Pairing With Your Dietitians To Diagnose, And The - ACDIS
Malnutrition: Pairing With Your Dietitians to Diagnose,Document, and Capture the Super DiagnosisVaughn Matacale, MD, Director, Clin Doc Adv PgmNjeri Njuguna, MS, RDN, LDN, Mgr Clinical NutritionAshley Strickland, RDN, LDN, CNSC, Clinical Nutrition SupervisorVidant HealthGreenville, NC1Learning Objectives At the completion of this educational activity, thelearner will be able to:– Discuss the impact of malnutrition on patient outcomemetrics and reimbursement– Implement a competency based development program fordietitians dealing with malnutrition2Introduction3 2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
Vidant Health 8 hospitals (3 CAHs)1500 bedsAffiliated medical schoolOver 30 IP coders and 15 CDSs43 dietitians 11,950 employeesOver 1,000 providers63,500 admissions35,000 surgeries5 physician advisors4ICD‐10 DiagnosesE40–46 MalnutritionE40 – KwashiorkorE41 – Nutritional marasmusE42 – Marasmic kwashiorkorE43 – Unspecified severe protein calorie malnutritionE44 – Protein‐calorie malnutrition of moderate and milddegree E45 – Retarded development following protein‐caloriemalnutrition E46 – Unspecified protein‐calorie malnutrition 5Why a Super Diagnosis?6 2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
The Impact of Diagnosing, Documenting,and Capturing Malnutrition Improved patient outcomes Profiling– Better portrayal of care Risk adjustment– Mortality, readmission rates, complication rates Utilization– Length of stay, resource utilization Financial– PQRS/VBPM, CCs/HCCs, MERs, MIPS– DRG7Outcomes: Malnutrition in the Hospital 1 in 3 patients enters a hospital malnourished Malnourished patients:––––2x more likely to develop a pressure ulcer in a hospitalHospitalized an average of 2 days longer than those screened and treated earlyComprise 45% of patients that fall in a hospitalHave 3x the risk for surgical site infection Benefits of nutrition intervention:––––25% reduction in pressure ulcer incidence28% decrease in avoidable readmissions14% fewer overall complications 2 day reduction in average length of stayRecommended further reading: Tappenden KA, Quantara B, Parkhurst ML, Malone AM, Fanjiang G, Ziegler TR. Critical role of nutrition in improving quality of care:an interdisciplinary call to action to address adult hospital malnutrition. JPEN J Parenter Enteral Nutr. 2013;37(4):482‐497. The Facts on Malnutrition. Available from: http://malnutrition.com/getinspired/factsheet. Accessed January 13 , 2016.8Profiling: Improved Portrayal of CareIndividualphysiciandata is nowavailable tothe public.Adjusted complication rate9 2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
Risk Adjustment/Utilization: UHC Models There are 214 expected mortality models There are 344 expected LOS models There are 338 expected cost modelsMalnutrition is found in: 38% of expected mortality models 83% of expected LOS models 79% of expected cost ionImpactYesYesYesYes11Case and Query ExampleThis patient with chronic alcoholism has presented with N/V feltto be due to alcoholic hepatitis. She had decreased appetite,weakness and weight loss of over 20lbs in 2 months. Dietitianconsult states “this patient meets criteria for severe proteincalorie malnutrition in the context of chronic illness based on wtstatus (12% loss x 2months) and energy intake [limited intake 2/2behavioral issues (alcoholism)].” Glucerna added to diet. Pleaseclarify if you feel this patient has:1.2.3.4.5.SEVERE PROTEIN CALORIE MALNUTRITIONNON‐SEVERE PROTEIN CALORIE MALNUTRITIONUNSPECIFIED PROTEIN CALORIE MALNUTRITIONOTHER (please specify)CLINICALLY UNABLE TO DETERMINEMD response: Non‐severe malnutrition12 2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
(DRG)Severity ofillness(APR)Risk ofmortality (APR)InpatientpaymentAddedHCCweightNo capture‐‐‐‐‐‐2.90.623ModerateMild 4,5100UnspecifiedMalnutritionnot specified4.10.917ModerateModerate 6,5150.713SpecificSevere P‐Cmalnutrition6.21.67SevereModerate 11,6500.71313Dietitian InitiativeInitial assessment and partnering with CDI142012 Malnutrition Consensus15 2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
