CYPRESS COLLEGE

LONG TERM CARE & THE HEALTH INFORMATION

PROFESSIONAL

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PRESENTED BY

Khaleelah Wagner, RHIATraining Coordinator, AHIS

Anderson Health Information Systems, Inc.

940 W. 17th Street, Suite B

Santa Ana, California 91706

Phone 714-558-3887 Fax: 714-558-1302

Email: khaleelahwagner@hotmail.com or office@ahis.net

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DATE & LOCATION

September 21, 2012

Cypress College

Italic = HIM Student Task

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AHIMA DOMAINS

Identify: Health Information Systems items for a Long

Term Care Facility The rules and regulations and how you stay “in

touch with regulations” Quality assurance and improvement systems

and will practice documentation review Health information systems and tasks for the

HIM Department HIM consultant reports

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AHIMA DOMAINS -2

Assist in identifying a schedule for a LTC facility that includes change of condition

Review the Change of Condition Instruction and receive guidance to conduct onsite visit with an HIM Consultant

Present data both manual and verbal

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HOW SHOULD I DO IT?

Attend a presentation by the HIM Consultant in Long Term Care

Review the ppt. and the handouts Practice one quality of documentation review

and prepare for onsite assignment Attend onsite assignment – Prepare a

summary of the key points learned, identify compliance items and best practices

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EVALUATION CRITERIA

1. Attend the LTC presentation. Identify the most important item learned.

2. Identify key tasks and evaluation of HIM Department.

3. Make a written list of organizational items that would be the same if you were in acute hospital setting, clinic, etc.

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EVALUATION CRITERIA -2

4. Practice of change of condition in classroom setting – identify questions. Use those questions and prepare a one-page summary of the Change of Condition review done onsite with the consultant.

5. Conduct change of condition for 5 residents and tabulate results.

6. Evaluate disclosure logs, HIPAA review of facility.

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EVALUATION CRITERIA -3

7. Identify the schedule of the LTC – Health Information/Record Designee. Assess the completeness and determine if carried out timely and completely. Prepare a one-paragraph summary re: your thoughts re: scheduling process.

8. Evaluate audit grid, evaluate if carried out; trend one or two of findings from audits for presentation to QA.

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EVALUATION CRITERIA -4

9. Prepare a summary of onsite visit with consultant that describes the results of the onsite visit and present the findings that identifies “system issues” and Best Practices.

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TASKS – ACTIVITY

1. Attend the LTC presentation.

2. Prepare a one paragraph summary of the most important item learned.

3. State the HIM – LTC common system/report by consultant.

4. Identify tasks in the LTC facility –HIM/Record Department that would be the same as an acute hospital setting, clinic, etc. **(have the list prepared prior to consult visits)**

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TASKS – ACTIVITY -2

5. List items to be evaluated in an LTC HIM Department.

6. Conduct Change of Condition for 4 residents and tabulate results.

7. Identify the HIM/Record Designees’ last two Change of Condition audits. Identify the deficient areas.

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TASKS – ACTIVITY -3

8. Review the schedule of audits/monitors from the HIM/Record Designee and review the Audit book re: timeliness and follow-up action.

9. Identify five items you learned and/or best practices you observed from the HIM/Record Consultant and/or the HIM/Record Designee’s work in the facility.

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EVALUATE – ACTIVITY

1. Attend the LTC presentation.

2. Prepare a one paragraph summary of the most important item learned.

3. Identify tasks in the LTC facility –HIM/Record Department that would be the same as an acute hospital setting, clinic, etc.

**(have the list prepared prior to consult visits)**

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EVALUATE – ACTIVITY -2

4. Conduct Change of Condition for 5 residents and tabulate results.

5. Identify the HIM/Record Designees’ last two Change of Condition audits. Identify the deficient areas.

6. Review the schedule of audits/monitors from the HIM/Record Designee and review the Audit book re: timeliness and follow-up action.

