3. • Please silence phones and pagers
• Sign in and out or NO credit for the
training and NO credit for the PCQIP
(Primary Care Incentive Program)
• You receive RVU’s with attendance
Introductions of presenters
Reflection
Welcome
4. Part I: Clinical Courses in HealthStream
17 Clinical Modules (Required by Federal Law, e.g. Title VI and
CLAS, CMS, TJC, & various certification entities)
RICHMOND PRESENTERS HAMPTON ROADS PRESENTERS
David Kelly, MD Phillip Snider, DO
Haroon Hyder, MD Anand Kapur, MD
Julie Selvey, MSN, RN Jason McHugh, DO
Bernie Bly, Director Quality Julie Selvey, MSN, RN
Becky Gruszkos, LCSW, ACHP-SW Bernie Bly, Director Quality
Emily Chrysler, LCSW, ACHP-SW Becky Gruszkos, LCSW, ACHP-SW
Emily Chrysler, LCSW, ACHP-SW
Required Training for FY15
5. Required Training for FY15
Part II: Corporate Responsibility Coding and Ethics
Annual Training
Presenters: George Butler, Director Corporate Responsibility
Charla Prillaman, CPCO, CPC, CPC-I, CCC, CEMC, CPMA
Required annual specialized training for anyone involved in
coding, billing, claims preparation, claim referrals, etc., for
government programs
6. HealthStream Log On Instructions
TO ACCESS ANY ADDITIONAL REQUIRED MODULES:
• Go to IRIS OR www.healthstream.com/HLC/bshsi
• Enter Lawson Employee Number (username and password)
• After initial log on, change your password by clicking on “My
Profile” tab
• Contact IS Support Center at 804-627-5070 with any issues
7. Educational Topics
Advance Care Planning
Cultural Competent Care
Abuse & Neglect
Assessing for Suicidal Intent
Developmentally Appropriate
Care of Adult & Peds Patients
F.A.S.T.
Chest Pain
Prevention of Falls
Obesity Awareness and
Sensitivity
Patient Rights
National Patient Safety
Goals
CDC Hand Hygiene
Rapid Regulatory
Event Reporting
Infant Security
Team Dynamics
8. Advance Care Planning
Advance Medical Directives
DDNR
ACP Module
Becky Gruszkos, LCSW, ACHP-SW
Emily Chrysler, LCSW, ACHP-SW
9. Advance Medical Directive:
A legal document that empowers a
competent adult to communicate
critical medical information to the
healthcare team that may be acted
upon should that person become
incapacitated.
10. Advance Medical Directives
Definition of Incapacity
• Incapacity means that the patient is incapable
of making an informed decision.
• That is, the patient is incapable of:
– Understanding the nature, extent and probable
consequences of a proposed health care decision
– Making a rational evaluation of the risks and
benefits of a proposed health care decisions as
compared with the risks and benefits of
alternatives to that decision
– Communicating such understanding in any way
11. Advance Medical Directives
Procedure for Determining Incapacity
• REMEMBER: The Advance Medical Directive is
held “in suspension” and only becomes
operative when the patient becomes
incapacitated.
• Incapacity must be documented by two
physicians before the authority of an
appointed agent becomes operative!
12. Advance Medical Directives
• Section I: Appointment of Powers of My Agent
• Section II: My Health Care Instructions
• Section III: Anatomical Gifts
• Affirmation and Right to Revoke Statement
13. First Steps® ACP
All adults
• Initiated as a component of routine healthcare
Goals
• Motivate individuals to learn more about
the importance of ACP
• Select a healthcare decision maker
• Complete a basic written advance
directive
16. CPR and DNR
• CPR was developed to sustain cardiac / respiratory function
in pts with reversible conditions. It was not intended for
seriously ill individuals. It might prolong, but cannot
reverse the dying process
• Low CPR survival rates: About 15% of all pts who receive
CPR in hospital survive to d/c. For those with advanced
illness, post-CPR survival to d/c is about 1%
• A DNR is not a “do not treat” order; patients should
continue to receive any other desired treatments
*Only the person who signed the Durable DNR can revoke it
17. Fundamental Communication Skills, Medical
Oncology Communication Skills, 2002
Resuscitation Discussion
• Discuss patient's medical condition and prognosis,
ensure patient's understanding*
• Elicit values, goals of care, and preferences for EOL care
• Explain and confirm patient’s understanding of the
nature of CPR, including its risks, benefits, and possible
outcomes
• Make a recommendation consistent with patient's
prognosis and values
18. The Conversation about Prognosis
• How do we know when to have the conversation?
