ACPA Update September 2021

In this Update Editor's Note Birth Announcement Use of Stigmatizing Language in Patient Medical Records by Healthcare Providers  Proactive Length of Stay Management  Supporting Patient-Centered Care with Interprofessional Collaboration: The Case Manager and Physician Relationship   Clinical Documentation and Coding of Skin Injury President's Corner ‌ ‌ ‌

Editor's Note Ronald Hirsch, MD, FACP, CHCQM-PHYADV, CHRI Member, ACPA Advisory Board  Editor, ACPA Update

Where have those long summer days gone? It’s already getting dark by early evening. Kids are back in school, at least for now, and vacations are past. And, like many of you, our kitchen is full of fresh tomatoes and cucumbers from the garden. I am already seeing pharmacies advertising their fall flu shots. As I recall, each year the scientists look at the circulating flu viruses in the southern hemisphere during the early part of the year and designate the flu strains that will be used in our vaccine for fall and winter. But the pandemic has nearly eliminated any circulating flu viruses due to social distancing and mask use so it will be interesting to see the effectiveness. I plan to get mine at the beginning of September along with that overdue Shingles vaccine.   This month’s issue has many great articles for you. Many are very practical, such as the article on length of stay management and documenting skin injury while others are more related to interpersonal relationships, such as the articles on stigmatizing language and collaboration. And there is even a birth announcement from the ACPA Pediatric Committee. Be sure to read all the articles this month.   Finally, one of the most valuable assets we have as physician advisors is our cumulative knowledge and desire to share. Yet we have received less than 20 responses to the August Observation cases. I know, many of you sit all day and decide inpatient v. observation but we don’t get to share in your wisdom. So take a minute and complete the survey. You may be surprised by the questions and the options. Simply go here: https://www.surveymonkey.com/r/8CHN2W9  Finally, want to expand your curriculum vitae? Write an article for the newsletter. Email me at [email protected] for the submission guidelines.

Birth Announcement

Barbara Abrams, MD   Member, ACPA Pediatric Physician Advisor Committee

Denise Goodman, MD, MS, FCCM  Member, ACPA Board of Directors Chair, ACPA Pediatric Physician Advisor Committee

The Pediatrics Committee of the ACPA is proud to announce that after a 10-month gestation, we have given birth to a bouncing baby Pediatric Denials Library! The Library got off to a rocky start, with low initial APGARs as it struggled with issues of content and form. But after those were resolved it had an APGAR of 9 and was quickly transferred to the newborn nursery of the ACPA website. There, its parent committee dressed it in many different outfits, trying to see which template gave it the best functionality and most pleasing appearance.  Having now had its first set of immunizations, the infant Pediatric Denials Library is ready for its first forays into the world. It can be found here. Please visit it and tickle its chin. Browse through its contents, and leave parenting suggestions (comments) as to what you find helpful (or not). As with any newborn, gifts are appropriate, and your case submissions are most needed and welcome! Using the submission button, you can submit any pediatric denial you think would help others, be it concurrent or retrospective, a peer to peer, or a letter of appeal. Please be sure to wrap it nicely in the provided template and to remove any sharp HIPAA objects (any identifying information of patient or payer) that might hurt our dear little one.  After many diaper changes, we are looking forward to our pediatric denials library someday growing up and producing an adult denials library! However, it takes a village to raise a denials library, and for this we’ll need the assistance of our adult colleagues. As our baby grows and we learn from its mistakes, we are happy to share our knowledge with you and help you produce a functional adult denials library! Just let us know when you’re ready to take your first steps . . .  If you would like to visit the nursery, go to https://acpadvisors.org/ and log in to your account. Then navigate to About-> ACPA Committees-> Pediatric Committee and you will see a link on the left side to the Denials Library.

