CDI and the Effect on Population Health Through Social ... · Microsoft PowerPoint -...

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CDI and the Effect on Population Health Through Social Determinants

Deanne Wilk, BSN, RN, CCDS, CCSManager, Clinical Documentation ImprovementPenn State Health Milton S. Hershey Medical CenterHershey, PA

2019 Copyright, HCPro, a division of Simplify Compliance LLC, and/or session presenter(s). All rights reserved. These materials may not be copied without written permission.

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Learning Objectives

• At the completion of this educational activity, the learner will be able to:– Understand the definition of population health and social determinants– Comprehend impact of social determinants for an organization– Be provided a working model to implement social determinant initiatives for CDI and coding

– Understand specific codes that can be utilized


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What Is Population Health and Social Determinants?


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Definition• “Population health ‘brings significant health concerns into focus and addresses

ways that resources can be allocated to overcome the problems that drive poor health conditions in the population.’ ”

• “Population health has also been summarized as referring broadly to the distribution of health outcomes within a population, the range of personal, social, economic, and environmental factors that influence the distribution of health outcomes, and the policies and interventions that affect those factors.”

• “It is the personal, social, economic, and environmental factors that we call “social determinants.”

Source: https://www.cdc.gov/pophealthtraining/whatis.html


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Social Determinants


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Why Does It Matter?

• Missed appointments due to lack of transportation• Medical and medication noncompliance due to lack of financial security• Lack of care plan understanding and discharge instructions due to illiteracy and education

• Physical stress and lack of care due to mental illness and/or violence• Chronic conditions due to environmental exposure/pollutants• Nutritional deficits impact on healing, mobility, etc.


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A Patient Needs Basic Physiological Needs Met First

https://en.wikipedia.org/wiki/Maslow%27s_hierarchy_of_needs


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Working Model Toward Population Health


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Where to Start?• Determine if your organization is looking at population health initiatives

– Morbidity, cost efficiency, quality, public reporting, and most importantly holistic patient care

• Action should be based on reliable data– Z coding must occur before data can be collected– Set a benchmark

• What Z codes are coded now?– Determine what codes you will incorporate

• Can be based on the World Health Organization factors of economic stability, neighborhood and physical environment, education, food, community and social context, and healthcare system


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Working ModelTeam approach Determine focus Actionable data Outcomes

Develop the team: What will the focus be: What action will result: What improved:

ProvidersCare coordinationNursingSocial workersCDICodingAnalysts

Limit the initial focusSocial factorsMortalityPSIsEfficiencyReadmissionsHierarchical Condition Cat.

Collection of the data will ultimately result in requiredactionResources requiredData analysisStaffingEMR assistance

Patient healthQuality measuresMortalityPSIsRisk adjustment factorsCoordinated patient care

Who needs to be added to the team:

Expand focus: Solid data: Effects of change:

Family practitionersCommunity resourcesNational collaborative

Community assistanceSocial supportIncrease tracked data Z codes

Community outreachState resourcesNational resources

Effecting community changePopulation health changeNational initiatives


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Social Determinants and the Organization

• Organizational awareness and implementation – Population health and social determinants needs to be an organizational initiative. Capture

of these conditions warrants data collection, analysis, action, and resources.• Provider and staff education

– Inclusion and education of providers, nursing, care coordination, quality, and social work teams is imperative to the success of a population health collaborative.

– include social determinant discussion in provider education.– Perform organizational grand rounds on population health and social determinants.– Hold lunch‐and‐learn sessions to include organizational and community providers and

partners.• CDI and coder collaboration

– CDI and coding must be educated and working together on appropriate Z code use, capture, and sequencing requirements of payers for reporting.


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CDI Role in Population Health and Social Determinants

• Documentation– “Assign as many codes as necessary to fully explain each healthcare encounter. Since patient history

information may be very limited, use any available documentation to assign the appropriate external cause of morbidity and Z codes.”