– Evidence-based prognostic models
– The “look back” (Functional review of 12 months
ago; 6 months ago, 3 months ago…now)
– Would you be surprised if your patient died in the
next 12 months?
– Cues from the patient and/or family
19. Ask –Tell - Ask
• ASK patient to describe current understanding of
the issue. Assess level of knowledge, emotional
state, and degree of education
• TELL patient in straightforward language what
needs to be communicated. Keep it
short/digestible, avoid medical jargon
• ASK patient to restate in his/her own words the
understanding of information given to make sure
it was clear
Fundamental Communication Skills, Medical
Oncology Communication Skills, 2002
20. What is Quality End of Life Care?
Measures Surveillance endorsed by the NQF:
• Proportion admitted to hospice for less than 3 days
• Proportion admitted to the ICU in the last 30 days of
life
• Proportion not admitted to hospice
• Proportion receiving chemotherapy in the last 14 days
of life
• Proportion with more than one emergency room visit
in the last days of life
Key: red lettering denotes potential quality metric for PCQIP
22. • Bon Secours Richmond, HCA Virginia, VCU
Health System
Five Promises
1. We will initiate the conversation
2. We will provide assistance with ACP
3. We will make sure plans are clear
4. We will maintain and retrieve these plans
5. We will appropriately follow these plans
23. • Phase I: January-June 2015
• 9 sites (3 in Bon Secours)
• 30 Facilitators (10 in Bon Secours)
• Phase 2: Summer 2015
• 2-3 additional sites, 10 additional Facilitators
• ***3 Facilitators trained as First Steps
Instructors
25. Recommendations to Increase ACP
Discussions and Documents
1) Physician letter mailed to patients requesting
a copy of any documents related to future health
care wishes (AMD, MPOA, etc.)
2) Reminder call prior to appointment to bring in
documents
3) During visit: review documents, make
recommendations, and enlist NN support
4) If no existing documents, initiate ACP
discussion, use care team to assist with follow up
26. Conclusions
• Complete your own Advance Directive
• Designate an ACP Office Champion
–Education and Training
• Ask yourself “Would I be surprised…?”
–Have the Conversation including ACP
• Read “Being Mortal”
29. 29
Cultural Competence
Bon Secours Resources:
o Cyracom Service/Personal Devices
o Trained Interpreters
o Sign Language Interpreter or
Web-cam
o Document Translation
o Cultural Navigator
crosscultural@bshsi.org
30. 30
Telephonic Interpreters
To access Cyracom from any phone:
Call 1-800-481-3293 with your BSVMG practice account
number & pin number
(easy to obtain from your practice manager—or contact
crosscultural@bshsi.org)
31. 31
On-site INTERPRETERS
• To request on-site Trained Interpreter -
crosscultural@bshsi.org
• Refer volunteer bi-lingual office staff for
Bon Secours interpreter training.
• Our interpreters are trained not only in Spanish,
but in many other languages.
PLEASE
DO NOT USE FAMILY, FRIENDS OR UN-
TRAINED INTERPRETERS!
32. 32
Hearing Impaired
To access a certified SIGN LANGUAGE Interpreter:
contact our preferred provider
Purple Communications
1-800-900-9478 Ext. 1640 (M-F 8 am-5pm)
(After Hours: 5 pm-8am M-F & Anytime on Weekends
1-800- 935-1054)
purplerichmond@purple.us
Fax: 1 877-846-9117
• For your protection and patient safety:
DO NOT USE FAMILY, FRIENDS OR NON-TRAINED INTERPRETERS
(Request credentials.)
