Inpatient Psychiatry: Are There Opportunities for Documentation Improvement?

Transcription

1 7th Annual Association for Clinical Documentation Improvement Specialists Conference Inpatient Psychiatry: Are There Opportunities for Documentation Improvement? Teresa Hegard, RN, BSN, CCDS Mayo Clinic Rochester, Minn. Emily Jazdzewski, RN, BSN, MAN Mayo Clinic Rochester, Minn. 2

2 Learning Objectives At the completion of this educational activity, the learner will be able to: Describe the prevalence of mental illness List common psychiatric illnesses and how they impact reimbursement Discuss the CDI role related to outcomes Explain ICD 10 opportunities related to mental disorders 3 Disclaimer No financial disclosure The content of this presentation does not directly or indirectly represent the views of the Mayo Clinic 4

3 Why Talk About Psychiatric Illnesses? Psychiatry is not a huge revenue generator Patients frequently have extended lengths of stay, averaging 5 7 days Patients often have limited incomes Not all treatments will have the same effect, and there may need to be a trial-and-error period Government regulations for psychiatry are some of the most stringent 5 Hospital-Based Inpatient Psychiatric Services Core Measure Set The Joint Commission: Core Measures Screening for violence risk, substance use, trauma history, patient strengths Hours of physical restraint use Hours of seclusion Patients discharged on multiple antipsychotics Appropriate justification if on multiple antipsychotics Discharge continuing care plan Discharge information sent to the next-level care provider 6

4 Advantages/Disadvantages DSM IV Axis I: depression, anxiety, bipolar, schizophrenia Axis II: personality disorders and mental retardation Axis III: brain injuries, medical and physical disorders Axis IV: psychosocial and environmental factors Axis V: global assessment of functioning (under age 18) Diagnostic and Statistical Manual of Mental Disorders (2014) 7 Case Study Patient is a 36-year-old female who got into an argument with her boyfriend and ingested 10 Tylenol tablets; reported to the emergency room for medical treatment. She was cleared by the medical team and has been admitted to the psychiatric unit. Patient has a history of multiple suicide attempts, borderline personality disorder, and major depression. Patient endorses smoking a pack of cigarettes per day and denies alcohol use. Medical conditions include hypertension and hyperlipidemia. 8

5 Case Study Impression/report/plan Admit to psychiatric unit Encourage group activities, including education, coping skills, problem solving, relapse prevention, discharge planning Diagnosis 1. Borderline personality disorder 2. Major depressive disorder, severe without psychotic features 3. Nicotine dependent 4. Hypertension 5. Hyperlipidemia 9 DSM IV Related to Case Study Axis I: major depressive disorder, severe without psychotic features, nicotine dependence Axis II: borderline personality disorder Axis III: hypertension, hyperlipidemia Axis IV: recent argument with boyfriend 10

6 Advantages/Disadvantages Axis I is what frequently gets listed as principal diagnosis, but it may not be the primary diagnosis CDI opportunities include: Recognizing the treatment Nicotine dependence ICD-10 terminology Identifying underlying comorbidities Severity of illness impact 11 Why Does It Matter? DRG Description Relative weights October 1, Acute adjustment reaction Depressive neuroses Neuroses except depressive Disorders of personality and impulse control Organic disturbances and mental retardation Psychoses Alcohol/drug abuse or dependence without MCC The Claro Group (2013) 12

7 Prevalence of Mental Illness Recent reports from a variety of sources suggest that anywhere from 5% to 30% of hospitalized patients meet the criteria for one or more psychiatric diagnoses. Does inpatient documentation support this? What are the challenges? How comfortable are general care providers making or using psychiatric diagnoses? CMS.gov (2013), PEPPER reports (2013) 13 Definition Borderline personality disorder (BPD) is a mental health disorder that generates significant emotional instability. This can lead to a variety of other stressful mental and behavioral problems. Mayo Clinic.org (2013) 14

8 Stigma Patients with BPD can be difficult to care for due to frequent mood fluctuations Nurses misinterpret self-destructive behaviors as attention seeking and manipulation when in reality these behaviors are the patient s way of releasing their inner turmoil Filler & Ward (2005) 15 Case Study: A Nurse View Patient is a 36-year-old female who got into an argument with her boyfriend and ingested 10 Tylenol tablets; reported to the emergency room for medical treatment. She was cleared by the medical team and has been admitted to the psychiatric unit. Patient has a history of multiple suicide attempts, borderline personality disorder, and major depression. Patient endorses smoking a pack of cigarettes per day and denies alcohol use. Medical conditions include hypertension and hyperlipidemia. 16

9 Co-Occurring Conditions Depression Anxiety Substance abuse More than 70% of patients with BPD have made suicide attempts as compared to 17% with other personality disorders Zanarini, Gunderson, Frankenburg, & Chauncey (1990) 17 Causes Genetics Brain disorders Environmental factors Mayo Clinic.org (2013) 18

10 Symptoms Impulsive Awareness of destructive behavior Mood swings Inappropriate anger Difficulty controlling emotions or impulses Suicidal behavior Feeling misunderstood, neglected, alone, empty, or hopeless Fear of being alone Mayo Clinic.org (2013) 19 Caring for the Patient in Crisis Neutrality Validating feelings of internal loss of control Encourage positive behaviors and give positive reinforcement Encouraging the completion and use of a safety plan for when crisis occurs Trust 20

11 Treatment Two primary approaches for treating patients with BPD: 1) Hospitalization for short-term supportive crisis care inpatient admissions are suggested to be brief with well-planned follow-up support 2) Outpatient psychotherapy and dialectical behavior therapy Bland, Tudor, & Whitehouse (2007) 21 Conclusion CDI staff need to be cognizant of possible diagnoses related to mental illness Awareness of DSM IV listing and how it can impact appropriate reimbursement Opportunities related to ICD-10 include nicotine dependence with withdrawal In June of 2013, President Obama spoke at the National Conference on Mental Health and encouraged a national conversation to increase the understanding and awareness about mental health 22

12 References Bland, R.A., Tudor, G., Whitehouse, N.D. (2007). Nursing care of inpatients with borderline personality disorder. Perspectives in Psychiatric Care, 43(4), CMS.gov (2013). Retrieved from The Claro Group (2013). Retrieved from Diagnostic and Statistical Manual of Mental Disorders (2014). Retrieved from Filer, J.N., Ward, C. (2005). Borderline personality disorder: Attitudes of mental health nurses. Mental Health Practice, 9(2), The Joint Commission (2014). Retrieved from Mayo Clinic (2013). Retrieved from PEPPER reports (2013). Retrieved from Zanarini, M.C., Gunderson, J.G., Frankenburg, F.R., Chanuncey, D.L. (1990). Discriminating borderline personality disorder from other Axis II disorders. American Journal of Psychiatry, 147, Thank you. Questions? Teresa Hegard Emily Jazdzewski In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the workbook. 24