Characteristics Supporting aMalnutrition Diagnosis Inadequate energy intakeWeight lossLoss of muscle massLoss of subcutaneous fatFluid accumulationDiminished functional status as measured by handgrip strength2 or more required for diagnosis16Data Collection: May 2014 VMC May 2014 malnutrition3 RDNs: n 39 patients– Patient population:surgery, general med,nephrology, ICUNormal43%Overweight Malnourished patients:– 26% underweightObese13%– 43% normal BMI– 31% overweight/obeseUnder weight26% Malnutrition at any BMI17Data Collection: November 2014 VMC November 2014 malnutrition––––––3 dietitians and clinical documentation specialistAdmitted: August–November 201483 patients identified with malnutritionPopulation: Surgery, general medicine, nephrology, ICUAge: 20 to 97 years43% male, 57% female18 2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
Data Collection: November 2014 Patients identified with malnutrition:– 83 patients identified with malnutrition– 71 (86%) were coded with a malnutrition code by HIMS Malnutrition added to problem list by provider on day ofdietitian evaluation:– 72 No (53 No, 19 No with explanation)– 11 Yes (4 Yes, 7 Yes with explanation) Did the CDS query the provider:– 69% Yes (57)– 31% No (26)19Malnutrition IdentificationRDN DxDoctor DxHIMs malnutritionDxModerate protein‐calorie malnutrition (1%)Severe nutrition (1%)no deferrals/rejections (2%)Moderate (2%)Severe‐ Moderate Malnutrition (2%)Non‐severe (9%)Severe (89%)Mild Malnutrition (4%)Malnutrition of mild degree (4%)Malnutrition of moderate degree (6%)Non‐severe malnutrition (4%)Clinically indeterminable (4%)Malnutrition (5%)Moderate malnutrition (6%)Severe protein calorie malnutrition (8%)Nutritional marasmus (43%)Other severe protein‐calorie malnutrition(28%)Unspecified protein‐calorie malnutrition(5%)blank (11%)Severe malnutrition (52%)20Category 261: Nutritional MarasmusICD‐9 261 Nutritional marasmus– Includes: Nutritional atrophy Severe calorie deficiency Severe malnutrition NOSICD‐10 E43 Unspecified severe protein calorie malnutrition21 2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
Baseline Malnutrition %FY11FY12VMC Maln CaptureUHC AMC Maln CaptureFY13VMC Severe Maln CaptureFY14UHC AMC Severe Maln Capture22AND/ASPEN:Development of Core Competency Program forEducation of Dietitians on How to Identify andDocument Malnutrition23Severe Malnutrition & EtiologyFor example:ICD‐10 code 43Acute illness/injuryChronic illnessSocial/environmentalWeight loss 2%/1 week 5%/1 month 7.5%/3 months 5%/1 month 7.5%/3 months 10%/6 months 20%/1 year 5%/1 month 7.5%/3 months 10%/6 months 20%/1 yearEnergy intake 50% for 5 days 75% for 1 month 50% for 1 monthBody fatModerate depletionSevere depletionSevere depletionMuscle massModerate depletionSevere depletionSevere depletionFluid accumulationModerate SevereSevereSevereGrip strengthNot recommended in ICUReduced for age/genderReduced for age/genderNeed a minimum of 2 of the 6 categories listed above2016 ICD-10 Codes; Centers for Medicare & Medicaid ServicesWhite et al, JPEN, 2012 Consensus Statement24 2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
Moderate Malnutrition & EtiologyFor example:ICD‐10 code 44Acute illness/injuryChronic illnessSocial/environmentalWeight loss1%–2%/1 week5%/1 month7.5%/3 months5%/1 month7.5%/3 months10%/6 months20%/1 year5%/1 month7.5%/3 months10%/6 months20%/1 yearEnergy intake 75% for 7 days 75% for 1 month 75% for 3 monthsBody fatMild depletionMild depletionMild depletionMuscle massMild depletionMild depletionMild depletionFluid accumulationMildMildMildGrip strengthNot applicableNot applicableNot applicableNeed a minimum of 2 of the 6 categories listed above2016 ICD-10 Codes; Centers for Medicare & Medicaid ServicesWhite et al, JPEN, 2012 Consensus Statement25Subject Matter Expert Ashley Strickland, RDN, LDN, CNSC– Instructs workshops on Nutrition Focused Physical Exam (NFPE)nationwide as an independent contractor for The Academy of Nutritionand Dietetics.– Attended a 2 day seminar titled “The Nutrition Focused PhysicalExamination” at Rutgers School of Health Related Professions.Competencies acquired were validated by a medical professional, uponcompletion of this seminar.– Attended a 1 day seminar titled “Diagnosing Malnutrition:Understanding the Role of Muscle and Fat Loss” at Novant HealthPresbyterian Medical Center. Competencies acquired were validated bya medical professional, upon completion of this seminar.– Completed an online education program titled “Patient Simulation:Putting Malnutrition Screening, Assessment, Diagnosis, andIntervention into Practice.” 1 hour of continuing education wasobtained, upon completion of this program.