33. 33
Document Translation
If you need after-visit information or
consent forms translated, check in
Connect Care or contact:
crosscultural@bshsi.org
Cultural Navigator
If you want assistance navigating for a
patient or family with particular needs,
please contact our Cultural Navigator,
Claudia Oystese at
crosscultural@bshsi.org
34. 34
34
“…For most encounters with medical caregivers,
LEP patients should be provided with an
interpreter. Providing LEP patients with interpreters
is especially important in services such as
behavioral and mental health services where
communication with the patients is imperative.
Additionally, LEP patients should be provided with
copies of vital documents, or documents that are
critical to the operation of a program such as a
medical consent forms, in their native languages.”
Quoted in letter from Office of Civil Rights
35. 35
RISKS and CONCERNS
We MUST be in Compliance with
Office of Health & Human Services
Office of Minority Health.
• Federal CLAS Standards
• Title VI & Joint Commission
For your protection and their safety:
• DO NOT USE FAMILY, FRIENDS OR NON-
TRAINED INTERPRETERS (Request their
credentials.)
37. Abuse and Neglect
Goal: ID & assess victims of abuse and neglect, then
assist with obtaining help.
Includes victims of:
• Physical assault
• Sexual Assault (nonconsensual genital, anal, oral
penetration)
• Sexual Molestation (nonconsensual sexual contact
short of rape OR any sexual act with a child)
• Domestic Abuse (including physical or psychological
injury, depriving spouse of food, medicine, clothing)
• Elder Abuse or Neglect
• Child Abuse or Neglect
38. Abuse and Neglect
Identification of Victims:
• Ask routinely as appropriate during encounters
• Ask direct questions about abuse by past or current
partners even if no obvious signs:
— eg. “Because domestic abuse is so common today, I
ask all pts about it.” “Does your partner hurt,
threaten, or force you to perform sex?”
• Be Alert for signs & symptoms of abuse (e.g.
unexplained or multiple injuries, bilateral or genital
injuries)
39. Abuse and Neglect
• Children and elders often do not disclose abuse.
Look for injuries at multiple sites and different
stages of healing or inadequately explained.
• Nonspecific behaviors in children that may suggest
abuse include:
— Fear of adults
— Hyperactive/ compulsive behavior
— Poor self-esteem
— Poor peer relations
— Bedwetting
40. Abuse and Neglect
• Create a supportive environment
• Interview caretakers separately
• For elders and children:
— Determine if immediate danger
— Determine how and when mistreatment occurs
— Who is responsible
— Frequency & severity
• Maintain current list of local resources
— Adult Protective Services (APS), Shelters, etc.
41. Abuse and Neglect
Documenting and Collecting Evidence:
• Describe injuries in detail
• Document with photos whenever possible
• Describe the events, name alleged abuser, and
the relationship to patient
42. Abuse and Neglect
Contacts
• Adult Protective Services
Investigates reports of abuse, neglect, or exploitation and provides services when
needed.
1-888-832-3858
www.dss.virginia.gov/family/as/aps.cgi
• Child Protective Services - Richmond, Virginia Department of Social
Services
801 East Main Street , Richmond, VA 23219
(800)552-7096
http://www.dss.virginia.gov/family/cps/index2.cgi
44. Assessing for Suicidal Intent
• Older adults have the highest risk of suicide of all age
groups
• 50 to 75 percent of older adults who commit suicide saw their medical
doctor in the prior month for general medical care
• Factors associated with completed suicide
• Male, white, age greater than 65 years
• Widowed or divorced
• Living alone, no children under age 18 in household
• Presence of stressful life events
• Access to firearms
• Psychiatric disorders
• Major depression
45. 45
Assessing for Suicidal Intent
• Indicators of high risk:
— Previous attempts (almost 50% had prior attempts)
— Family history of suicide
— Stating suicidal thoughts (concrete plans= greater intent)
— Depression or other psychiatric illness
— Recent major loss or caregiver stress
— Chronic medical illness, especially CNS disorders, pain
— Feelings of helplessness, hopelessness, worthlessness,
and anhedonia
46. 46
BSMG Suicide Policy
• High risk = current thoughts or attempts of harming
or killing self, with means and intent to follow through
• Action Steps:
1. Refer for immediate assessment with mental health
specialist, local crisis program, or local emergency dept.
