Implementing Improvements in Clinical Documentation ... · •Name one method to obtain a copy of...

San Francisco Mental Health Plan (SFMHP)

Behavioral Health Services (BHS)

BHS Quality Management &

BHS Compliance

December 2017 (updated after 12/18/17 session)

Implementing Improvements in

Clinical Documentation &

Documentation Monitoring:

Follow-Up to Triennial Audit (2016)

AGENDA & OBJECTIVES

Mins Item Objective

60

Documentation Improvements:

• Best practices-implementation

• Best practices-quality improvement

• Efficiency in Documentation

• Read prompts

• Priority Domains

• Case Formulation

• Insights from DHCS

• Agencies must have a QA plan…is yours up to

date?

• Efficiency relies on “standard work”

processes…are yours documented?

• Name the three elements of CDIP’s case

formulation model!

60

Documentation Monitoring:

• BHS Desk Reference Guide

• BHS Chart Review Protocol

• Name two “source documents” that are the

basis for both the Desk Reference and Chart

Review Protocol?

• Name one method to obtain a copy of the

Reference Guide and Chart Review Protocol

60

Documentation Q/A + Practice:

• Client cases

• Your biggest implementation struggle

• How to recognize “problems” and take steps to

make improvements?

SFMHP-BHS Implementing Improvements in Clinical Documentation & Monitoring (Dec 2017) 2

MENTAL HEALTH MEDI-CAL

“Medi-Cal Insurance”

Physical Health

Medi-Cal

Mental Health

Medi-Cal

Drug Medi-Cal/

ODS

San

Francisco

Health

Plan

Blue

Cross

Partner.

Plan

BHS

(County

MHP)

BHS

(County

SUD Plan)

• Physical health care

• Mild/Moderate MH care

• Autism Spectrum/BHT

• SMHS

• Moderate

to severe

MH care

• SUD

Treatment

Services



Area Clinic Model Rehabilitation Model

Definition from

Federal Social

Security Act

§1905(a)(9): “Clinic services [are

those] furnished by or under the

direction of a physician, without

regard to whether the clinic itself is

administered by a physician,

including such services furnished

outside the clinic by clinic personnel

to an eligible individual who does

not reside in a permanent dwelling

or does not have a fixed home or

mailing address”

§1905(a)(13): “Other diagnostic, screening,

preventive, and rehabilitative services,

including any medical or remedial services

(provided in a facility, a home, or other setting)

recommended by a physician or other

licensed practitioner of the healing arts

[LPHA] within the scope of their practice under

State law, for the maximum reduction of

physical or mental disability and restoration

of an individual to the best possible functional

level”

Treatment

ModelMedical model Recovery model

Focus Stabilization Active treatment and participation

Locations Clinic-based Community-based

Type of StaffLicensed; higher degree

professionals

Professionals, mental health technicians and

peer specialists

Organizational

ModelOrganized clinics

Organizations that provide one or more

covered servicesSFMHP-BHS Implementing Improvements in Clinical Documentation & Monitoring (Dec 2017) 4


Provide Treatment

Interventions

M-Cal

Logic

Conduct assessment Create treatment plan Provide interventionsClinical

Practice

“The Golden Thread” of Clinical Practice & Mental Health Medi-Cal

Establish Diagnosis &

Functional

Impairments

Create Treatment

Plan/Client Plan

“what is the problem?” “why problem exists” “how to address it”


Best Practices: Implementation

• Your Roadmap to Implement Doc Improvements

• Your agency/program must have a plan for clinical documentation:

• Agency-level (e.g., as part of accreditation, like Joint Commission)

• Program-level (e.g., as part of BHS Contract, Appendix A, CQI description)

• What do you know about your agency’s plan?

• Is your plan up to date?SFMHP-BHS Implementing Improvements in Clinical Documentation & Monitoring (Dec 2017) 6


• Implementation Science

Component In Vivo Use

Theory & Discussion Only 0%

+ Demonstration (in Training) 0%

+ Practice/Feedback (in Training) 5%

+ Coaching (in vivo) 95%

Source:

Fixsen, D. L., Naoom, S. F., Blase, K. A.,

Friedman, R. M. & Wallace, F. (2005).

Implementation Research: A Synthesis

of the Literature. Tampa, FL: University

of South Florida, Louis de la Parte

Florida Mental Health Institute, The

National Implementation Research

Network (FMHI Publication #231). 7


• Your Roadmap to Implement Doc Improvements

• Pre-service training:

• General documentation curriculum

• In-service training:

• Specific tools/modules for program

• Live observation:

• Real-time reviews of documentation (e.g., self-review)

• Close-to-time reviews of documentation (e.g., supe review, UR review)

• Data feedback & monitoring:

• Staff- and program-level data are reported and monitoredSFMHP-BHS Implementing Improvements in Clinical Documentation & Monitoring (Dec 2017) 8

Best Practices: Quality Improvement

• Your Toolkit to Implement Doc Improvements

• Your agency/program must have a plan for quality improvement:

• Agency-level (e.g., as part of accreditation, like Council on Accreditation)

• Program-level (e.g., as part of BHS Contract, Appendix A, CQI description)

• What do you know about your agency’s plan?