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EVALUATE – ACTIVITY -3

7. Identify five items you learned and/or best practices you observed from the HIM/Record Consultant and/or the HIM/Record Designee’s work in the facility.

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AHIS OFFICE RESOURCES

Anne Soukup, Business Manager Office 714-558-3887 Email bosslady@ahis.net

Monique Brennan, Consult / Contract Coordinator Office 714-558-3887 Email monique@ahis.net

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HIM CONSULTANTS

Khaleelah Wagner, RHIA Training, Medicare, Coding, eHR Resource

All AHIS Consultants Training – On site records evaluation, Medicare,

Coding, eHR Resource

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ANDERSON HEALTH INFORMATION SYSTEMS

Anderson Health Information Systems, Inc. (AHIS) agreement: Assists [facility/agency] in meeting the

immediate and long range goals of quality improvement through consultation

Identifies the facility status, survey, quality measures

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RE-ENGINEERING OF THE HEALTH INFORMATION

AHIS has Health Information/Record Department tool for evaluation of the Department’s systems (see H.O. #1) Sample HI Department Evaluation Summary (

see H.O. #2) [Facility/Agency’s] current Department

evaluation tools, policies and procedures will be reviewed/recommendations made based on your input

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ANALYZE THE MEDICAL RECORDS SERVICES

Conduct an evaluation of each of the HI/Record Department’s systems and provide input as to the suggested approaches for HI/Records in coordination with the [facility/agency’s] designated staff

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ANALYZE THE MEDICAL RECORD SERVICES -2

Focus items will include: schedule, efficiency and integration into the overall Quality Assurance model (see H.O. #3)

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PERFORMANCE MEASURES

Clinical Records Systems Staff Performance Measures (see H.O. #4)

Criteria represent a fairly complete outline of the duties and responsibilities of the HIM Dept staff

Written in outcome oriented terms Tied to F-tags, Title 22 and other regulatory

requirements and standards of practice in the field of HIM

Key items are introduced and trained and/or evaluated based on facility needs and the experience of the staff member

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PERFORMANCE MEASURES -2

Clinical Records Systems Orientation and Training Checklist

(see H.O. #5) Tracks progress of HIM Staff Training and Skills

Mastery

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PROVIDE WORKSHOPS

For HI/Record Department and clinical staff based on identified needs (see H.O. #6)

Example for records staff training – coding, new regulations/requirements, audit and monitoring systems, Daily Quality Assurance AKA Change of Condition etc. (see H.O. #5)

Workshops for clinical staff may be provided based on agreed topics

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HEALTH INFORMATION/ RECORD MANUAL – AHIS

Will evaluate the current HI/Record Manual to determine if there are policies and procedures that need revision

Regulations that apply Title 22 –State Regulations – Skilled Nursing Federal Regulations by Center for Medicare

and Medicaid Services – Omnibus Budget Reconciliation Act, OBRA – F- Tags

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REGULATIONS

Hospice, Dialysis, Sub-acute Medi-Cal Regulations

Joint Commission OSHA HIPAA Fire and Life Safety Disaster Planning HITECH Automated Clinical Record requirements

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HEALTH INFORMATION/ RECORD MANUAL – AHIS 2

Admission Monitor Admission/7/14/21/30 Day Combined Monitor Admission/7/14/21/30 Day Monitor Admission/JCAHO Sub-Acute Monitor Advance Directive/IHCI/Preferred Intensity of

Care (PIC) Monitor Behavior Drug Monitor Bowel/Bladder Training Monitor

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HEALTH INFORMATION/ RECORD MANUAL – AHIS 3

Care Plan Monitor Change of Condition/Daily Quality

Assurance Monitor Clinical Record Monitor Combined Admission Monitor – see

Admission/7/14/21/30 Day Combined Monitor

Diabetic Monitor Dialysis Monitors Hospice Monitor

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HEALTH INFORMATION/ RECORD MANUAL – AHIS 4