2. Determine if reliable support person is available to
transport patient for immediate assessment; alternative is
EMS transport
3. If patient hangs up the phone or refuses to agree to safety
with clinician, dial 911 and inform police of patient’s intent
to do harm
47. How to Find PHQ 2/9 for Depression
Screening in ConnectCare
48. How to Find PHQ 2/9 for Depression
Screening in ConnectCare
49. How to Find PHQ 2/9 for Depression
Screening in ConnectCare
51. Developmentally Appropriate Care
Consideration of the following age-specific
characteristics helps you to take better care of your
patients:
• Physical characteristics and changes
• Psychosocial and developmental tasks and challenges
• Other stressors and challenges
• Ability to understand and learn
• Safety needs
• Nutritional needs
• Medical needs, risks, and problems
55. 55
Atypical Presentations of Cardiac
Chest Pain
• More common in women, ESRD, dementia, diabetes,
and elderly (>75)
• Examples of atypical presentations
– Epigastric pain, indigestion, occasionally stabbing or with
pleuritic features
– Exertional dyspnea without pain
– Exertional pain in ear, jaw, neck, shoulder, arm, back,
epigastric area
– Nausea and vomiting, diaphoresis, or fatigue alone
57. 57
Prevention of Falls – Key Points
• Balance is affected in the elderly by reduced function of
the vestibular system, decreased vision, and decreased
somatosensory input
• Impaired mental status and use of multiple medications
are the two most important risk factors for falls. Most
falls occur near the patient’s bed
• Patients with impaired mobility may be helped by using
appropriate assistance, wearing non-skid footwear, and
rising slowly from bed/chair
• Functional mobility tests include the “Get Up and Go”
test, for office mobility assessment
60. 60
BSV Bariatric Program Focus
• Obesity is a disease affecting > 1/3 of US adults
• List of Bariatric Centers:
– St. Mary’s Hospital
– Maryview Medical Center
– DePaul Medical Center
– Mary Immaculate Hospital
• Provider role:
– Empathy
– Avoid stereotypes of obesity being secondary to laziness or
lack of willpower
– Lead by example in demonstrating sensitivity to those with
this disease
64. Patient Rights
Information Disclosure
Patients have a right to know:
• Facility Information:
— Complaint filing process
— Accreditation
— Quality ratings
• Provider Information:
— Name
— Education/ training
— Practice Experience
— Quality Ratings
65. Participation in Treatment
Patients have a right to know:
• Diagnosis
• Treatment
• Options (including no treatment)
• Risks
• Benefits
• Potential medical consequences of each
treatment option
Patient Rights
66. Patient Rights
Informed Consent
• Procedure discussed in full according to learning
assessment
• Procedure is written on informed consent according to
learning assessment
• Patient signs, dates and time stamps consent form
• Provider signs, dates and time stamps consent form
• Procedure cannot start until consent form is signed by
provider
• Document time out in ConnectCare utilizing smart
phrase (be sure to include patient education).
67. • Patients have the right to refuse treatment or
withdraw consent
• Patients are to be informed of decision around
refusing treatment
Patient Rights
68. Patient Rights
Complaints and Grievances
• Patients have the right to file a grievance with
regulatory agencies.
• Your office must provide contact information for the
these agencies providing oversight
• Examples of complaints
• Provider’s actions
• Staff’s actions
• Wait time/limited or no access
• Medical treatment
72. Hand Washing
Soap and Water Alcohol-Based
Time Involved? 20-30 seconds Until hands are dry
When to Use?
C. diff infections or
hands visibly soiled
Before and after
patient contact
Effectiveness?
