Understanding the Role of a Physician Advisor in Healthcare

Care New England A Collaborative Team Physician Advisor & CDI Laura Shawhughes, MD, FHM October 17, 2018

Learning Objectives At the conclusion of this activity, participants will be able to: 1. Describe the roles and responsibilities of the Physician Advisor at Kent Hospital 2. Discuss the ways in which a Physician Advisor and CDI team can collaborate to achieve institutional goals and metrics 3. Understand the rationale for and benefits of CDI/PA "Case Review" sessions 4. Give examples of methods for communication to and education for hospital medical staff including development of "CDI Documentation Tip Sheet" 5. Identify ongoing challenges faced by a CDI/PA Team

What is a Physician Advisor?

What is a Physician Advisor? Emerging field (ACPA founded in 2014) Administrative role - part time vs. full time Evolving responsibilities Role may vary based on institutional structure/needs Consultant to and resource for physicians Peer educator

What is a Physician Advisor? Physician clinical expert on topics such as Length of stay Transitions of Care and Readmissions Utilization review and Level of care Quality/patient safety Regulatory compliance Denials and Appeals Contract Negotiations with Insurance Payers Clinical documentation

My Journey to PA Residency in Internal Medicine Employed as a hospitalist for over 10 years at 4 different hospital systems Personal interest in UR, CM, Transitions of Care, and Documentation Hospital opportunity - need for physician leadership and input Personal opportunity - career development, reduce burnout, improved work hours Mentor Dr. O Brien

Kent Physician Advisor Role Liaison between the physician staff, care management/utilization review and CDI. 2 Physicians, each with ~50% of time devoted to PA role ~7 clinical shifts/month as a hospitalist Member of multiple hospital committees Administrative roles within the hospitalist group

Current Kent PA Roles/Initiatives Kent Readmissions Committee Chair Utilization and Level of Care reviews Code 44/Medicare 1 Day Stay reviews Clinical High Risk Meeting (Long Stay Case Reviews, 2x/wk) Denials/Appeal Reviews CDI

Kent CDI Physician Advisor PA acts as a liaison between the CDI professionals, HIM, and the hospital s medical staff to facilitate Effective documentation to support level of care Accurate and complete documentation for coding and abstracting of clinical data Capture of severity, acuity, and risk of mortality Appropriate MS-DRG/DRG assignment PA provides ongoing support and education to the medical staff regarding the need for comprehensive, quality documentation

Team Work- PA Supporting CDI CDI targeted case reviews Documentation Tip sheet Development Query Template Development CNE Diagnosis Criteria Development Clinical Validation Case Review Physician Education Resident Education Query Reply Assistance - identified in daily physician query report sent to leadership and department heads Physician Query Escalation Process Reviews CDI Query Reply Metrics with Medical Staff (Monthly reports sent to CMO and department heads) DRG Denials and Appeals chart reviews

CDI/PA Case Reviews Scheduled twice weekly clinical case reviews to identify documentation and/or query opportunities CDI RNs present cases 30-60min time allotted on Tuesday and Thursday Via conference call or in office PA also available by email for any additional case review questions

CDI/PA Case Reviews Support CDI in improving the accuracy, clinical validation, consistency, and quality of documentation in the MR to support the SOI/ROM and care provided to the patient. Educational opportunity for PA Allows for PA to provide concurrent, real time feedback to CDI RNs and to providers

CDI/PA Case Reviews Presentation Format Acct# Unit location: Admit date: DRG Title: DRG Number: A/LOS: PDX: Brief Hx: Reason for Admit: Risk factors, Signs and Symptoms and Treatment Name:

CDI/PA Case Reviews No MCC/CC identified, SOI/ROM 1/1 PDX uncertain Question on if or how to query Clinical clarification of a diagnosis, lab, or test result. Clinical validation diagnosis assistance MD peer to peer support needed for education e.g. query reply, documentation consistency, diagnosis criteria

CDI Tip Sheet Each month, a CDI RN is asked to create a documentation Tip Sheet" to present to the hospitalists and residents at monthly meetings and by email to the surgery department Prior to distribution, the PA reviews and provides input from the physician perspective Monthly topics are identified by query volume, denial targets, PA suggestions from peer discussions, new coding guidelines, etc. and approved by the CDI supervisor If needed, CDI, PA and Coding specialists meet to review final edits prior to presentation/distribution Goal: 1 page, concise review, high yield, easily digestible

CDI Tip Sheets Past Topics Query Types (Clinical Validation, Additional Diagnosis, Abnormal Result, Conflicting Dx, etc.) Clinical Validation Queries Alcohol Abuse/Dependence/Withdrawal Pneumonia Hypertension Heart Failure

CDI Tip Sheet - Example

CDI Tip Sheet - Example

Successful Outcomes from a collaborative team CDI program success meeting 100% CNE CDI metrics Physician Query reply rate within 72 hrs > 90% ( July high of 94%) Development of CNE clinical definition of Respiratory Failure. More word to do on denial focused diagnoses (Sepsis, Encephalopathy) Clinical Validation Education and Query Development to decrease audit risk Increased Physician and Leadership engagement for query reply from specialty providers (Surgical service lines) Private Attending query reply significantly improved with collaboration PA/CDI case reviews= increased diagnosis validation and query opportunity and identified possible LOC/LOS issues for PA from UR/CM perspective role.

Challenges Physical Location of CDI staff Are queries the most effective way to improve documentation? CDI vs. Coding queries Hospital metrics, Timely response Culture Change Provider Buy In Professionalism Query as part of the Medical Record Denials/Appeals Residents, Staff Turnover ongoing education Time PA role spread thin Sepsis (Clinical Validation)

Challenges Do you have physician advisors at your institution? How are you collaborating with your PA? Do you have suggestions or examples or initiatives that have worked at your institution? What challenges or issues are you wrestling with?

PA Resources The Physician Advisor s Guide to Clinical Documentation Improvement (ACDIS, 2014) American College of Physician Advisors www.acpadvisors.org CDI Committee RAC Relief Google Group RACmonitor www.racmonitor.com ICD10monitor www.icd10monitor.com Report on Medicare Compliance (HCCA)

Questions? Thanks to Mary Behbehani, Jen Couri, and all of the CDI staff My mentor/former colleague, Dr. Jill O Brien Thank you! Please feel free to contact me with additional questions. Laura G. Shawhughes, MD, FHM Physician Advisor to Utilization Review, Care Management, and CDI Hospitalist lshawhughes@kentri.org 401 737-7010 x31420 (Desk) 973 464-2509 (cell)