– Completed multiple peer reviewed nutrition focused physical exams.26Education: Dietitian Competency‐BasedOrientationPre reading NUTRITION‐FOCUSED PHYSICAL EXAM (NFPE) Each participant reads 4 selected articles and signs document attesting they have completedthe selected readings. Curriculum review: PowerPoint Nutrition‐focused physical exam assessment: Fat wasting, muscle wasting, edema 3 case studies, complete a physical assessment simulation, identify if malnutrition diagnosisis appropriateInitialPerform head to toe exam (on mannequin) based on ASPEN/academy guidelines and meetcompetency competency1–3 monthsannual Each dietitian completes 2 nutrition‐focused physical assessments completed on livepatients identifying patients with malnutrition. Validation will be completed by subjectmatter expert. December 2014–February 2015: Validation completed for all VMC staff. This validation period included 19 VMC RDNs, 1 ECU RDN, and 1 ECU surgical oncologist. All newly hired RDNs will complete the above competency process within their 3 monthprobationary period.27 2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
Education: Dietitian Competency‐BasedOrientationPre reading Hand grip strength Each participate will read and attest to reading 2 articles and hand dynamometer owner’smanual Occupational therapist (subject matter expert) Trained dietitians on use of hand dynamometer to assess for hand grip strength Dietitian completed return demonstrationInitialcompetency1–3 months June 2015: Clinical nutrition staff completed competency New employees: Training and CBO completed within 3 months of hireannual28Malnutrition: Interdisciplinary ApproachDietitian(RDN)PharmacistHome s29Education: DietitiansTraining: Identify and train subject matter expertAshley Strickland, RDN, LDN, CNSCSubject matter expert competencyTraining: Vidant Medical CenterClinical dietitiansProvider, pharmacists, CDI specialistsTraining: OtherRegional and community dietitiansDietetic interns, home health agencies,case management30 2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
Dietitian and CDI interventions31Order Entry32Query StructureYour professional clinical opinion is requested regarding the following query. Since this is a concurrentquery your response will become part of the patient's permanent record; however, also choosing toinclude your response in the patient's current and future notes will help to maintain chart integrity.FOR RISK OF MORTALITY & SEVERITY OF ILLNESS PURPOSES, please address the following.This patient has been admitted for loculated pleural effusion likely malignant, and family reportedsignificant loss of appetite/anorexia at admission. The nutritionist evaluated the patient on 11/20 andnotes the patient meets criteria for severe protein calorie malnutrition (in the setting of chronicillness) as evidenced by 20% wt loss within 6mos, est intake 75% or less x1mo or more. The patient's pointake since admission has remained low at 0‐25%. Since diagnosis coding comes from MDdocumentation, please render your opinion regarding this patient's nutritional status.‐‐SEVERE PROTEIN‐CALORIE MALNUTRITION‐‐NON‐SEVERE PROTEIN‐CALORIE MALNUTRITION‐‐OTHER (Please specify)‐‐CLINICALLY INDETERMINABLE‐This option will close the query with no clarification of the currentdocumentation, thereby limiting accurate representation of the patient’s care delivery and complexity.PLEASE NOTE: To access further information & criteria for MALNUTRITION & other clinical documentationtips & subjects, please go to the Vidant Health Physician intranet page under the Clinical DocumentationTips Section.33 2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
Dietitian DocumentationComprehensive nutrition assessmentNutrition interventions & recommendations for provider:1. Replete electrolytes before starting enteral feeding as pt is at risk for refeeding syndrome.2. Start Vital AF 1.2 with a very slow progression of rate to help prevent refeeding syndrome. Start Vital AF 1.2 @20 mL/hr X 24‐36 hrs, if tolerated and electrolytes stable, increase by 10 mL every 24‐36 hrs to a goal rate of 50mL/hr 1200 mL formula, of which 972 mL are free water, 1440 Kcals, 90 gm pro, 133 gm CHO, 1519 mg Na, 52mEq K, and 101% RDI.3. Obtain daily wts here and at home.Recommended malnutrition diagnosis:Severe protein‐calorie malnutritionPt meets criteria for severe protein‐calorie malnutrition in the context of chronic illness based on energy intake(less than 75% of est needs for greater than 1 mo) and severe body fat/muscle mass loss.Nutrition focused physical findings/examBraden score: 16Subcutaneous fat loss locations: Orbital region—severe, triceps region—severeMuscle loss locations: Temple region—severe, clavicle bone region—severe, shoulder/acromion bone region—severe, dorsal hand region—severe, patellar region—severeEdema: (LLE weeping of extremity)34CDS, Coder, and Provider Education35Education: Coders and CDSsExternal consultant educationDietitian in‐service with existing codersCoding academy for new codersArticles for coder monthly focused education timeCDS orientation and preceptor for new CDSsCDS meeting education for existing CDSsPilot program CDS presentationDietitian presentation at joint CDS and coder meetingASPEN criteria education and references during CDSorientation Doc tips ASPEN material on shared drive 36 2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