Best for contact with spore
forming bacteria
Best for reducing bacterial
counts
Skin Effects? Dry skin Less dry skin
73. • Ongoing Hand Hygiene monitoring in each
practice
• 5 observations per week
• Reported to Infection Prevention at each
facility
Hand Washing
77. •Call Code RED within the office
•Designate someone to call 911
R = rescue
A = alarm
C = contain
E = extinguish and/or evacuate
Fire Safety: Response
Rapid Regulatory
78. Fire Extinguisher Use:
P = pull the pin
A = aim at the base of the fire
S= squeeze the handle
S = sweep back and forth
*Stand approximately 6 feet from the source of the fire for safety
Fire Safety: Response
Rapid Regulatory
79. Rapid Regulatory
Safety in Work Areas
• Back Safety:
— Proper care of the spine
— Proper posture
— Regular exercise
• Slips, Trips, and Falls:
— Keep areas clear and uncluttered
— Repair uneven flooring or post safety signs
— Use proper lighting
80. Security and Workplace Violence
• Recognize- aggressive behavior
and warning signs of potential
violence
• Respond- appropriately to the
level of aggressive behavior
• Report- all unsafe situations
immediately
Rapid Regulatory
81. Emergency Preparedness
• Healthcare responds to emergency situations:
• Know your role in this situation
• Know your emergency operations plan
• Know how your office will respond
Rapid Regulatory
83. 83
Event Reporting
Why is this important?
Many events/incidents are symptoms of system
failures- not personal failures
Reporting events provides an avenue to improve
processes
How do we report errors or near misses?
Notify your Practice Administrator
Notify your Risk Manager
87. Team work equals QUALITY patient care
From check in to check out and everything in between.
88. Quality Data
YTD Reporting
Month # of MWV # of Visits % of MWV
Sep-14 120 393 30.5% Numerator: Those patients from denominator that have had an annual wellness visit in last 12 months (rolling 12 months)
Oct-14 234 656 35.7% Denominator: Patients with a PCP office visit YTD (Fiscal Year 15 - 9/1/14 - 8/31/15)
Nov-14 310 865 35.8% These are unique patients, so if a patient was seen multiple times for an office visit during the fiscal year,
Dec-14 367 1005 36.5% they are only counted once in the denominator.
Jan-15 419 1100 38.1%
Feb-15 Example of YTD Reporting:
Mar-15
Apr-15 Numerator: Patients from the denominator that have had an AWV from Feb 14 – Jan 15
May-15 Denominator: : Unique patients with a PCP office visit from Sept 14 - Jan 15
Jun-15
Jul-15
Aug-15
Goal FY15 YTD 55%
Medicare Wellness Visists YTD FY14
Month # of MWV # of Visits % of MWV
Sep-13 53 438 12.1%
Oct-13 97 734 13.2%
Nov-13 129 931 13.9%
Dec-13 146 1058 13.8%
Jan-14 167 1147 14.6%
Feb-14 210 1209 17.4%
Mar-14 188 1244 15.1%
Apr-14 213 1282 16.6%
May-14 230 1317 17.5%
Jun-14 258 1342 19.2%
Jul-14 281 1370 20.5%
Aug-14 321 1391 23.1%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
MWV FY15
89. Quality Data
Final Medication Reconciliation Performed by
Physician Each Visit
Goal: 95%
Utilization of Learning Assessment
Form
Metric shows percentage of office visits closed for which the medications were last reviewed by the Physician
(not Clinical Staff). The data is viewed in comparison to the percentage of visits where final med rec was
performed at all, regardless of by whom.
This metric checks to see if the Learning Assessment Questionnaire is being completed for each patient
seen. For each Office Visit closed during the reporting period, the report evaluates whether the
questionnaire was used at any point prior to the visit.
Medication Reconcilliation Learning Needs Assessment
Month Compliance Month Compliance
as of 1/31/15 98.4% as of 1/31/15 83.0%
Oct-14 Oct-14
Nov-14 Nov-14
Dec-14 Dec-14
Jan-15 Jan-15
Feb-15 Feb-15
Mar-15 Mar-15
Apr-15 Apr-15
May-15 May-15
Jun-15 Jun-15
Jul-15 Jul-15
Aug-15 Aug-15
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Med Rec
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Learning