– Source: https://www.cdc.gov/nchs/icd/data/10cmguidelines‐FY2019‐final.pdf• Capture

– Truly paint the picture of the “whole” patient!– Z codes are utilized to report social determinants. Ensure that the code is not on the “primary diagnosis”

list only. These codes should be contained in the first 25 spots as a reportable condition for CMS.• Clinical support

– Z codes are reportable if there is “sufficient documentation to support them.” This may include documentation from the provider, social services, case managers, care coordination, utilization management, nursing, and other clinical professionals. (Refer to Coding Clinic, First Quarter 2018, p. 18: Coding of Social Determinants Using Non Physician Documentation.)

– CDI and coding staff should review the “entirety” of the record in order to collect adequate information to support these codes.


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Z Codes (Limit the Initial Scope)

• Z codes to get you started:– Z55.0 Illiteracy and low level literacy– Z55.8 Other problems related to education and literacy– Z56.0 Unemployment, unspecified– Z56.9 Unspecified problems related to employment– Z59.0 Homelessness– Z59.1 Inadequate housing– Z59.4 Lack of adequate food and safe drinking water– Z59.5 Extreme poverty– Z59.6 Low income– Z59.7 Insufficient social insurance and welfare support– Z59.9 Problems related to housing and economic

circumstances (transportation)– Z60.2 Problems related to living alone

– Z60.4 Social exclusion and rejection– Z60.9 Problems related to social environment– Z62.21 Child in welfare custody– Z63.3 Absence of a family member– Z63.31 Absence of a family member due to military

deployment– Z63.8 Other specified problems related to primary

support group– Z74.01 Bed confinement– Z74.09 Chair ridden/reduced mobility– Z74.1 Need for assistance in personal care– Z74.3 Need for continuous supervision– Z75.1 Person awaiting admission to adequate facility

elsewhere– Z75.4 Unavailability and inaccessibility of other helping

services


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Z Code Specifics

• Specific codes to capture as they impact as a CC, HCC, PSI, or mortality risk factor– Transplant status– DNR and palliative care status– Bedbound/wheelchair bound– Cardiac and heart assist device status– Dependence on vent, dialysis, or supplemental O2 status– HIV status asymptomatic– Multiple birth codes– Attention to an “ostomy” site– Amputation status– Physical restraint status– Long‐term insulin use


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Impact

• Patient– Needs

• Housing• Mental• Nutrition

– Satisfaction• Caring for the patient holistically improves overall health of the patient and the organization

– HCAP scores» Patient satisfaction

– Quality of care– Data

• Screening tools• EMR assistance

– Portal/EMR• Consideration must be given to the diagnosis (Z code) given to a patient as it will be discoverable


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Impact

• Organization– Quality measures

• Mortality• MIPS/QPP/star ratings• PSI exclusions

– Revenue• Comorbid conditions• HCC risk adjustment factors• Quality incentives/penalties

– Mortality risk factors• Outlier payments• Government funding for programs

– Public reporting


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Organizational Change

• Patient‐centered– Meet the needs of the patient population based on the data

• Specialized clinics (diabetes, moms/babies)• Mental health resources

– Abuse/violence/crime– Condition‐specific

• Patient education opportunities• Case management/social work services within outpatient clinic sites

• Community – Community support

• Volunteers– Social support

• Community resources– Housing– Food– Elderly– Transportation– Unemployment– Occupational exposure


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ANA Code of Ethics for Nurses (Provisions 1–3 and 8)

• The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person

• The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population

• The nurse promotes, advocates for, and protects the rights, health, and safety of the patient

• The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities

Source: http://nursing.rutgers.edu/civility/ANA‐Code‐of‐Ethics‐for‐Nurses.pdf


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Additional Resources

• https://www.cdc.gov/pophealthtraining/whatis.html• https://www.cdc.gov/socialdeterminants• https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2019‐ICD10‐Coding‐Guidelines‐.pdf

• http://www.ihi.org/Topics/TripleAim/Pages/default.aspx• https://community‐wealth.org/content/clevelands‐greater‐university‐circle‐initiative

• http://www.pathways2pophealth.org


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Thank you. Questions?

[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 of the program guide.


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