• Is your plan up to date?SFMHP-BHS Implementing Improvements in Clinical Documentation & Monitoring (Dec 2017) 9


• Quality Improvement Approaches-A3

Source:

Shook, J.S. (2008). Managing to Learn.

Cambridge, MA: Lean Enterprise

Insititute.

A3 Element & Question

Background: What are you talking about and why?

Current Conditions/Problem Statement: Where do things

stand now, today/What is the problem?

Goals & Targets: What specific outcome is required?

Analysis: Why does the problem or the need exist?

Recommendations: What do you propose and why?

Plan: How will you implement?

Follow-up: How will you ensure ongoing PDCA/PDSA10


• Your Toolkit to Implement Doc Improvements

• Identify the “problem” and collect/analyze information to understand the it;

• Identify an improvement and conduct structured PDSA cycles to investigate the improvement;

• Based on insights, abandon the change, adopt the change or adapt with further PDSA;

• GOAL is standardizing processes that lead to quality and reducing variation away from those standard work processes


Efficiency: Medical Necessity

• Medical Necessity In SMHS:

• Four general areas for medical necessity:

• Included diagnosis

• Impairments resulting from diagnosis

• Interventions to address impairment

• Not a health-based disorder

• Four “specials” of SMHS medical necessity:

• Special diagnosis (“on a list”)

• Special impairments (“today” vs. “tomorrow”)

• Special interventions (“today” vs. “tomorrow”)

• Special setting (“not general health clinic”)


Efficiency: Medical Necessity

• Medical Necessity In SMHS: Pick a pathway and justify it!

13

Efficiency: Read the Prompts

• Answer the question being asked by reading the screen:

• Assessment documents vary across programs:

• Children 0-4 vs. 5-18

• Adults & Older Adults-Short vs. Long

• Psychiatric Assessments

• Prompts vary slightly across documents:

• Some documents “squish” symptoms and impairments together

• Stop copying/pasting—answer the question!



• Disaggregate and directly address prompts: CYF 5-18 example…

15


• Disaggregate and directly address prompts: AOA example…

16

Efficiency: Priority Assessment Areas

• Never leave blanks in an assessment:

• Strategies if you don’t have the information:

• “not yet assessed” (RISK: but you will need to)

• “insufficient information” (RISK: is information attainable)

• “does not account for impairment” (RISK: how do you know?)

• Remember the purpose of SMHS Assessment:

• Is there medical necessity for SMHS (vs. problem due to drugs, health, etc.)

• Work smarter!SFMHP-BHS Implementing Improvements in Clinical Documentation & Monitoring (Dec 2017) 17


• Prioritize the Assessment Domains:

• MUST HAVES for SMHS Medical Necessity:

• Presentation: behaviorally specific symptoms for DSM dx

• Functional Impairments: current/sig vs. risk of decline

• Risks/Strengths: context for impairments & interventions

• Mental Status Exam: evidence for assessment/diagnosis

• Case Formulation: pull clinical story together

18


TWO

SETTINGS

TYPE OF FUNCTIONAL IMPAIRMENT

Home/Living School/Work Community

Traditional

Outpatient

• Client cannot maintain

housing due to cognitive

& behavioral impairments

from Schizophrenia

• Client cannot maintain

employment because he

is withdrawn & cannot

maintain hygiene due to

Schizophrenia

• Client cannot engage in

community activities

(support group) because

he is so confused &

disorganized

Outpatient

within

Residential

• Resident cannot

maintain roommate due

to paranoia & risk of

assault related to

Schizophrenia…risk of

losing placement

• Client cannot pursue

interests & hobbies

(e.g., listening to music)

because he is distracted

by hallucinations that

stem from

Schizophrenia…risk of

social isolation &

decreased quality of

life

• Client cannot engage in

community activities

(e.g., lunch; movie night)

because of the risk of

aggressiveness that

stems from

paranoia…risk of social

isolation & cognitive

decline


Efficiency: Case Formulation

• Case Formulation: DHCS’ View

• “case conceptualization is your attempt to understand the

client’s predicament or to develop a comprehensive

conceptualization that would provide an understanding of

[the client’s] state of mind and the reasons for [the

client’s] behavior.”

Source:

DHCS (2015). Improving Documentation

for Acute Psychiatric Inpatient Hospital

Services (August/September 2015). 20


• Case Formulation: CDIP’s View

1. Restate medical necessity criteria:• Client meets criteria for (diagnosis) as evidenced by

(behaviorally-specific symptoms) that lead to (impairment

area and severity)…

2. Formulate the case theoretically:• Client’s mental health needs and impairments appear to

stem from (your understanding of the core

problems/themes). There are related dynamics and

processes that (maintain/aggravate) these problems…

3. Outline a 12-month course of treatment:• The services and supports that best address the client’s

goals and impairments (as well as dynamics/processes)…SFMHP-BHS Implementing Improvements in Clinical Documentation & Monitoring (Dec 2017) 21