Use of Stigmatizing Language in Patient Medical Records by Healthcare Providers  Erica E. Remer, MD, FACEP, CCDS   Member, ACPA Board of Directors Co-Chair, ACPA Clinical Documentation Integrity Committee

I read an article in JAMA a few weeks ago which intrigued me called Physician Use of Stigmatizing Language in Patient Medical Records.1 When I teach my documentation course to providers who have gotten in trouble with their medical boards, I instruct them that they must tell the truth but should consider how their words may resonate with the patient. As of April 2021, according to a provision of mandated medical transparency afforded by the 21st Century Cures Act, it is required that patients have access to their own medical record. Does this, and should this, affect how the provider documents the encounter? And does the way we document affect other caregivers?  The study’s findings were that the majority of negative language was not explicit and fell into one or more of five categories:   questioning patient credibility  expressing disapproval of patient reasoning or self-care  stereotyping by race or social class  portraying the patient as difficult  emphasizing physician authority over the patient.  They found that positive language was often more explicit and fell into these categories:  direct compliments  expressions of approval   self-disclosure of the provider’s positive feelings toward the patient  minimization of blame  personalization  highlighting patient authority for their decisions  The premise is that negative perception of groups of patients may affect the quality of care provided to them and may be reflected in the language used to describe the encounter in the medical record. Two examples offered were the use of the word, “sickler,” to describe an implicit negative attitude toward patients with sickle cell disease, and using the phrase, “substance abuser,” as opposed to a patient “having a substance use disorder.” The article alluded to participants in the study expressing attitudes that these patients were personally culpable and less deserving of treatment and compassionate care. They posit that bias can be perpetuated throughout the medical record and can sway how future caregivers perceive and treat patients.  This article made me think of a paradigm shift I have seen recently and have embraced where media persons refer to “the enslaved” as opposed to “slaves.”2  The former expression conveys a sense that something was forcibly perpetrated on the individual in contradistinction to them actively or volitionally accepting the role of servitude. Another language shift we all have experienced is shunning the expression, “committed suicide.” The generally accepted term now is “died by suicide.” The word, “commit,” evokes criminality, like “committing murder or adultery.”3  How we document things and the language we use matters. The article details “doubt markers,” which are ways of conveying suspicion or distrust about the authenticity of symptoms or the patient’s adherence to prescribed treatment. Words like, “supposedly,” “claims to,” or “alleges” can call into question the legitimacy of the premise. The authors also mention a tactic known as “scare quotes,” which is using quotation marks to cast doubt on the diagnosis or the scenario (e.g., “She takes albuterol for ‘chronic bronchitis’”). They state that this practice also can convey disapproval or negative judgment of the patient’s actions or thought processes.  Other behaviors which were disparaged in the study were racial or social class stereotyping, adjectives which impart condescension or frustration, and paternalistic language (e.g., “I impressed upon him the importance of…”).  Positive language practices included use of positive adjectives (e.g., “This is a pleasant 83-year-old…”), explicit approval of positive patient behaviors (e.g., “hard work following instructions” or “good insight into a disease process”), and self-disclosure of positive sentiments towards the patient. If a provider felt positive towards the patient they might minimize blame by expressing barriers to following a treatment plan in a more favorable light (e.g., “limited short term memory making it difficult to carry out recommended interventions”). Providers also sometimes included details about the patient’s life or activities judged through the lens of their own interests or background (e.g., “She has a strong faith which she feels uplifts and strengthens her.”)  How does this impact the provider-patient relationship now that the patient has access to their own electronic medical record? An article regarding the impression patients have of outpatient notes found 10% of patients reported feeling judged and/or offended by something they read in their notes.4 These patients often had diagnoses in the Social Determinants of Health category (e.g., unemployment, financial hardship). The specific issues were errors and surprises, labeling, and disrespect. Does this mean that clinicians should stop documenting words like “obese,” “anxious,” “depressed,” and or “elderly?”   My advice is that practitioners must tell the story and tell the truth. If a patient is morbidly obese or clinically depressed, this must be reported and the condition addressed. However, it may take a few extra moments to critically analyze documentation from the perspective of the reader and try to avoid offense. Dr. Fernandez, author of the outpatient note study was quoted as saying, “I try to mirror the concept of what would it feel like if I was reading this out loud to the patient.”5  We must acknowledge that we all have implicit biases. As healthcare providers, it is our responsibility to try to minimize the effect our biases have on our decision-making and strive to rise above our prejudices. When we document, we should be aware of how we say things; we do not want to negatively influence subsequent caregivers to provide lesser care. Stigmatizing language should be avoided whenever possible, not just to avoid upsetting the patient, but to change how we think about and treat patients.   1 Park J, Saha S, Chee B, Taylor J, Beach MC. Physician Use of Stigmatizing Language in Patient Medical Records. JAMA Netw Open. 2021;4(7):e2117052. doi:10.1001/jamanetworkopen.2021.17052  2 Hylton BL, Why We Must Stop Referring to Enslaved People as ‘Slaves,’ Human Parts, June 12, 2020.     3 Spencer-Thomas S, Language Matters: Why We Don’t Say “Committed Suicide,” IRMI, June 2018.   4 Fernandez L, Fossa A, Dong A, et.al., Words Matter: What Do Patient Find Judgmental or Offensive in Outpatient Notes?, J Gen Inter Med, (2021).   5 Heath S, How to Write Open Clinical Notes for a Good Patient Experience, PatientEngagementHIT, June 28, 2021.   Dr. Remer is the founder and president of Erica Remer, MD, Inc., icd10md.com

