– The Leapfrog Group

– Healthgrades

– The Joint Commission

– Hospital Compare

– Agency for Healthcare Research & Quality (AHRQ)


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Concept 5:Impact of Diagnosis Codes on Risk Adjustment

• The diagnosis codes assigned to a patient can have a huge impact on the patient’s calculated risk score

• There is a validation process associated with the submitted diagnosis codes to ensure they are accurately reported– Code assignment validation

– Clinical validation

Provider documentation is key to support accurate codeassignment and clinical support

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Concept 5: Risk AdjustmentWhich patient presents with higher risk?

• 85 years old• Lives at home• Participates in yoga and

aerobic dance 2x a week

• History of osteoporosis• Nonsmoker

• 87 years old• Lives at SNF• CKD stage 4• Chronic respiratory failure,

oxygen‐dependent • Insulin‐dependent, DM 2• Diabetic foot ulcer


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Concept 5: Specificity Is Key

• Documentation states “Heart failure w/ depression”

– HCC 85 adds .317 risk score

• Documentation states “Acute systolic heart failure with recurrent endogenous depression”

– HCC 85 adds .317 to risk score

– HCC 58 adds .388 added to risk score

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Concept 6:Observed to ExpectedActual to Predicted

– Focusing attention on whether this ratio is greater or less than one shifts the focus from how the provider actually performed to how the provider performed relative to expectations, given the provider’s particular case mix.

– For example, a provider treating very sick beneficiaries might have high per capita costs but much lower costs than would have been expected for beneficiaries of comparable risk. On a risk‐adjusted basis, this provider would be considered a strong performer.


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Concept 6:Observed to ExpectedOrganization‐Specific & Provider‐Specific

CMS also uses this data to calculate a value modifier that adjusts each physician’s Medicare Physician Fee Schedule payments upward, downward, or not at all, based on the provider’s performance. Measures include:

– 30 day all‐cause readmissions

– Acute and chronic Ambulatory Care Sensitive Condition (ACSC) composite

– Medicare Spending per Beneficiary

– Mortality rates

– Complication rates

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• The documentation should clearly support the diagnoses documented, including related clinical indicators and medical decision‐making.

Patient admitted with the diagnosis of diabetic foot ulcer with related gangrene. Ulcer located on left great toe, Wagner grade 2. Excisional debridement identified gangrenous, necrotic tissue invading the phalanx and the tip of the metatarsus. After consult with the patient, family, and orthopedic surgeon, it is felt that a partial amputation of the foot is required.

Concept 7:↑ Pa ent Complexity = ↑ E&M Levels


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Concept 8:Beware of the Dangers of Cut & Paste

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Tailor Your Teaching to the Provider


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Respect Each Provider’s Unique “Style”

• Recognize you can’t cater to every specific provider need, but personalize your approach

– Don’t provide them education they don’t need

– Don’t interrupt the process of patient care

– Understand their specific learning style

– Learn the best time to approach them

• Morning, evening, Monday, Friday, etc.

Learn what motivates each provider. Is it money, quality scores, time, patient safety, etc.?

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Traditional Methods of Motivating Physician Engagement

• Physician report cards (metrics)

• Peer benchmarking

• Expectations outlined within medical bylaws—consequences if not met

• Physician advisor counseling

• Employment contracts

Add some carrots ...


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Carrots (Tangible & Intangible)

• Recognize “gold star performers”• Bonuses & awards• Food/prizes/fun

• Lunch for the office staff• Their favorite candy

• Celebrate improvement from baseline• Public recognition• Medical staff meetings• Billboards

• Highlight great documentation when it occurs• Identify time savings (less time with query, denial appeals, etc.)

• Ask to use as a resource (physician champion)

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Know Your Audience

• Physicians, as a group, tend to have similar personality traits. For example, physicians are:

– Educated, so give them definitions

– Scientists, so give them data

– Proud, so illustrate how they rate against their peers

– Results‐oriented, so give them a goal

75% are independent learners> 75% learn best with hands‐on activities


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Now Who is in ChargeWho Drives the Bus?

• Who runs the provider’s schedule?

• Who is the “gatekeeper”?

• Who can reinforce your teaching when you are not there?