Education:Doc Tips37Education: Provider Short Version 10–20 minutes Combined presentation: Physician advisor anddietitian Includes 4 parts––––Education on ASPEN/AND criteria for malnutritionEducation on dietitian competency programDocumentationCoding and impact clinical example Used for service line meetings, agenda items onregularly scheduled meetings Leave‐behinds—pocket cards, criteria references38Education: Provider Long Version 50–60 minutes Combination presentation: Physician advisor and dietitian More detail and additional sections––––––––Background (why not use albumin, prealbumin, etc.)More detail in ASPEN/AND criteriaIncludes material for a nutrition‐focused physical examStudy outcomesDocumentationClinical case and impact on outcomes and dataOutcomesTransitions Grand rounds format39 2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
Summary of Impact/Results40Capture Results: Total and MCC Level7.0%6.0%5.0%4.0%3.0%2.0%1.0%0.0%FY11FY12VMC Maln CaptureFY13FY14FY15 Q1UHC AMC Maln CaptureFY15 Q2FY15 Q3VMC Severe Maln CaptureFY15 Q4FY16 Q1UHC AMC Severe Maln Capture41Malnutrition Capture Vidant HealthCommunity .0%FY12FY13VH RegionalFY14UHC 250 Non AMCFY15 Qtr1FY15 Qtr2VH Regional Maln MCCFY15 Qtr3FY15 Qtr4FY16 Qtr1UHC 250 Non AMC Maln MCC42 2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
Malnutrition Capture and Expected Y13VMC Maln CaptureFY14FY15 Q1UHC AMC Maln CaptureFY15 Q2FY15 Q3VMC Exp MortFY15 Q4FY16 Q1UHC AMC Exp Mort43Malnutrition Capture and LOS 0%0.90.0%FY11FY12FY13VMC Maln CaptureFY14FY15 Q1UHC AMC Maln CaptureFY15 Q2VMC LOS IndexFY15 Q3FY15 Q4FY16 Q1UHC AMC LOS Index44Summary Points Malnutrition is a diagnosis that impacts healthcareacross the board and is worth focused effort Assess your baseline and opportunity Support dietitians’ training in nutrition‐focusedphysical examination Utilize the expertise and skills of your dietitians in acollaborative fashion for maximum results Make it easy for providers to do the right thing Education, education, education Ensure compliance and clinical validation (education!)45 2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
Dietitian resources The Academy of Nutrition and Dietetics Nutrition Focused Physical ExamWorkshop: https://ams.eatright.org/eweb/StartPage.aspx?Site ACAD2014References White J, Guenter P, Jensen G, Malone A, Schofield M; Academy of Nutritionand Dietetics Malnutrition Work Group; ASPEN Malnutrition Task Force;ASPEN Board of Directors. Consensus Statement of the Academy ofNutrition and Dietetics/American Society for Parenteral and EnteralNutrition: Characteristics Recommended for the Identification andDocumentation of Adult Malnutrition (Undernutrition). J AcadNutr Diet.2012 May; 112 (5): 730‐738 ICD‐10 Code Lookup; Centers for Medicare & Medicaid Services. (n.d.).Retrieved February 1, 2016, from /staticpages/icd‐10‐code‐lookup.aspx?KeyWord Malnutrition&bc AAAAAAAAAAACAA &46Thank you. th.comIn order to receive your continuing education certificate(s) for this program, youmust complete the online evaluation. The link can be found in the continuingeducation section at the front of the program guide.47 2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
19 Data Collection: November 2014 Patients identified with malnutrition: – 83 patients identified with malnutrition – 71 (86%) were coded with a malnutrition code by HIMS Malnutrition added to problem list by provider on day of dietitian evaluation
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DIETITIANS IN PRIMARY HEALTH CARE: A PAN-CANADIAN ENVIRONMENTAL SCAN DIETITIANS OF CANADAI 4PAGE Recommendations For government: . 1. Support innovative primary health care delivery of nutrition services (e.g. teledietetics) in underserviced areas in Canada, as an adjunct to local team-based care. 2.
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