Proactive Length of Stay Management  Sue Erwin DNP, RN, MHA, ACM-RN, CMAC  Member, ACPA Advisory Board

Hospitals employ many interventions to impact Length of Stay (LOS) since we all face increasing financial challenges and an increased LOS where care and services are being provided but there is no financial reimbursement paid beyond the original Diagnosis Related Group (DRG).  One tool used by hospitals is to conduct a long LOS meeting weekly to evaluate those inpatients who have been in the hospital for seven days or more. I maintain that evaluating these patients at seven days is too late to obviate barriers to discharge and make a meaningful impact on hospital LOS.  At my organization we are privileged to have a robust internal Physician Advisor (PA) program which is foundational for meaningful change.   At Wake Forest Baptist Health we hold a LOS meeting every Tuesday and Thursday named the “Quality Collaborative”. When we initially started this meeting to address LOS and barriers to discharge, we reviewed all inpatients with a length of stay of eight days or longer.  The meeting would take about 2 hours.  We have progressed to reviewing all patients in the hospital who have been an inpatient for three days or more and this takes 2.5 hours to complete.  By intervening earlier in the stay we are able to more effectively manage barriers to discharge or secure faster placement for post-acute needs.    This meeting is led by our Physician Advisor and Manager of Care Coordination. Prior to Covid-19 we held this meeting in person and each case manager and social worker would attend at a specified time and give report on the medical reason that the patient remains in the hospital and what the barriers to discharge are in a rapid-fire fashion. Since Covid, we have been utilizing Webex to accomplish this meeting to preserve social distancing.    In addition to reviewing inpatients, the Physician Adviser reviews the Observation list of patients daily seven days a week with the Utilization Review Nurse to make determinations regarding discharges or conversions to inpatient that are appropriate.  Our organization has established rich relationships with the skilled nursing facilities, assisted living facilities and behavioral health providers and often a bed can be located in one day. We meet with our post-acute providers on a quarterly basis to foster those relationships and communicate our expectations.    In addition to reducing the Average LOS at an 885 bed Academic Medical Center by almost one full day, this meeting has served to educate our case managers and social workers on how to eradicate barriers to discharge, and increase knowledge of when it is appropriate to use Hospital Issued Notices of Noncoverage (HINNs).  We believe that our case managers are the “nucleus of care” and serve to integrate the various team members toward effectuating a coordinated and comprehensive discharge plan.  In conclusion there are many other innovative programs in place including the High Risk Initiative, active multi-disciplinary rounds and Letters of Guarantee (LOG) for our skilled nursing facilities to empower our team to reduce LOS. I will share more on those initiatives in future ACPA articles.  Sue Erwin DNP, RN, MHA, ACM-RN, CMAC is Associate Vice President Care Coordination, Wake Forest Baptist Health in Winston Salem, NC.