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Don’t Forget the Social Game

• Always present with positive tone

• Share some personal facts

• Share a great article you read on a clinical subject

• Ask them to teach you about their subject of expertise

Your son is on my daughter’s soccer team?

What does COPD Gold stage 4 mean? And how does that relate to chronic

respiratory failure?

Did you watch last night’s

episode of The Walking Dead?

How is your How is your dad? Last time we talked, he was having surgery …


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Discussions With a Provider …They Are Never “One and Done”

Laurie, did you know on average it takes 12 attempts to train a German shepherd to

fetch?

Actually Dr. P, I did not know that; what are you trying to tell me?

Compare that to the 21 years it takes to educate a doctor!

Dr. P, are you trying to tell me that German shepherds are more

intelligent than doctors?

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Developing the Educational Plan


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Develop an Education PlanDon’t Go In Blind

Assess

Analyze

PlanImplement

EvaluateNurses …

Does this look familiar?

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AssessmentEstablish Baseline “Function”

Complete a review of the provider’s documentation

Use a check sheet to capture objective data

• Missed opportunities/missed charges

• Needed specificity

• Maintenance of the problem list

• Risk adjustment/E&M level/medical necessity of care

Gather the data (compare to peers)

Denial rates

Risk scores

E/M levels

Quality metrics


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Analyze

• Analysis of the data should help identify areas in need of improvement

• Identify strengths and

– Identify the opportunities

– Examples:

• Missed HCC capture/risk score

• Error in E&M leveling

• Denials due to lack of specificity

• Specificity required for quality measures

• Etc.

Notice I said “opportunities,” not

problems!

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Plan

• Know your audience

• Identify the best method to communicate

– One to one—face to face

– Email feedback with follow‐up

– Phone consultation

• Communicate the data/facts

– Peer comparison (risk scores, quality scores, E&M, denials)

– Financial impact

• Use concrete, personal documentation examples

– Before & after comparisons with rationale


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Concrete Documentation ExamplesCompare Actual to Desired Documentation

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Discuss where improvements can be applied

and whyRisk

adjustment—HCC capture

Higher E&M

leveling

Don’t forget to point out examples where the provider has documented very well.

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ImplementationPutting the Plan Into Action

• Review the results

• Offer education and rationale to capture opportunities

• Leave written summary of your discussion for later review—with your contact information

• Contact provider the following day to say thank you and reinforce teaching

– Email/phone/face to face

– Identify timeline for revaluation/assessment

– Provide “tip sheet” related to identified opportunities

• Include contact information for Q&A, troubleshooting


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Evaluate

• Establish when you reevaluate/audit the record for progress and ensure you return with the new assessment when complete

• Compare the results to those completed prior to the education

– Identify areas of improvement

– Identify areas of needed opportunity

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Finding Opportunities,Developing Teaching Strategies


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Physician Engagement

Educational opportunities

• New physician orientation

• Resident training

• Medical staff presentations

• Newsletters/email blasts/pocket cards

• Face to face (Johnny on the spot)

• Targeted educational materials

• 1:1 meetings

• Shadow experience

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Seven Times, Seven Ways

• Communicate creatively, concisely, and consistently








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What Did I Just Say???

Communicate creatively, concisely, and consistently

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Seven Is the Magic Number

• Identify your message

Message specificity required to code depression

Specify: Single episode or recurrent Mild, moderate, severe With/without psychoses Partial/full remission


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Seven Is the Magic Number

• Identify 7 ways to communicate that message

1. Face‐to‐face discussion related to missed opportunity on risk adjustment

2. Follow‐up email with DSM‐5 diagnostic criteria3. Introduction of the PHQ‐9 screening tool into

documentation, with instructions on how to use/interpret4. Cheat sheet/pocket card related to documentation of

depression5. Copy of article related to the prevalence of depression

within the MCR population6. Education to nursing staff in the office related to topic7. Delivery of a candy bar thank‐you for improving

documentation (e.g., depression that includes specificity needed, etc.)

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Keys to Successful Communication

1. Communicate in a regular rhythm or cycle2. Make your communication digestible3. Be focused in each communication4. Follow up individually with 1:1 conversation


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Facts to Remember

Become the resourceBecome part of the provider’s teamThe provider’s success and your success are one and the same!

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Thank you. Questions?

Laurie Prescott ‐ [email protected]

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide.


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