Intake/Output/Catheter Monitor JCAHO Sub-Acute Monitor – see

Admission/JCAHO Sub-Acute Monitor Licensed Progress Note Monitor –

Option I/II Medicare/MDS Monitor Medication Monitor Minimum Data Set (MDS) Monitor Nursing Assistant Flow Sheet Monitor

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HEALTH INFORMATION/ RECORD MANUAL – AHIS 5

Pressure Sore/Ulcer/Skin Conditions Monitor

Rehabilitation Monitor Respite Care Monitor Restrictive Device/Restraint Monitor

Therapy Monitor Treatment Monitor Weight Monitor/Weekly Weight

Monitor/Weight Log

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HEALTH INFORMATION/ RECORD MANUAL – AHIS 6

AHIS will offer recommendations for policy/procedure updates/changes when indicated and when new regulations or interpretations are identified. AHIS will advise on current changes in our own manual and assure [facility/agency] is informed

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ASSIST

With implementation of [facility/agency’s] policies and procedures, as applicable

Adapt the Medical Record Consulting processes that would compliment the Corporation’s policies and procedures

NEED TO BE KEPT CURRENT RE: _____________ CHANGES THAT AFFECT HIM/RECORD SYSTEMS

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CORPORATE QUALITY IMPROVEMENT PROCESS

Will collect information based on predetermined topics and criteria, provide a summary, conclusions and analysis for problem solving and follow up

Coordination will be carried out with the interdisciplinary team members

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CORPORATE QUALITY IMPROVEMENT PROCESS -2

AHIS will utilize [facility/agency’s] Quality Indicators / Measures for care documentation

[Facility/Agency] to provide guidance to AHIS in this area to assist with coordination

Sample Medical Records Compliance Study (see H.O. #7)

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QI INDICATORS FOR DOCUMENTATION

AHIS = manual of Quality Improvement Documentation and Outcome indicators

Will assist in maximizing the use of eHR automated tools that are available

Informed Consent Monitor (see H.O. #8) DPH – AFL letter (see H.O. #9)

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EXAMPLES OF REPORT & TRENDING

Consultant will review and explain Sample consultant’s report (see H.O. #10)

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COMPUTERIZATION

Will evaluate the record tasks related to computerized systems

eHR Checklist – partial (see H.O. #11) Document Management System Checklist –

partial (see H.O. #12)

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CONSULTANT COORD. & MTG. ATTENDANCE

AHIS will attend meetings as designated and arranged corporate-wide participation

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RESOURCES

Provide health information management resource materials

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HEALTH INS. PORTABILITY & ACCOUNTABILITY ACT

HIPAA Security Rule Part of the Health Insurance and Portability and

Accountability Act 1996 Administrative Simplification Privacy Rule enforceable April 14,2003 Security Rule enforceable April 20, 2005

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HIPAA -2

Will provide the basic part of HIPAA as a part of the consultation services. AHIS has experts in the area of Transaction Code Sets, Privacy and Security

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HIPAA -3

Under separate agreement, AHIS can provide an outline for HIPAA assessment, training & implementation Privacy Transaction and Code Sets Security National Provider Number Attachments AND MORE---

HIPAA II

HITECH – deals with the privacy and security of electronic data, i.e., encryption

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NEWS & TRAINING

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OFFSITE ASSISTANCE & TRAINING

Some training maybe appropriate to be provided via Webinar

AHIS will provide Webinar training and/or offsite training via phone and instructional material

Can establish training for online computerization…if arranged

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OFFSITE ASSISTANCE & TRAINING -2

Webinar Schedule Dates

TBD

Time TBD

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MANUALS (Electronic/Copy)

Health Information / Record Administrative Quality Assessment / Indicator Dialysis Psychiatric HIPAA

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QUALITY THROUGH CONSULTATION

Our intent is to enhance skills, reduce costs and increase efficiency

Find better ways of doing things Increase automation Assist to meet legal expectations, reduce

risks Assist with compliance HAVE FUN!

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JOIN THE CONSULTING WORLD…

IT’S FUN!