Supporting Patient-Centered Care with Interprofessional Collaboration: The Case Manager and Physician Relationship   Rebecca Perez, MSN RN CCM Case Management Society of America

Healthcare delivery and reimbursement have evolved, moving from fee-for-service models to those based on quality and value. Most providers and clinicians have been trained to focus on diagnosing and treating illnesses, injuries, and diseases but now must transition to caring for the whole person- the individual with a unique story and situation. To care for the whole person, comprehensive, multifaceted, seamless care may be delivered by health care professionals from differing disciplines. These professionals include physicians, nurses, social workers, therapists, dieticians, and community resource providers, all creating a culture of interprofessional collaboration.  While this may seem like a simple concept to implement, many professionals are baffled about how to begin. Professional collaboration requires providers and clinicians first to recognize and understand the role, function, and responsibilities of and demonstrate respect for their colleagues. Traditionally, the hierarchy of medical professionals had physicians situated at the top of the pyramid, with other disciplines descending from that dominant position. Those uppermost in the hierarchy may or may not have been open to collaborating with other professionals beyond giving or writing orders.  The current shortage of health care professionals, a focus on improving health equity, new requirements and expectations related to quality measures, patient-reported outcomes, reimbursement models are more or less dictating the need for professionals to put aside old practices and embrace a new culture of collaboration (Folkman, 2019). A culture change must be supported to develop and deploy education related to interprofessional relationships and cooperation. According to Zechariah et al., to be successful, qualified, and competent, health care professionals must develop collaborative working environments before delivering high-quality care (Zechariah, 2019). Zechariah also shares that nurses, social workers, and other professional are usually better prepared for interprofessional collaboration than are physicians (Zechariah, 2019). Interprofessional education (IPE) fosters that collaborative spirit, nurtures the team approach, resulting in improved quality of care and decreasing hospital length of stay. (Zechariah, 2019). Working with teams is seen in nursing and social work curricula.  Medical schools in the U.S. have not routinely included IPE in their curricula, but medical schools outside of the U.S. often do. The majority of medical students offered IPE with other disciplines reported positive experiences (Zechariah, 2019). IPE primarily focuses on communication as an essential competency. If included in medical school and other allied health programs would ensure medical professionals entering the workforce are well-equipped and prepared to function as part of a collaborative team.  Cooperation and collaboration among health care professionals have been shown to improve the quality of services delivered, improve patient outcomes, and increase job satisfaction among the various professionals (Eman, 2021). The following are practices that support interprofessional collaboration (Brennan, 2018):  Put patients first by asking, "what is best for this patient?" The question and subsequent answer unite and align the team members. All organizations should have a mission and vision dedicated to patient-centered care.  Demonstrate leadership commitment to interprofessional collaboration by establishing partnerships between and among all team members and include Chief Medical Officers and Chief Nursing Officers.  Create a level playing field by removing obstacles and siloes among and between professions.  Cultivate effective communication channels with and among team members by establishing standards, policies, and protocols that all understand and follow.  Hardwire practices using organizational structure to prevent the preference for autonomy. A culture of interprofessional collaboration only exists when leadership supports the team's ability to work together.  Train the different disciplines together by incorporating proven methods of team building.  Case managers are found in nearly every healthcare setting and often are the team member chosen to lead an interprofessional team. In most cases, the professional case manager is the primary care coordinator and is well-equipped to function and collaborate with all team members and stakeholders. Care plan development and execution are primary case management functions developed with the patient as the primary focus. Interprofessional collaboration allows for robust care plan development with input from patients and team members. The result is a document that is then shared with everyone involved in the patient's care. Case managers have long been unrecognized for their ‘behind the scenes’ work. The ability to coordinate care from multiple providers and settings, make sure it is delivered as ordered, find resources no one else has found, and then communicate the results is not something every professional can handle. But because they are used to working with so many different pieces and parts, case managers can bring it all together, incorporating everything the team has identified as important to the patient or important to their health and recovery.  The case manager – physician relationship is one that can significantly impact care plan development, implementation, and adherence. The case manager has a relationship with the patient and support system that differs from that of a treating provider. The case manager brings the patient perspective to the physician which enhances what and how care is delivered. Case managers and physician advisors similarly collaborate to determine the best way to impact care and outcomes by sharing of their perspectives. This collaboration benefits the patient and improves the satisfaction of both the physician and case manager.  Case managers often lead these initiatives, but regardless of who leads a team, each plays an important role and deserves the respect of the others. Physicians often lead but perhaps may co-lead with another team member. Regardless of team leadership, the patient must remain central to all of the team's activities and include family, support system, and any other stakeholder (e.g., employer, school). Together, goals are developed, reasonable initiatives are implemented, and success is measured as the patient moves through the continuum of care. If the patient's interprofessional team is functioning as anticipated, the patient will experience success, maximized outcomes, and team member's job satisfaction.  Rebecca Perez, MSN RN CCM is Sr. Manager of Education and Strategic Partnerships for Case Management Society of America/Parthenon Management Group

