HIM Frontlines covers HIM professionals working in emerging roles and tackling difficult HIM problems.
As clinical documentation improvement (CDI) programs become more popular, providers are still struggling with implementing CDI programs for several different reasons, including: geographical location; a shortage of outpatient coders and CDI specialists; or even the lack of physical space.
Renown Health, in Reno, NV, is one organization that had to balance a growing demand for CDI with the shrinking square footage needed to support it, according to Jennifer Crossley, MSN, RN, CNML, the director of CDI at Renown. When Crossley entered her current role at Renown a year and a half ago, the organization’s CDI program had been up and running since 2010. But while all of the CDI specialists lived locally, they all worked from home for half the week, and in the office (which has more room now) for half the week. She says she’s unsure exactly how long this set up was in place before she joined the organization.
A System that Works
Crossley oversees 10 CDI nurses—five of them work in the office for the first part of the week while the other five work at home, and then each team switches places.
“The team likes it and I think it helps a lot with recruiting to the department. It allows people to still be able to collaborate when they’re in the office and build relationships with each other—and with physicians—versus just working from home all the time,” Crossley says. “This model works really well for us because everybody works in town. A lot of places don’t have that luxury. We haven’t had to hire contract CDI staff, and we’ve been able to fill open positions internally, which is a big benefit for us.”
The arrangement contains all the perks advocates of on-site CDI tout, such as comfortable rapport with physicians, who CDI staff can query in person, and team cohesion.
“These are experienced nurses that have been dealing with doctors for many years. They know how to handle those conversations and build those relationships,” Crossley says.
The full team also meets twice a month to catch up with each other, and they meet quarterly for breakfast. And because the team know each other so well, their communication when working from home is strong. Being able to work from home also contributes to the low—practically nonexistent—turnover rate.
“I haven’t had anyone resign since I’ve been in this position. The team is very stable,” Crossley says.
She says that as a morale building exercise, she will assign each member of the CDI team a diagnosis. Each specialist must take on that diagnosis and then provide education to the rest of the team about it.
Currently, Crossley’s CDI team only reviews Medicare charts, and they review between 28-29 percent of Renown’s total Medicare claims. The team reviews Medicare records from two of Renown’s facilities: Renown Regional Medical Center, which has an 800-bed hospital with a census of 500-550 patients per day, and Renown South Meadows Medical Center, which has 80 beds and a census of about 30 patients per day. Additionally, CDI specialists review charts fed into their system from the Nevada and California prison systems.
Crossley would like to expand the CDI program to cover the ICU and telemetry unit, and review claims for payers other than Medicare.
A specialty that Renown’s CDI team has been able to provide is CDI support for the health system’s home health claims. Tammy Combs, MSN, CCS, CCDS, CDIP, a director of HIM practice excellence at AHIMA, says she is just starting to hear about more facilities using CDI in the home health setting, and it shows potential for growth.
Crossley says CDI for home health doesn’t work exactly like it does in a traditional inpatient setting, where CDI specialists query physicians. Instead CDI specialists review the lengthy OASIS form—that is the form home health agencies submit to Medicare for reimbursement—and then follow up with the nurses filling the form out.
“So it’s sort of a CDI model, but they don’t really query, mostly because we don’t have that support in our EMR for home health—but it’s similar in that they’re reviewing records concurrently.”