22



3 Most

Problematic

Symptoms

2 Domains

Of Life

Impairments

1 Hypothesis: How Do Symptoms Drive Impairments?

(aka “THEORY OF CHANGE”)




3 Most

Problematic

Symptoms

2 Domains

Of Life

Impairments

1 Hypothesis: How Do Symptoms Drive Impairments?

(aka “THEORY OF CHANGE”)



• Case Formulation: Example 1 with TPOC

1. Medical necessity: (a) Schizophrenia; (b) Home/Living impairment; (c) Meds & skills building services will help

2. Theoretical formulation: (a) Client hears auditory hallucinations, interacts with them & then becomes confused & agitated; (b) this leads to yelling & spitting; (c) client’s behavior creates problems maintaining a roommate & receiving care—risk of increased LOC.

3. Course of treatment: Plan is to reduce interactions with auditory hallucinations (meds & CBT) to decrease & manage confusion/agitation (calming skills).




• Problem & Goal: Schizophrenia; Restore functioning in Living/Home

• Objective: Reduce the instance of interacting with auditory hallucinations. Initial step is helping client distinguish hallucinations from real voices (from a baseline of 0 times/day to 3 times/day per client’s report)

• Interventions: Medication support services (1/week/15mins for 12mos) to reduce hallucinations; CBT Therapy (1/week/15mins for 12mos) to increase reality orientation; Rehab (1/week/30mins for 12mos) to build distress tolerance & calming skills; Collateral with mother (1/month/30mins for 12mos) to teach her to implement reality orientation/calming skills.




1. Medical necessity: (a) Schizoaffective Disorder; (b) Physical/Medical; (c) Meds & stress/anger management therapy will help

2. Theoretical formulation: (a) Client becomes stressed & then angry & then refuses meds; (b) this leads to increased paranoia & confusion; (c) client believes staff are out to get him & he refuses his medications; (d) the refusal behavior is angry outbursts & physically hitting staff

3. Course of treatment: Plan is to reduce client’s stress (CBT skills) & anger (calming skills) & decrease paranoia (Medication Support Services)




• Problem & Goal: Schizoaffective Disorder; Restore functioning in Medical/Physical

• Objective: Reduce client’s level of unmanaged stress & anger to baseline, one year ago. Initial steps are to reduce stress-levels from a current Subjective Units of Distress/SUDS rating of 100 to 80 (per client report)

• Interventions: Medication support services (1/week/15mins for 12mos) to reduce paranoia; CBT Therapy (1/week/15mins for 12mos) to increase reality orientation; Rehab (1/week/30mins for 12mos) to build anger management & calming skills


Efficiency: Standard Work

• You cannot manage 50 different flows:

• “Standard work” is the key to efficient clinical documentation programs;

• Everyone documents in the same framework:

• diagnosis, impairments, interventions….

• claim your pathway and justify

• Supervisors, Utilization Review & Audits follow same framework:

• Stop “hunting and pecking” for information

• Mandate structure formats (e.g., P-I-R-P)


Parting Thoughts….

• Implementing Clinical Documentation Improvements:

• Have a plan for clinical documentation (i.e., a plan for implementation strategies of improvements);

• Standardize the work so you can manage the work

• Make sure “efficiencies” fit with your agency’s risk appetite and risk management stance.


Parting Thoughts….

Joseph A Turner, PhD, PSY22453

Clinical Documentation Specialist

Clinical Documentation Improvement Program (CDIP)

Phone: 415-255-3723

Fax: 415-255-3567

Email: [email protected]

San Francisco Department of Public Health

Behavioral Health Services, Quality Management

1380 Howard Street, 4th Floor, #428e

San Francisco, CA 94103

Clinical Documentation Resources

0. CDIP Homepage: https://www.sfdph.org/dph/comupg/oservices/mentalHlth/CBHS/CBHSQualityMgmt.asp

1. BHS Documentation Manual (2017 Ed.): https://www.sfdph.org/dph/comupg/oservices/mentalHlth/CBHS/

2. BHS Policies/Procedures: https://www.sfdph.org/dph/comupg/oservices/mentalHlth/CBHS/default.asp

3. BHS Contract Performance Objectives (FY17-18):

https://www.sfdph.org/dph/comupg/aboutdph/insideDept/CDTA/documents.asp

4. Organizational Provider Manual (FY15-16): https://www.sfdph.org/dph/files/CBHSdocs/2015-2016-ProviderManual.pdf

5. BHS Outpatient Billing Codes (eff. 7/1/15): https://www.sfdph.org/dph/comupg/oservices/mentalHlth/BHIS/avatarUserDocs.asp

6. Outpatient MH Service Codes Definitions (eff. 7/1/15):

https://www.sfdph.org/dph/comupg/oservices/mentalHlth/BHIS/avatarUserDocs.asp

7. Mental Health & Substance Abuse Staffing Qualifications for Service and Billing Privileges (7/1/2017-MHRS, MHW, Peers):

https://www.sfdph.org/dph/files/CBHSdocs/BHISdocs/Forms/Service-Billing-Privileges-Matrix.pdf31

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