Clinical Documentation and Coding of Skin Injury Melinda Battaile, MD, FHM, MMCI, CHCQM-PHYADV, CCDS Member, ACPA Clinical Documentation Integrity Committee

As a member of the American College of Physician Advisor’s clinical CDI Committee I have had the opportunity to participate in meetings with colleagues that lead to the development of the CDI tip sheets for ACPA. These documents are designed to augment our physician advisor colleagues' understanding of CDI for specific topics and to assist them in educating providers at their institutions with a goal of clinical documentation improvement. After recently addressing best practice documentation for myocardial infarction and GI bleed we lately turned our attentions to the topic of pressure ulcer/ injury. Coincidentally, there was a recent thread on RAC Relief that was addressing the topic of acute skin failure, the documentation of this diagnosis, and the ICD 10 Codes attached to it. I will take advantage of this recent topic to introduce some basic coding principles and how they apply to this topic as well as giving a brief summary of the pressure injury document that will be available shortly on the ACPA website.   As an avid reader of RAC Relief I never fail to pick up useful information almost on a daily basis that I can apply to my practice as a physician advisor. I must confess that while reading the thread related to acute skin failure, I had never before heard of this diagnosis. After reading the thoughtful posts from our colleagues as well as the Power Point that was provided in the thread I did some more research for my own edification from both a clinical standpoint and the documentation and coding standpoint. I also did an unscientific, low-powered verbal query of my colleagues on the diagnosis and can report with some relief that I was not the only one who had never heard of it. After a literature search including the citations associated with the acute skin injury PowerPoint on RAC Relief I did find a very nice review article from a dermatology journal summarizing acute skin failure. Here the phenomenon was described as what most of us would recognize as the dermatological emergencies that we learned about in training e.g. Stevens-Johnson syndrome, erythroderma, graft-versus-host disease, cutaneous T-cell lymphoma, etc. However, most of the articles that I found related to acute skin failure postulated a process that results in physical findings that resemble pressure injury/ulcer but has a different underlying mechanism. An excellent literature review from the Journal for Advances in Skin and Wound care summarizes their findings as follows:   These results highlight a substantial evidence gap regarding the etiology, diagnostic biomarkers, and predictors of ASF. Further research focused on these gaps may contribute to an accurate and agreed-upon definition for ASF, as well as improved skin integrity outcomes.  This brings me back to the coding of the diagnosis of Acute Skin Failure (ASF). The Power Point quoted a Coding Clinic from 2021 – an excellent source but not the final arbiter for the assignation of ICD 10 codes. There is no code for ASF in the Alphabetic Index or the Tabular List which are the definitive sources for code application. Still, the question from Coding Clinic and their reply is recopied below.   ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2021 Pages: 39-40 Effec.ve with discharges: March 10, 2021   Question: What are the appropriate ICD-10-CM code(s) for skin failure due to underlying coagulopathy and microvascular changes due to COVID-19? (12/11/2020)   Answer: Assign codes U07.1, COVID-19, D68.8, Other specified coagulation defects, and L99, Other disorders of skin and subcutaneous issue in diseases classified elsewhere. (In this case they are using the manifestation code, i.e. the skin failure is due to the COVID 19 illness, the code for the ASF process as the primary concern is L98.9)   The Coding Clinic knows that there is no definitive code for this specific diagnosis so they have assigned a code from ICD 10 that is four characters. Recall, ICD 10 codes allow for 7 characters with each subsequent space (subcategory) providing increasing information and specificity for the diagnosis that is documented. Three characters assigns the diagnosis to a category. In this case, the fourth character “9” indicates Disorder of the skin and subcutaneous /tissue, unspecified. To make my point I will contrast this to another coding clinic:   Question: (second quarter 2013) [… patient was admitted for workup of gastrointestinal (GI) carcinoma and skin lesions. The physician documented "acrokeratosis paraneoplastica, Bazex syndrome," in the final diagnostic statement. What is the ICD-10-CM code for this syndrome?   Answer: Assign code L98.8, Other specified disorder of skin, for Acrokeratosis paraneoplastica, Bazex syndrome. It would be appropriate to assign additional codes for any other manifestations of the syndrome as documented Bazex syndrome is a paraneoplastic syndrome. The syndrome is also referred to as acral psoriasiform dermatosis and acrokeratosis paraneoplastica. It is uncommon, affects the skin, and is usually associated with a malignant neoplasm (e.g., squamous cell carcinoma of the upper digestive tract).   In other words, this Coding Clinic says to assign a relatively rare but well described disorder of the skin to an ICD 10 code, L98.8 (Other specified disorders of the skin and subcutaneous /tissue). It lacks a specific individual code but it is still recognized as a specific individual diagnosis. The codes are essentially telling us that one diagnosis has been well established and the other has not, at least not yet.   Dr. Levine, an author frequently cited on the topic of ASF is quoted in his own review as stating . . .we are seeing skin failure invoked more frequently these days, at least in narrative documentation, even though there is no current ICD-10 code that corresponds to it. This trend may reflect improved general recognition among practitioners of this type of skin breakdown, Skin failure due to underlying coagulopathy due to COVID-19 often widespread, as part of a multiple organ dysfunction syndrome, or it may reflect attempts to reduce liability by calling these ulcers something other than pressure ulcers. Probably both factors play a role in the increased use of this terminology. This does not mean that this finding should not continue to be documented and captured in a code. Coding, per the ICD 10 Guidelines is done based “on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.” Of course, this could set one up for clinical validation audits later on though this particular code does not impact reimbursement, mortality or severity of illness. Also, this is one of the primary uses of ICD 10 codes. They provide a reservoir for future research. An enterprising MD/PhD in dermatology somewhere could notice that a slew of COVID patients carry this ICD 10 code indicating acute skin injury and begin a study that results in a better understanding of the process and leads to a specific diagnosis with therapeutics and prognostications implied. It could be that those studies are already underway. Likely then it will get its own specific code as well.   The ACPA tip sheet and summary for pressure ulcers/injury will, in addition to defining the diagnoses, highlight a few coding pearls that are important for this group of diagnoses. For example, this is one of the few, specific instances where the coding guidelines allow for someone other than the provider to do the specific documentation for a diagnosis. The wound care nurse can and does document specifically the physical findings and treatment recommended for whatever pressure injury is found on physical exam. Still, in order to code the documented pressure injury the provider in charge of the patient’s direct care – MD, DO etc. must document the presence of that injury. For example, in the assessment and plan the provider states: ‘Stage III ischial pressure injury’, the type and site must be captured for appropriate coding. If they do not, they can expect a query from the coder who knows what information must be documented and by whom in order to capture the diagnosis. Other findings documented by nursing or EMTs may be coded as well provided the attending attaches a diagnosis e.g. the nurse documents BMI 36 and the attending diagnoses obesity, an EMT documents GCS 6 and the attending documents coma. Without the confirmation from the provider these diagnoses will not be captured. CMS does limit the conditions that can be coded from the documentation of support staff, these are a few of them.   Another coding issue that is well illustrated by pressure injury is the necessity to document present on admission (POA) status. Every patient who is admitted to the hospital has a documented skin swarm by the nursing staff that is looking for any skin injury that is present at the time of admission. If a patient has a pressure injury, it is ultimately up to the attending to document whether that lesion was present on admission. The answer to this question impacts quality, reimbursement, and mortality indices. Other coding pearls and tips are included in the final pressure injury document that will be posted soon. I encourage you to take the time to peruse it and pass these on to your clinical colleagues.  References Levine JM. Skin Failure: An Emerging Concept. Journal of the American Medical Directors Association. 2016; 17: 666-669. https://pubmed.ncbi.nlm.nih.gov/27161850/  Dalgleish, Lizanne BSN, RN; Campbell, Jill PhD, RN; Finlayson, Kathleen PhD, RN; Coyer, Fiona PhD, RN. Acute Skin Failure in the Critically Ill Adult Population: A Systematic Review. Advances in Skin and Wound Care: February 2020 - Volume 33 - Issue 2 - p 76-83  https://pubmed.ncbi.nlm.nih.gov/31972579/  Arun C Inamadar 1, Aparna Palit.Acute Skin Failure: concept, causes, consequences and care. Indian J Dermatol Venereol Leprol. Nov-Dec 2005;71(6):379-85. https://pubmed.ncbi.nlm.nih.gov/16394477/  Dr. Melinda Battaile is a CDI and UR Physician Advisor at Vidant Health, Greenville NC and is the Medical Director for the Utilization Review Physician Advisors

American College of Physician Advisors President's Corner

September 2021

Everything old is new again, as the saying goes, but BOY could we have done without an encore of COVID-19 spikes courtesy of the Delta variant. The shining promise of vaccines at the start of the year has degraded into protests, refusals, and continued dissemination of “information” not based on scientific reality.    As if the onslaught of more and more patients hospitalized with COVID-19 isn’t enough, many of us are also faced with an upcoming uncertainty around staffing. More and more hospitals and health systems around the country are mandating immunization for their employees leading to threats of massive loss of support in nursing, environmental services, office staff, and more. These external pressures have an impact on everyone – not the least of which include hospital medical staff. While a year ago, providers were pre-occupied with a census bursting at the seams and patients suffering from a novel infection with virtually unknown clinical expectations and treatment, now they CONTINUE to be plagued with much of the same situation, super-imposed with the looming threat of lack of support.  For physician advisors, utilization managers, clinical documentation specialists, coders, and others, it can be easy to consider the work we do as inconsequential in the face of such hardship. How can I initiate a conversation with a hospitalist about why picking Inpatient status on admission was the wrong move when she has eight patients boarding in the Emergency Department and four dying of COVID-19 in the Intensive Care Unit? How can I approach a discharge planner about not extending his search radius for Skilled Nursing Facilities yesterday when he’s working with a caseload normally covered by three case managers since we are short-staffed with FLMA absences and positive COVID-19 cases who are still in quarantine?    “You’ve got to be shitting me,” is the response I recently received from a provider when I asked about a patient’s plan of care and if it really required continued hospitalization.    “I most certainly am NOT shitting you, let’s talk this through as quickly as we can so you can get back to taking care of your patients,” was my reply.    I get it. My questions and requests and cajoling to document more comprehensively were politely tolerated back in the day but now, in the Time of COVID, is more-often-than-not received as maddening and a verifiable waste of time.  But, we still have to do what we have to do. Perhaps we’re a little softer with the delivery of the message, a little more steely with the reception of the response.  However we manage it, we have to manage it. And roll with the punches. And serve as a support whenever we can.  If you’ve found successful ways to tailor your message/education/requests of the medical staff or others on the team during this overwhelming time, please share them with us at [email protected]. If you wish to remain anonymous, just let us know. Once we get enough examples, we will compile them for future publication in an upcoming newsletter or article.

Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV (Pronouns: She/Her) President, ACPA Dr. Juliet B. Ugarte Hopkins is Physician Advisor for Case Management, Utilization, and Clinical Documentation for ProHealth Care, Inc. in Waukesha, WI.

‌ ‌ ‌ The American College of Physician Advisors (ACPA) publishes and distributes materials created by our members and speakers for the benefit of all ACPA members. ACPA does not certify the accuracy or authority of these materials. These materials are distributed and presented as research information to be used by ACPA members, in conjunction with other research deemed necessary, in the exercise of ACPA members’ independent professional judgment. Original and fully-current sources of authority should be researched by ACPA members. ACPA disclaims all liability in relation to reliance on the content of these materials. The views expressed in the materials are the views of the material's authors and do not represent the views of ACPA. Any references are provided for informational purposes only and do not constitute endorsement of any sources.